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Case report: Successful management of a patient with alcoholic cirrhosis and
intractable ascites with a novel device - the alfapump® system
D. Adebayo, M. Malago, R. Jalan
Institute for Liver and Digestive Health
Royal Free Hospital
Pond Street, London NW3 2QG
Email address: [email protected]
Introduction
Ascites is defined as the pathological accumulation of
fluid within the peritoneal cavity. It is a common
manifestation of cirrhosis with approximately 50% of
patients with cirrhosis developing ascites within 10
years of diagnosis1. The development of ascites in a
cirrhotic patient is an important landmark for a
number of reasons: (1) it is associated with a poor
quality of life and an increased 1-year mortality; (2) it
functions as a risk stratification marker for orthotopic
liver transplantation; (3) it is a common complication
and thus associated with high contingent costs2,3. The
initial management of ascites is diuretics and sodium
restriction. Despite this, up to 10% of ascitic patients
develop diuretic-refractory or diuretic intractable
ascites per annum4. Ascites is classified as diuretic
refractory when there is a lack of response to high
doses of diuretics (400mg spironolactone per day plus
160mg of furosemide per day) or diuretic-intractable
when the development of side effects prevent the use
of diuretics in a patient5. The first-line therapy
strategy for diuretic-refractory/intractable ascites is
large volume paracentesis (LVP) with the concomitant
administration of intravenous albumin. However,
some patients treated with regular LVP may develop
post-paracentesis circulatory dysfunction. In addition,
there are cost considerations associated with the
need for repeated LVP. An alternative treatment
strategy involves the insertion of a Transjugular
Intrahepatic Porto-systemic Shunt (TIPS). Although
TIPS is effective in controlling ascites in up to 66% of
patients, approximately half of these patients are at
risk of developing hepatic encephalopathy. In addition,
its use is contraindicated in patients with severe liver
disease4. In selected patients, who are suitable
candidates, orthotropic liver transplantation is the
definitive treatment strategy.
We report a case of 48-year-old male, with diureticintractable ascites, who was the first patient in our
centre to be treated with a novel therapeutic devicethe alfapump® system (Automated Low-Flow Ascites
Pump System, Sequana Medical, Zurich, Switzerland).
This device is a fully implantable battery-powered
pump that transports ascites from the peritoneal
cavity into the bladder so it can be eliminated by
micturition.
Case Report
A 48- year old man with alcoholic cirrhosis and
ascites diagnosed 3 years ago was referred to our
centre for consideration of a liver transplant. He had
been abstinent from alcohol since his diagnosis with
liver disease. At presentation, he was requiring
paracentesis about every two weeks with on average
8-litres of ascites being drained. He had no history of
spontaneous bacterial peritonitis. He had a medical
history of hepatic encephalopathy, systemic arterial
hypertension, renal impairment and two previous
deep vein thromboses in the right calf. Medications
included Bisoprolol, Citalopram, Amitriptyline,
Omeprazole, Spironolactone and vitamins.
Physical examination revealed reduced muscle mass
and a distended abdomen in keeping with grade 3
ascites. Blood tests at the initial visit revealed:
haemoglobin of 12.8g/dl, platelet count of 153x10 9/L,
INR 1.2, sodium 142, urea 7.3 mmol/L, creatinine 119
umol/L, bilirubin 8 umol/L, ALT 16 u/L, AST 26 u/L,
ALP 75 u/L, gamma-GT 37 u/L, albumin 39 g/L giving a
MELD score of 11 and UKELD score of 48.
He had a complete transplant work-up and it was felt
that in view of his relatively well-preserved liver
function, he was too early to be considered for a liver
transplant. In view of his previous episode of hepatic
encephalopathy, it was felt he would be high risk for
TIPS.
As our centre was in the process of recruiting
patients for a large, multi-centre, randomised control
trial of the alfapump system, we offered the patient an
opportunity to participate in the trial. The patient
consented to be involved in the trial and was
randomised to receive the alfapump. A surgeon
performed the procedure under general anaesthesia
and the implantation took approximately 45 mins.
