• carcinomatous peritonitis
• cell‐free and concentrated ascites reinfusion therapy (CART)
• lung cancer

• Humans
• Female
• Aged
• Ascites/therapy
• Ascites/pathology
• Ascites/etiology
• Lung Neoplasms/pathology
• Lung Neoplasms/drug therapy
• Lung Neoplasms/therapy
• Lung Neoplasms/complications
• Carcinoma, Non-Small-Cell Lung/pathology
• Carcinoma, Non-Small-Cell Lung/therapy
• Carcinoma, Non-Small-Cell Lung/complications
• Carcinoma, Non-Small-Cell Lung/drug therapy
• Antineoplastic Combined Chemotherapy Protocols/therapeutic use

• CART
• filter obstruction
• polyether sulfone filter

• Humans
• Sulfones/chemistry
• Ascites/therapy
• Retrospective Studies
• Membranes, Artificial
• Male
• Female
• Filtration/instrumentation
• Middle Aged
• Polymers/chemistry
• Aged
• Equipment Design

• Automated low-flow ascites pump
• Cell-free and concentrated ascites reinfusion therapy
• Large-volume paracentesis
• Liver cirrhosis ascites
• Peritoneal catheter drainage
• Peritoneovenous shunt
• Transjugular intrahepatic portosystemic shunt

• Ascites
• CART
• Fever

• Humans
• Ascites/therapy
• Ascites/etiology
• Female
• Retrospective Studies
• Male
• Middle Aged
• Aged
• Ascitic Fluid
• Fever/etiology
• Fever/therapy
• Adult
• Cell-Free System
• Aged, 80 and over

• Ascites filtration membrane washing method
• Cell-free and concentrated ascites reinfusion therapy (CART)
• Processing time
• Protein recovery rate

• drop-type CART
• external pressure
• leak test
• pressure loading
• pressure monitoring

• Humans
• Ascites/diagnosis
• Ascites/etiology
• Ascites/therapy
• Reproducibility of Results

• cardiac involvement
• cell‐free and concentrated ascites reinfusion therapy (CART)
• hematopoietic stem cell transplantation (HSCT)
• immunoglobulin light chain (AL) amyloidosis

• Refractory ascites
• cell-free and concentrated ascites reinfusion therapy
• cirrhosis
• coagulation
• fibrinolytic

• Humans
• Ascites/therapy
• Ascites/metabolism
• Ascites/pathology
• Retrospective Studies
• Japan
• Ascitic Fluid/metabolism
• Liver Cirrhosis/complications
• Liver Cirrhosis/therapy
• Liver Cirrhosis/metabolism

• Adult congenital heart disease
• Advanced heart failure
• Cardiac ascites
• Case report
• Cell-free and concentrated ascites reinfusion therapy

A 60-year-old woman with POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) syndrome and intractable ascites presented with acute renal failure and received hemodialysis (HD) therapy. Due to frequent intradialytic hypotension, ultrafiltration with cell-free and concentrated ascites reinfusion therapy (CART) was performed to adequately manage the body fluid status and massive ascites. During HD with CART, her blood pressure was maintained compared with that during HD without CART, and an ultrafiltration volume of 3.7 L was achieved after HD with CART. In HD patients with intradialytic hypotension and massive ascites, the combination of CART and ultrafiltration during HD may be an effective therapeutic option for body-fluid management.

• cell-free concentrated ascites reinfusion therapy
• membranoproliferative glomerulonephritis
• proliferative glomerulonephritis with monoclonal immunoglobulin G deposits
• rituximab

• Antibodies, Monoclonal/therapeutic use
• Ascites/complications
• Ascites/drug therapy
• Female
• Glomerulonephritis/complications
• Glomerulonephritis/drug therapy
• Glomerulonephritis, Membranoproliferative/drug therapy
• Humans
• Immunoglobulin G/therapeutic use
• Middle Aged
• Nephrotic Syndrome/complications
• Nephrotic Syndrome/drug therapy
• Rituximab/therapeutic use

Cell-free and concentrated ascites reinfusion therapy (CART) is a strategy for improving various intractable symptoms due to refractory ascites, including hypoalbuminemia. CART has recently been applied in the treatment of cancer patients. This study was performed to assess the safety of CART in a single cancer institute.

We retrospectively reviewed 233 CART procedures that were performed for 132 cancer patients in our institute.

The median weight of ascites before and after concentration was 4,720 g and 490 g (median concentration rate, 10.0-fold), The median amounts of total protein and albumin were 64.0 g and 32.6 g (median recovery rates, 44.9% and 49.0%), respectively. Thirty-three adverse events (AEs) were observed in 22 (9.4%) of 233 procedures; 30 of these events occurred after reinfusion. The most common reinfusion-related AEs were fever (13 events) and chills (10 events). Univariate analyses revealed no significant relationships between the frequency of AEs and age, sex, appearance of ascites, weight of harvested and concentrated ascites, the ascites processing rate (filtration and concentration), weight of saline used for membrane cleaning, amount of calculated total protein for infusion, or prophylaxis against AEs; the reinfusion rate of ≥ 125 mL/h or ≥ 10.9 g/h of total protein affected the frequency of AEs, regardless of the prophylactic use of steroids.

