Response to “Reflections on the Study of Physiological Determinants in Cirrhosis With Ascites”

Conflicts of Interest

The authors declare no conflicts of interest.

Dear Editors,

We read with interest the letter from Maksic [1] about the article recently published by our group on ascites pressure during outpatient paracentesis [2]. We agree with Maksic that personalized care for portal hypertension is the future of the field. In this paper, we describe a bedside method with which the intra‐abdominal pressure can be measured during paracentesis using a simple open ended manometer commonly found in a lumbar puncture kit. We explored the underpinnings of ascites‐related symptoms which are commonly ascribed to this pressure by explicitly measuring it. We found that while the pressure that generated symptoms varied widely between patients, the relationship between pressure and symptoms was strongest above an ascites pressure of approximately 6 cm H₂O (4.4 mmHg) relative to the right atrium. This corresponded to a seven question Ascites Symptom Inventory (ASI‐7) score of 16 (maximal symptoms = 35). Additionally, by examining the pressure‐volume relationship during paracentesis, we determined that taller patients experienced less relief when prescribed the same drainage volume as shorter patients. Specifically, to achieve the same relief, these patients required approximately 670 mL additional drainage per inch (2.54 cm) above the cohort mean height of 5′8″ (172.7 cm) due to their larger body size.

Maksic raises the question of the clinical applicability of our technique and findings. We acknowledge that there is no currently accepted role for ascites pressure measurement, with most practitioners initially prescribing a volume to be drained that is subsequently titrated on a trial and error basis. While we had initially hoped to describe a pressure–symptom relationship that could be used to guide drainage on a personalized level, we were unable to find one. We hypothesize that this is due to the significant “floor” effect of the ASI‐7 score after paracentesis that we observed. In other words, after undergoing paracentesis, patients seemed to optimistically report more relief than their pressure drop would seem to predict. This not only speaks to the limitations of the ASI‐7 score, a validated measure of ascites symptoms, but also potentially suggests opportunities for symptom modulation without paracentesis [3].

Another future role for ascites pressure is in personalized care for acute kidney injury. Velez et al. have described an intravascular volume‐based approach for AKI management involving point of care ultrasound [4]. In this approach, treatment of AKI in patients with cirrhosis is personalized based on IVC flow characteristics to guide renal perfusion through fluid resuscitation, diuresis, or even paracentesis in the case of intra‐abdominal hypertension (IAH). Future adaptation of this protocol could involve our pressure measurement technique to fine‐tune the management of AKI in patients with IAH.

In summary, we appreciate the interest in our study, and we are excited to continue to explore the physiology of ascites symptomatology in the pursuit of eventually personalizing care for this heterogeneous group of patients.

Data Availability Statement

The authors have nothing to report.