Peri-operative prophylactic antibiotics, Ceftazidime
and Teicoplanin were administered at the time of the
procedure and 12-hours afterwards. The alfapump
was turned on the day after the operation and
programmed to drain 500 ml/day.
Day 2 post implantation, the patient developed a
stage-1 acute kidney injury with a rise in creatinine
(see Table 1). This was managed with intravenous
volume replacement using Human Albumin solution
and settled by day 5.
Day 5 post implantation, a rise in inflammatory
markers was noted despite the patient being clinically
well (CRP 203mg/L, WCC 18.80x109/L). A septic
screen yielded no positive results and the blood test
results improved after 48 hours. Antibiotic therapy
was not required. The patient was discharged at day 7
post implantation with the pump set to drain 1
litre/day.
Approximately 6 weeks post implantation, the patient
complained of difficulty with micturition. Ultrasound
demonstrated evidence of urinary retention.
Subsequent urodynamic studies suggested the
presence of a urethral stricture. The patient
underwent a cystoscopy and urethral dilatation. In
that period, the pump volume was turned down from
1 litre to 500 ml/day. The patient recovered within
days of the procedure and the pump setting was
readjusted to drain 1litre/ day. The patient
encountered no further adverse events.
which are likely to be related to surgery rather than
the device. It is possible that the urethral stricture
was long-standing and only aggravated when the
urinary tract was challenged with the increased
amount of ascites. Nevertheless, we now routinely
carry out a detailed urological survey on all our
patients before implantation. The alfapump system
should be considered as a treatment option for
refractory ascites in selected patients.
At 8-months post pump insertion, he had drained
approximately 100 litres of ascites and an abdominal
ultrasound revealed less than 100 mls of ascites in the
peritoneal cavity. His nutritional status improved
significantly and he reported an “excellent” quality of
life. To date (more than 12 months post
implantation), he has not required paracentesis or
hospital admission. His laboratory results have
remained improved (Table 1) giving a current MELD
of 10 and UKELD of 43.
1. Gines, P., et al. Compensated cirrhosis: natural history and
prognostic factors. Hepatology 7, 122-128 (1987).
2. Planas, R., et al. Natural history of patients hospitalized for
management of cirrhotic ascites. Clinical gastroenterology
Summary
Liver international : official journal of the International
Association for the Study of the Liver 30, 937-947 (2010).
5. Moore, K.P., et al. The management of ascites in cirrhosis:
This case report describes our first experience in
managing a patient with the new alfapump system. In
the initial post-operative period, the patient
experienced stage-1 acute kidney injury and showed
evidence of a systemic inflammatory response both of
References:
and hepatology : the official clinical practice journal of the
American Gastroenterological Association 4, 1385-1394
(2006).
3. Moore, C.M. & Van Thiel, D.H. Cirrhotic ascites review:
Pathophysiology, diagnosis and management. World journal
of hepatology 5, 251-263 (2013).
4. Salerno, F., et al. Refractory ascites: pathogenesis, definition and
therapy of a severe complication in patients with cirrhosis.
report on the consensus conference of the International
Ascites Club. Hepatology 38, 258-266 (2003)
.
TABLE 1
PARAMETER
Haemoglobin (g/dL)
White blood count (x109/L)
Platelet count (x109/L)
INR
AST (u/L)
ALT (u/L)
Alkaline phosphatase (u/L)
Gamma glutamyl transferase (u/L)
Total bilirubin (μmol/L)
Creatinine (μmol/L)
Urea (mmol/L)
Serum albumin (g/L)
Sodium (mmol/L)
Potassium (mmol/L)
C-Reactive Protein (mg/L)
1 DAY
pre-implantation
12.5
9.23
143
1.3
30
21
74
42
25
116
8.3
44
142
4.6
8
2 DAYS
post-implantation
11.0
16.72
99
1.4
22
12
51
27
24
184
10.5
46
136
4.4
14
360 DAYS
post-implantation
14.3
9.54
125
1.1
26
16
66
47
8
111
6.5
48
147
4.3
6