The observed AEs were mainly mild reactions after reinfusion, which were related to a reinfusion rate of volume ≥ 125 mL/h, a simple indicator in practice, or total protein ≥ 10.9 g/h. Although our study was retrospective in nature and undertaken in a single institute, this information may be helpful for the management of cancer patients with refractory malignant ascites using CART.

The online version contains supplementary material available at 10.1186/s12885-022-09298-6.

• Adverse effects (AEs)
• Cell-free and concentrated ascites reinfusion therapy (CART)
• Fever
• Malignant ascites
• Reinfusion rate

Malignant ascites often causes discomfort in advanced cancer patients. Paracentesis is the most common treatment modality, but it requires frequently repeated treatment. Cell-free and concentrated ascites reinfusion therapy (CART) may prolong the paracentesis interval, but controlled trials are lacking. We assessed the feasibility of a randomized controlled trial of CART vs. paracentesis alone for patients with refractory malignant ascites.

This study was an open-label, fast-track, randomized controlled, feasibility trial. Patients admitted to four designated cancer hospitals who received no further anticancer treatments were eligible. Patients were randomly assigned 1:1 to a CART arm or control (simple paracentesis) arm. The feasibility endpoint was the percentage of patients who completed the study intervention. Secondary endpoints included paracentesis-free survival, patient’s request on the questionnaire for paracentesis (PRO-paracentesis)-free survival (the period until the patients first reported that they would want paracentesis if indicated), and adverse events.

We screened 953 patients for eligibility. Of 61 patients with refractory malignant ascites, 21 patients were determined as eligible. Finally, 20 patients consented and were allocated; 18 patients (90%, 95% CI: 68.3–98.8) completed the study intervention. All patients had an ECOG performance status of 3 or 4. The median drained ascites volume was 3,200 mL in the CART arm and 2,500 mL in the control arm. In the CART arm, the median reinfused albumin volume was 12.6 g. Median paracentesis-free survivals were 5 days (95% CI: 2–6) in the CART arm, and 6 days (3–9) in the control arm. Median PRO-paracentesis-free survivals were 4 days (2–5) and 5 days (1–9), respectively. A total of 73% of patients received paracentesis within 2 days from their first request for the next paracentesis. One patient in the CART arm developed Grade 1 fever.

A fast-track randomized controlled trial of CART for patients with malignant ascites is feasible. The efficacy and safety of CART should be assessed in future trials. PRO-paracentesis-free survival may be a complementary outcome measure with paracentesis-free survival in future trials.

Registered at University Hospital Medical Information Network Clinical Trial Registry as UMIN000031029. Registered on 28/01/2018.

The online version contains supplementary material available at 10.1186/s12885-022-09336-3.

• Cell-free and concentrated ascites reinfusion therapy
• Malignant ascites
• Paracentesis

• Gastric adenocarcinoma
• intraperitoneal therapy
• peritoneal dissemination

• ascites
• cell-free and concentrated ascites reinfusion therapy (CART)
• cirrhosis
• malignancy

• ascites
• cancer
• filtration
• membranes
• scanning electron microscopy

Cell-free and concentrated ascites reinfusion therapy (CART) was a safe and effective palliative therapy in malignancy-related ascites. Abdominal distension, dyspnea, and fatigue were alleviated significantly after CART. The mean time to the next paracentesis was 20.7 days. In total, 17% of patients had improved performance status after CART.

Background: Malignancy-related ascites (MRA) is one of the symptoms causing discomfort in advanced cancer patients. Cell-free and concentrated ascites reinfusion therapy (CART) is one of the palliative treatments widely conducted in Japan only. Methods: A systematic review following a meta-analysis of CART was performed. The efficiency and adverse events were evaluated. Results: A total of 2567 patients and 6013 procedures of CART were identified in this study. The mean volume of MRA collected was 4.29 (95% confidence interval (CI) 3.47–5.11) L, and the volume reinfused after concentrating was 0.49 (95% CI 0.39–0.60) L. A total of 86.1 (95% CI 77.1–95.2) g protein and 42.9 (95% CI 36.0–50.0) g albumin was reinfused. The mean time to the next paracentesis was 20.7 (95% CI 15.6–25.8) days. The body weight was reduced by 3.38 (95% CI 1.90–4.86; p < 0.01) kg, and abdominal circumference was reduced by 7.86 (95% CI 6.58–9.14; p < 0.001) cm. Serum albumin increased an average of 0.14 (95% CI −0.01–0.28; p = 0.07) mg/dL the day after CART. Abdominal distension, dyspnea, and fatigue were alleviated by 6.0 (95% CI 5.59–6.51), 2.66 (95% CI 2.05–3.28), and 2.64 (95% CI 1.86–3.42) points using a numerical rating scale system ranging from 0 to 10. Overall, 17% (95% CI 0.03–0.31%) of patients had improved performance status after CART. Significant body temperature elevation was observed, at an average of 0.4 °C (95% CI 0.18–0.62 °C). Conclusions: CART might be a safe and effective palliative therapy in MRA and further clinical trials are necessary.

