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Ascites In Dialysis Patients

Hemanth P
Dialysis Tutor
B N Patel Institute of Paramedical Science
• Defined as the accumulation of fluid in peritoneal cavity.
• Etiology:
– Most commonly seen in patients with Portal Hypertension and
Cirrhosis, Intra-abdominal malignancy, CHF, and MT.
• Diagnosis:
– Liver Diseases, Risk factors for Hep C & B, cancer, HF, TB, dialysis and
pancreatitis.
– Operative injury to the ureter or bladder can lead to leakage of urine
in to peritoneal cavity.
Clinical Features

• Asymptomatic Ascites:
– Fluid <100 – 400ml
– Mild Ascites

• Symptomatic Ascites:
– Fluid >400ml
– Increased abdominal girth, presence of abdominal pain or discomfort,
early satiety, pedal edema, wt. gain and respiratory distress.
Physical Examination Findings

• Umbilicus eversion
• Tympany at the top of abdomen
• Fluid wave
• Peripheral edema
• Shifting dullness (>500ml fluid)
• Bulging flanks (>500ml fluid)
Ascites in Dialysis Patients

Incidence of Ascites is decreased over time as there has been


technical development in the field of RRT with the better
control of fluid balance, progress in nutritional and
psychological treatment of HD patients, and use of more
biocompatible membranes.

Almost 70% of ascites cases will be due to glumerulonephrities


and hypertensive renal disease. Most patients presents with
the sign of persistent fluid overload, cachexia or low serum
albumin levels.
• Most of the patients suffering from Ascites shows sustained
fluid overload with disproportionate interdialysis body weight
increases and arterial hypertension.
• Diagnosis of ascites in dialysis patients
– Physical findings like increased abdominal girth, early satiety, anorexia,
dialysis associated hypotension, cachexia, massive ascites combined
with minimal edema.
– Ascitic fluid characteristics: Straw color, WBC count of 25 to
1600/mm3, negative to culture and cytologies.
– No evidence of portal hypertension, cirrhosis, malignancy, peritoneal
infection and urinary extravasation.
• Other possible contributing causes of ascites in patients with
ESRD include hypoproteinemia, secondary
hyperparathyroidism - induced serositis, Congestive heart
failure, Constrictive pericarditis and liver cirrhosis with portal
hypertension.
Therapeutic options for Dialysis related ascitis

• Fluid and salt restriction with intensified hemodialysis with


ultrafiltration and/or albumin infusion.
• Hyperalimentation
• Repeated paracentesis
• Reinfusion of ultrafiltrated
• CAPD
• Peritoneovenous shunt
• Kidney transplantation
• Isolated ultrafiltration
• More aggressive approach to treatment includes peritoneal
instillation of steroids, reinfusion of ultrafiltrated ascites,
bilateral nephrectomy, peritoneal dialysis, renal
transplantation and continuous reinfusion of ascites directly
into the venous system using a peritoneovenous shunt (PVS).
• Renal transplantation is considered to be most effective so far.
• Complication of PVS placement includes malfunction from
occlusion or migration of the venous end out of the superior
vena cava and infection. These complications require either
minor revisions or removal of the shunt.
• CAPD, peritoneovenous shunt placement and renal
transplantation offer best hope for an improvement in the
quality of life and recovery.