Fresh Frozen Plasma as a Substitute for Albumin in Patients Receiving a Large Volume Paracentesis

PI confirmed that while coordination and planning was conducted upon IRB approval, no participants were enrolled into the study

Large volume paracentesis (LVP) with albumin administration is the standard of care for patients with refractory ascites complicating end-stage liver disease. However, the use of albumin is frequently limited due to expense and occasional short supply. The goal of this study is to determine if the administration of Fresh Frozen Plasma (FFP) during large volume paracentesis is effective in lowering plasma renin activity by 25% compared to baseline.

There will be three periods of this study, one for each of three consecutive routine large volume paracenteses. The length of the study will be 6 days post paracentesis for each period, for a total of 3 periods. The interval between successive LVP's will be determined by patients' need. In order to ensure follow up on Day 6, Day 1 will be restricted to a Tuesday, Wednesday, Thursday, or Friday. All participants will be monitored for 3 consecutive routine large volume paracenteses. The 3 periods (LVP's) of this study will differ in administration of volume replacement solution. First LVP will be with intravenous albumin (12.5gm 25% Human Albumin for every 2 liters removed), 2nd LVP with administration 1 unit of FFP for every 2 liters removed for the first 4 liters followed by 12.5gm 25% albumin for every subsequent 2 liters removed, and 3rd LVP again with administration of intravenous albumin. The first LVP serves as the study entry time period and also as a control period for the same patient. The second LVP is to test the new intervention with FFP. The third LVP is included so that we can monitor the patient's status. Albumin or FFP administration: Albumin administration: 50ml of 25% albumin for every 2L removed FFP administration: 2 units of FFP for the first 4L removed followed by 50ml of 25% albumin for every additional 2L removed FFP will be supplied by the Blood Bank and albumin from the pharmacy at Montefiore Medical Center. Details for each study period: st Period: Day 1: Enrollment, baseline pre-LVP laboratory testing and measurements, and large volume paracentesis with administration of albumin Day 6: Laboratory testing and measurements nd Period: Day 1: pre-LVP baseline labs and measurements, LVP with FFP administration Day 6: Laboratory testing and measurements rd Period: Day 1: pre-LVP baseline labs and measurements, LVP with albumin administration Day 6: Laboratory testing and measurements

All participants who are scheduled for a LVP and meet the eligibility criteria will be monitored for 3 consecutive periods. At the second drainage participants will receive 2 units, or about 500 ccs, of fresh frozen plasma intravenously, plus 1 bottle, or 50 ccs, of 25% albumin if more than 4 liters of fluid are removed

All participants who are scheduled for a LVP and meet the eligibility criteria will be monitored for 3 consecutive periods. At the first and third drainage participants will receive 1 bottle, or 50 ccs, of 25% albumin intravenously for every two liters of fluid removed

Efficacy of LVP with FFP will be measured as the change of plasma renin activity (PRA) from Day 1 to Day 6 during the 2nd LVP with FFP. We hypothesize that FFP will reduce the PRA by 25% from Day 1 to Day 6.

We hypothesize that the PPCD incidence will reduce in the 2nd LVP with FFP in comparison to the 1st LVP with albumin.

We hypothesize that the overall adverse events (including PPCD incidence) will be reduced in the 2nd LVP with FFP in comparison to the 1st LVP with albumin. AE's will be summarized by presenting the number and percentages of patients having any AE.

Inclusion Criteria: Age 18 years or older Cirrhosis of the liver based on biopsy or clinical and radiographic criteria Ability to provide informed consent (Grade 0 to 1 HE) Grade 3 ascites or refractory ascites Ascites requiring frequent large volume paracentesis of at least 5 liters at least once a month No diuretic use INR > 1.7, <2.5 Exclusion Criteria: Inability to obtain informed consent Age less than 18 Hepatic Encephalopathy Grade > 1 as defined by the presence of an impaired mental status or the presence of asterixis Septic shock Active infection Respiratory failure Heart failure with reduced ejection fraction of ≤ 50% Moderate or severe pulmonary hypertension History of stroke Unstable coronary artery disease Chronic kidney disease (GFR <60) GI bleed within 2 weeks Any licorice within 2 weeks of starting the study Any Beta Blocker use within the last 2 weeks Any diuretic use within 2 weeks Absence of paracentesis within 2 weeks Absence of volume expanders within 2 weeks INR > 1.7 Pregnancy - pregnancy test will be administered for all female patients

Data collected during the study will only be shared with researchers that have been IRB approved as key-personnel on the study protocol.