VA Report: Low SAAG ascites in cirrhosis!

The Pearl:
In patients with cirrhosis and a low pretest probability for non-portal hypertension-related ascites, a low SAAG has a poor predictive value.

Often, when the SAAG is repeated in these patients, it will return to a level >1.1!

In other words, many patients with cirrhosis and a low SAAG do not actually have a second reason besides portal hypertension for their ascites.  In a 2009 study of patients with cirrhosis and a low SAAG, Khandwalla et al. found that only a minority of these patients had a second cause (most commonly peritonitis or peritoneal carcinomatosis).

As such, the recommendation is to evaluate the other usual peritoneal fluid studies (e.g. cell count/diff, protein, cytology). If there is no clear secondary cause, it is reasonable to repeat the paracentesis – the aforementioned study found that on repeat testing, the SAAG often returned to the expected level >1.1!

NEJM Journal Watch

Khandwalla et al. The utility of evaluating low serum albumin gradient ascites in patients with cirrhosis. Am J Gastroenterol. 2009;104:1401-1405.

Evernote Link

 

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