refractory ascites causes abdominal distention , abdominal pain and dyspnea and thereby aggravates patient quality of life and activities of daily living .
the effect of abdominal paracentesis is temporary , but loss of albumin and globulin can cause deterioration of nutritional and immune status and lowered colloid osmotic pressure .
cell - free and concentrated ascites reinfusion therapy ( cart ) is a treatment which maintains albumin and globulin by filtration , concentration , and reinfusion of drained ascites .
the advantages of this method are that albumin transfusion can be employed sparingly , and the risk of infection or allergic reaction is thus reduced . however , cart is dangerous to spontaneous bacterial peritonitis ( sbp ) patients because inadvertent reinfusion of filtrated , concentrated endotoxins in ascites has caused adverse effects of temporary fever and shock .
we report our pursuit of cart for refractory ascites in sbp after finding that ascites were negative for endotoxins .
a 58-year - old japanese male with end - stage renal failure due to chronic glomerulonephritis and receiving chronic hemodialysis since 1980 underwent kidney transplantation from an unrelated donor in october 1998 .
this case was also complicated by chronic hepatitis c. in january 2004 , liver cirrhosis with a child - pugh score of 6 points ( grade a ) was diagnosed based on total serum bilirubin ( t - bil ) of 0.7 mg / dl , serum albumin ( s - alb ) of 2.8 g / dl , prothrombin time - international normalized ratio ( pt - inr ) of 1.1 , and medical control of ascites . during follow - up ,
immunosuppressive therapy consisted of mycophenolate mofetil ( 500 mg / day ) , tacrolimus hydrate ( 2 mg / day ) , and prednisolone ( 7.5 mg / day ) . in november 2004 ,
160 mg / day furosemide and 4 mg / day thiazide were administered for increased ascites , but the effect was insufficient . on december 26 , 2004 , the patient was hospitalized for fever , abdominal pain , dyspnea , and copious ascites . on admission ,
patient height was 167.6 cm , body weight 59.2 kg , body temperature 39.2c , blood pressure 154/92 mm hg , and pulse 72 beats / min .
table 1 presents the laboratory findings on admission , including a white blood cell count of 8,500/l and a c - reactive protein ( crp ) level of 11.3 mg / dl .
based on t - bil 2.6 mg / dl , s - alb 2.7 g / dl , pt - inr 1.1 , and the presence of refractory ascites , liver cirrhosis with a child - pugh score of 9 points ( grade b ) was diagnosed .
the ascites were exudative and demonstrated a specific gravity of 1.032 , total protein of 3.1 g / dl , total albumin of 1.6 g / dl , rivalta 's reaction positive , and polymorphonuclear leukocyte ( pmn ) count of 940 cells / mm .
renal failure was identified based on a blood urea nitrogen ( bun ) level of 55 mg / dl and s - cr of 2.3 mg / dl .
tacrolimus trough concentration was not problematic , at 6.2 ng / ml ; urinalysis was also normal ; fractional excretion of urea nitrogen ( feun ) was low , at 20% ; and on this basis , prerenal failure was diagnosed .
abdominal computed tomography scan and abdominal ultrasound showed copious ascites , but there was no evidence of abscess , perforation , or penetration .
1 presents the clinical course and treatment pursued . immediately after ascites puncture , we began empirical antibiotic therapy with ceftriaxone intravenously ( 1 g / day ) , and mycophenolate mofetil and tacrolimus hydrate were discontinued .
two days after initiation of treatment , body temperature was normal , and abdominal pain had ceased , but the copious ascites were not improved .
abdominal paracentesis ( 3 l / day ) and albumin transfusion ( 25% , 100 ml / day ) were performed 6 times , but the effect was temporary , and control of ascites was poor .
s - alb decreased to 1.8 g / dl , renal failure deteriorated , urinary volume declined , and ascites increased yet further . due to normal urinalysis and low feun of 20% , aggravation of prerenal failure was a suspected factor . because the pmn count in ascites decreased to 58 cells / mm and ascites were also endotoxin negative ( 0.8 pg / ml )
, cart was initiated , with 3.0 l of ascites filtrated and concentrated to 0.3 l in 120 min .
the concentrated fluid was drip - infused back into the patient at the rate of 0.15 l / h .
the apparatus used was the plascit 01 and the columns used were model ahf - mow for the ascites filtration and the model ahf - unh for the ascites concentration , all manufactured by asahi kasei medical ( tokyo , japan ) . at such time , s - alb rose gradually , and the level of ascites decreased .
cart was performed a total of 6 times , and ascites were well controlled , with no observation of fever , hypotension , or other adverse effects .
