Ascites and Dialysis

My mother has cirrhosis in addition to ESRD and is developing abdominal fluid (ascites). Since dialysis does not take out the abdominal fluid, wouldnt this effect the dry weight calculation and dialysis process.? (e.g. - She gains 2 kg in between dialysis sessions and 200 g of that was due to an increase in abdominal fluid. Dialysis takes out the entire 2kg to return to dry weight since the abdominal fluid gain is ignored/not known. Dialysis should have taken out only 1.8 kg If this happens every week, isnt there a negative effect?).

Dear Muraiken

That is a very sensible, thoughtful but difficult question … it’s not so easy a one to answer … but I’ll try.

I have already explained ‘ascites’ to Jane in an earlier question – though there, I responded to her more in the context of ascites from renal disease (like nephrotic syndrome). As noted there …

‘Ascites is the name used for the collection of fluid inside the abdominal cavity … most commonly associated with liver disease or with advanced cardiac failure’

Cirrhosis is perhaps the commonest cause of ascites and this would seem the likely cause in your mother. You are clearly right that dialysis does not remove the ascites … indeed, ascites is usually reabsorbed quite slowly at the best of times and, as the splanchnic circulation (the blood supply of the gut) tends to contract and shut down during dialysis … one of the reasons why people are discouraged from eating on dialysis … absorption would be only slight, at best, as a result of a single dialysis run – though admittedly, over time and a number of runs, the absorptive effect may be greater.

If the ascites is tense (in other words, her tummy is fairly tight and distended (I don’t know if this is so or not), then as the dialysis progresses and the overall circulating blood volume is contracted by dialysis fluid removal, the pressure of the ascitic fluid in the abdominal cavity may even exert a ‘collapsing effect’ on the venous return to the heart through pressure on the now less-filled inferior vena cava – the great vein that returns blood to the heart and lungs from the lower half of the body and the liver. This may lessen the return of blood to the heart and complicate the capacity to effectively remove fluid back to dry weight.

I doubt that fluid removal from the ascites, per se, during dialysis is going to be sufficient to throw out the over-all calculation of her dry weight. But, not knowing her, her weights, her BPs, and all the nuances of her treatments, treatment to treatment, it’s hard to say for sure.

The serum albumin is vital here … and the administration of albumin during dialysis may be very helpful in raising her plasma oncotic pressure … albumin is what holds fluid within the blood circulation or attracts fluid back into the circulation from body tissues or ‘sequestrated’ fluid (fluid – like ascitic fluid or pleural fluid that is being trapped in body cavities).

Many (most) patients with liver disease – especially severe enough to be complicated by ascites – have a low blood albumin level and the administration of albumin (say 1-2 x 100ml 25% albumin given early on dialysis at each dialysis run) to build her serum albumin levels up may just do the trick for her … but her team is best placed to know and decide this.

I am not sure if that has made it clearer – or more opaque! I was not an easy one to answer.

John Agar