Midodrine vs albumin to prevent paracentesis induced circulatory dysfunction in acute on chronic liver failure - a randomized controlled trial

BackgroundParacentesis-induced circulatory disturbance (PICD) occurs in 12-20% of patients receiving human albumin for large-volume paracentesis and can occur at lower than five liter paracentesis in acute-on-chronic liver failure (ACLF). Albumin infusions are associated with higher costs and more prolonged daycare admissions. The aim of the study was to determine if oral midodrine-hydrochloride can prevent PICD in these patients by increasing the mean arterial pressure.MethodsThis open-labeled randomized controlled trial included ACLF patients undergoing paracentesis between 3-5 litres who were randomized to receive either 20% Human-albumin or midodrine-hydrochloride 7.5 mg thrice daily for three days, 2 hours before paracentesis. MAP was recorded daily. The primary outcome was the plasma renin activity (PRA) on day six, and a 50% increase from baseline was considered PICD.Results183 consecutive patients of ACLF were screened, and 50 patients were randomized to either arm. Alcohol was the most common underlying cause of cirrhosis. Day 6 PRA was non-significantly (p =0.056) higher in the midodrine group. The absolute change of PRA between the two groups was not significant (p=0.093). Four (16%) patients in albumin and five(20%) in the midodrine group developed PICD. MAP increase was not different between the albumin and midodrine arms (p=0.851). Midodrine was found to be more cost-effective.ConclusionsThree days of oral midodrine is as effective as a human-albumin infusion in preventing PICD in ACLF patients undergoing paracentesis lesser than that done in large volume paracentesis.