Evaluation Of The Clinical Value Of Serum-ascites Albumin Gradient And The Efficacy Of Diuretic On Cirrhosis With Ascites

Background Serum ascites albumin gradient (SAAG) was considered to be a credible parameter identifying portal hypertension and nonportal hypertension. But the traditional methods based on exudate-transudate concept was also applied in clinical practice in our hospital, need to establish serum ascites albumin gradient detection methods, statistical analysis the clinical research data of SAAG determine the nature of ascites. Furthermore, need to reasonable application of diuretic treatment of cirrhosis with ascites, the most rational diuretic treatment of cirrhotics with ascites is spironolactone alone or in combination with furosemide. How about the difference of efficacy and safety between two kinds of treatment? How to quantify the efficacy of diuretic treatment of cirrhosis with ascites to making treatment standardized? There is yet to be conducted a prospective clinical observational study, to guide the clinical use of drugs.ObjectiveTo study the clinical value of serum-ascites albumin gradient in differentiation ascites of portal hypertension from non-portal hypertension. Comparing spironolactone alone versus spironolactone associated with furosemide, in terms of efficacy and safety, in cirrhotic patients with ascites.MethodsCollection of ascitic fliuid date from two hundred and twelve patients with an identifiable cause of ascites. Serum and ascitic fluid were obtained on the same day, serum-ascites albumin gradient (SAAG) and ascitic fluid total protein (AFTP) were measured. Diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of the serum ascites albumin gradient and AFTP for the separation of ascites into transudate and exudate were compared. Using receiver operating characteristic curve (ROC) assessed the accuracy of a SAAG of at least 11 g/L in detecting portal hypertension and of an AFTP of at least 25 g/L in detecting exudate.One hundred and thirty-seven cirrhotic patients with ascites, who were consecutively enrolled and treated, were assigned a treatment with spironolactone alone (65 patients) or with spironolactone in combination with furosemide (72 patients). During the study, body weight, urine volume and abdominal perimeter of each patient were measured daily. 24h urinary sodium excretion, renal function and electrolytes were measured every 3-5 days. Comparison of the curative effect and security between the two groups was carried out according to the curative effect judgement criterion about diuretic management of ascites in cirrhosis, which proposed by the international ascites club in 2003.ResultsSAAG in group with portal hypertension and in group with nonportal hypertension was (21.34±4.64)g/L and (9.56±2.53)g/L respectively. SAAG in group with portal hypertension was significantly higher than that in group with nonportal hypertension (p<0.001). SAAG in group with mixed ascites was (21.87±5.78)g/L, because of the presence of portal hypertension, patients with mixed ascites have a high gradient. The accuracy and Youden's index of SAAG≥11 g/L diagnose portal hypertension were 88.68% and 0.6777 respectively. In contrast, The accuracy and Youden's index of AFTP≥25 g/L in the diagnosis exudates were 76.89% and 0.5714 respectively. The area under the ROC curve of SAAG≥11 g/L prediction of portal hypertension and AFTP≥25 g/L prediction of exudate were 0.990 and 0.800.Mobilization of ascites was achieved in 62 out of the 65 patients in the group treated with spironolactone alone (95.4% ), and in 66 out of the 72 patients in the group treated with spironolactone in combination with furosemide(91.7%), the difference between two groups was not significant (χ2=0.769, P=0.380). At the end of the treatment, no significant differences between the two groups were found regarding the total amount of body weight loss (t=-0.772,P=0.440), mean daily loss of weight (t=-1.326,P=0.187), the increment in urinary sodium excretion (t=-0.594,P=0.553). However, The onset of diuresis of the group treated with spironolactone in combination with furosemide faster than the group treated with spironolactone alone, the difference was statistically significant (t=3.539,P=0.001). The difference between the cumulative probability of mobilization of ascites was statistically significant in both groups (χ2=10.370,P=0.001). The difference of the rate of complications induced by diuretic between the two groups was not significant (P=0.687). After treatment with diuretics, patients with serum sodium in both groups decreased significantly, serum potassium increased in the group treated with spironolactone alone, the difference was statistically significant (P<0.01), however, the value after the change was still within the normal range. The value of serum creatinine was increased in the group treated with spironolactone in combination with furosemide, the difference was statistically significant (P=0.012).ConclusionsSAAG in group with portal hypertension was significant1y higher than that in group with nonportal hypertension. It may indicate that ascitic fluid samples should be characterized as high gradient or low gradient rather than as transudate or exudates, it is contribute to the differential diagnosis of ascites.In the treatment of cirrhotic patients with ascites, spironolactone alone seems to be as safe and effective as spironolactone associated with furosemide. Compared with treated with spironolactone alone, spironolactone in combination with furosemide with the advantages of a faster onset time.