biochemical results also improved to t - bil 0.7 mg / dl , s - alb 3.2 g / dl , bun 37 mg / dl , s - cr 1.2 mg / dl , and crp 0.0 mg / dl .
no findings suggesting rejection of a transplanted kidney were observed , mycophenolate mofetil ( 500 mg / day ) and tacrolimus hydrate ( 2 mg / day ) were reinitiated , and the patient was discharged .
the diagnostic criteria for sbp are bacterial growth from the ascitic fluid plus an ascitic pmn count of more than 250/l , or ascitic fluid with a pmn count of more than 500/l , even in the absence of a positive culture . in this case , sbp was diagnosed on the basis of an ascitic pmn count of 940 cells / mm and the absence of an obvious intra - abdominal source of infection .
sbp is thought to result from a combination of factors inherent in cirrhosis and ascites , such as prolonged bacteremia secondary to compromised host defense , intrahepatic shunting of colonized blood , and defective bactericidal activity within the ascitic fluid .
some 40% to 50% of all patients with sbp have negative cultures of both blood and ascitic fluid , as in this case [ 4 , 5 ] .
since the 1985 seminal study , which showed better outcomes with cefotaxime than with the combination of ampicillin and tobramycin , third - generation cephalosporins have been the agents of choice in the management of sbp .
subsequently , several studies have reinforced the role of third - generation cephalosporins in an effort to determine the optimal dose and duration of therapy [ 5 , 6 , 7 , 8 , 9 ] .
guidelines for sbp have been published by the international ascites club and suggest several antibiotics that may be used for empirical treatment , including cefotaxime , cefonicid , ceftizoxime , ceftriaxone , ceftazidime , and amoxicillin - clavulanic acid . based on the reports cited , we selected ceftriaxone , and given the prerenal failure status , dosage was reduced to 1 g / day .
acute renal failure develops in 33% of patients with sbp and is a major cause of death .
after abdominal paracentesis , intravenous infusion of albumin has been used to avoid reduction of the effective volume and prerenal failure [ 12 , 13 ] .
a randomized , controlled study of patients with sbp showed that patients receiving cefotaxime with a high - volume albumin transfusion ( 1.01.5 g / kg ) were significantly less likely to have irreversible renal failure and had lower mortality .
japan , however , relies on imports for 70% of its albumin formulations , which complicates high - volume albumin transfusion ( e.g. , 1.01.5 g / kg ) .
cart is a treatment which maintains albumin and globulin by filtration , concentration , and reinfusion of drained ascites .
a single cart treatment reportedly can reinfuse approximately 60 g of albumin , and this amount corresponds to a high - volume albumin transfusion capable of reducing the associated risk of infection or allergic reaction . however , cart is more expensive than the high volume of albumin transfusion ( 60 g ) in japan ( 90,000 vs. 60,000 yen ) .
cart can not eliminate endotoxins , which present a danger to sbp patients as a risk of endotoxin shock or temporary fever .
sbp is deemed resolved when all signs of infection have disappeared and the ascitic fluid pmn count is below 250 cells / mm . in our case , cart was pursued after the pmn count in ascites decreased to 58 cells / mm and the ascites were found to be endotoxin negative . at such time , no shock or temporary fever was observed .
though administration of prednisolone ( 7.5 mg / day ) as immunosuppressive therapy may have prevented occurrence of a temporary fever , we believe that cart is a safe treatment even for endotoxin - negative sbp patients .
 a 58-year - old japanese male with chronic hepatitis c underwent kidney transplantation from an unrelated donor in october 1998 . in december 2004 , the patient was admitted for spontaneous bacterial peritonitis ( sbp ) . 
 abdominal paracentesis and albumin transfusion were performed , but control of ascites was poor . a randomized , controlled study of patients with sbp showed that patients receiving cefotaxime with a high - volume albumin transfusion ( 5075 g/50 kg ) were significantly less likely to have irreversible renal failure and had lower mortality . 
 japan , however , relies on imports for 70% of its albumin formulations , which complicates high - volume albumin transfusion . 
 consequently , albumin transfusion is often limited to single treatments in the range of only 25 g ( 25% , 100 ml ) . 
 a single cell - free and concentrated ascites reinfusion therapy ( cart ) treatment can reinfuse approximately 60 g of albumin , corresponding to a high - volume albumin transfusion capable of reducing the associated risk of infection or allergic reaction . though this case was an sbp patient , after the ascites were found to be negative for endotoxins , cart was performed , and control of ascites was achieved without observation of fever , hypotension , or other adverse effects . 
 cart provides greater supplementation of albumin than albumin transfusion and can be an effective modality of treatment for hypoalbuminemia in sbp patients if ascites are negative for endotoxins . 