الفهرس 
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Abstract
Ascites is a common complication of cirrhosis. The development of ascites marks the onset of worsened prognosis and increased mortality in patients with cirrhosis. Ascites causes considerable morbidity in the affected individual by producing abdominal distension, respiratory distress, development of hernias especially paraumbilical, worsening of nutritional status, and increased susceptibility to infections (Hou and Sanyal, 2009). LVP may be performed to alleviate discomfort or respiratory compromise in patients with tense ascites who are hemodynamically stable. Three serial LVP may be required in patients with refractory ascites (Thomsen et al., 2007). However removal of large volumes of ascitic fluid carries the risk of development of circulatory dysfunction characterized by a reduction of effective blood volume, a condition known as post-paracentesis circulatory dysfunction (PPCD) (EASL, 2010). PPCD has been defined as a 50% increase in plasma renin activity (PRA) over baseline on the sixth day after treatment, up to a value > 4 ng/mL per hour (Appenrodt et al., 2008; Salerno et al., 2010). As far as we know, only one study had discussed the effect of flow rate of ascites extraction and development of PPCD .However this study was not enough for conclusive determants. So, we design this study to evaluate whether there is a relationship between the flow rate of ascitic fluid during abdominal paracentesis using low dose albumin and the development of PPCD. Sixty patients with cirrhosis and tense ascites attending the inpatient unit of clinical hepatology department, National Liver Institute, Menoufiya University, were prospectively included in this study, for proper control of their ascites. These patients were randomized to 3 groups: Slow flow rate (20 patients) with flow rate of 80 ml/minute, Medium flow rate (20 patients) with flow rate of 180 ml/minute, Rapid flow rate (20 patients) with flow rate of 270 ml/minute, Paracentesis was done by using cannula connected to sterile urinary collection bag as we did not use suction tubes. All patients were subjected to: Large volume Paracentesis about 8 liters with low dose albumin replacement (given at a dose of 2.5 g/L of ascitic fluid removed at the end of LVP). Changes of the effective arterial blood volume were evaluated by measuring PRA at baseline and on the day of hospital discharge (6 days later). Day 6 measures were studied for evaluating; development of PPCD which was defined as an increase in PRA of > 50% of the pretreatment value (Salerno et al., 2010). On comparison of the demographic, clinical data, laboratory, CTP, MELD and MELD Na of all patients among the three studied groups at the time of inclusion; there were no statistically significant differences among the three studied groups (p > 0.05). By comparing the different means of clinical data, laboratory, CTP, MELD, MELD Na in our study on the day of discharge (day 6) among the three studied groups, no statistically significant differences were found among the three studied groups (p > 0.05).The flow rate of paracentesis in our work had significantly affected weight, MAP, MELD, MELD Na, serum urea and creatinine level (p < 0.05). Although there were no statistically significant differences were found regarding development of PPCD among the three flow rate patients, the incidence of the PPCD was found to be higher in the rapid flow group compared to the other two groups as it occurred in 30% (6 patients), 25% (5 patients) and 35% (7 patients) in the slow flow, medium flow and rapid flow groups respectively (p >0.05). PRA was higher in the rapid flow group compared to the other two groups but no statistically significant differences were found regarding mean ± SD of the serum PRA level between the three studied groups (p > 0.05). These results may reflect either a reality or may be on the other hand conceively related to the small number of the studied cases. Practically it was more beneficial clinically to detect the predictors of PPCD development. By univariate logistic regression analysis, gender was the only significant predictor (dependent factor) of PPCD development where females were 3 times more liable than males for development of PPCD, however using multivariate regression analysis of all baseline variables, none of them carried the possibility of prediction of PPCD development. In conclusion; this study suggests that there is no a relationship between the flow rate of ascitic fluid extraction during abdominal paracentesis (using low dose albumin) and the development of paracentesis induced circulatory dysfunction (PPCD). However flow rate extraction of paracentesis had significantly affected weight reduction and renal function tests.