• cell-free and concentrated ascites reinfusion therapy
• chemotherapy
• malignant-related ascites

Cell‐free and concentrated ascites reinfusion therapy (CART) is performed by collecting the ascites from the patient, followed by filtration and concentration. Thereafter, concentrated cell‐free ascites is reinfused into the patient intravenously. The new type of machine, Plasauto μ, for managing the process of CART was launched onto the market. We have evaluated the machine through postmarketing clinical study in 17 patients with malignant ascites. The amounts of original and concentrated ascites were 3673 ± 1920 g and 439 ± 228 g, respectively. Recovery rates were acceptable regarding values of total protein, albumin, and IgG that were 55.6% ± 17.3%, 60.2% ± 20.8%, and 58.2% ± 20.5%, respectively. Recovery rates were positively associated with amounts of original ascites and negatively associated with total protein concentration. No adverse events related to the machine were observed. The new type of machine showed preferable performance in processing malignant ascites.

• a new type of machine
• ascites
• cell-free and concentrated ascites reinfusion therapy
• post-marketing clinical study
• recovery rate

• Acute-on-chronic liver failure
• Albumin
• Cirrhosis
• Hepatic encephalopathy
• Hepatorenal syndrome
• Large-volume paracentesis
• Spontaneous bacterial peritonitis

• Ascites
• Cell-free and concentrated ascites reinfusion therapy (CART)
• Color Doppler ultrasonography
• Congestion
• Inferior vena cava (IVC)
• Liver cirrhosis

• Ascites
• Cell-free and concentrated ascites reinfusion therapy
• Gynecological malignancy

The symptoms of drug-induced hepatic injury are manifold; however, the presence of ascites indicates a severe disease condition. The rapid accumulation of ascites is distressing and requires palliative treatment. Because many cases are addressed by repeated large-volume paracentesis, often resulting in impairment due to protein and electrolyte loss, a different approach is required.

A 61-year-old Japanese man on maintenance dialysis was admitted to our hospital with acute liver injury. Our patient was diagnosed as having drug-induced liver injury due to warfarin or diltiazem, which started immediately after coronary artery bypass grafting 7 months previously. One month after admission, our patient’s hepatic encephalopathy remained grade 1 and his prothrombin time international normalized ratio was maintained at < 1.5. However, the liver was markedly atrophied with massive ascites. Although liver transplantation was desired, he was considered unfit for transplantation because of his renal and cardiac complications. Therefore, we devised a strategy to manage the massive ascites with cell-free concentrated ascites reinfusion therapy while awaiting liver regeneration. At first, cell-free concentrated ascites reinfusion therapy was required frequently because ascites accumulated rapidly. But the fluid retention interval was gradually extended as intended, and cell-free concentrated ascites reinfusion therapy was withdrawn after 8 months. During that time, the size of his liver increased from 1419 cm³ to 1587 cm³ on computed tomography.

Cell-free concentrated ascites reinfusion therapy is an apheresis therapy in which ascites are collected aseptically by paracentesis, concentrated, and then reinfused intravenously. This treatment has the advantage of preserving nutrition by reusing the fluid. Previously, cell-free concentrated ascites reinfusion therapy was used only for the management of ascites in patients with cirrhosis or carcinomatous peritonitis. This case suggests that palliation and maintenance of nutritional status with cell-free concentrated ascites reinfusion therapy may be useful as an adjunct to liver regeneration in drug-induced hepatic injury.

• cell-free concentrated ascites reinfusion therapy
• diltiazem
• drug-induced liver injury
• warfarin

• Gastric adenocarcinoma
• malignant gastric outlet obstruction
• palliative care
• palliative gastrectomy
• palliative radiotherapy

• albumin
• ascites
• carcinoma
• immunoglobulin
• liver cirrhosis

• cell-free and concentrated ascites reinfusion therapy
• hexadecyl ligand adsorbent
• inflammatory cytokine
• serum amyloid A expression

Cell‐free and concentrated ascites reinfusion therapy (CART) is an effective therapy for refractory ascites. However, CART is difficult to perform as ascites filtration and concentration is a complicated procedure. Moreover, the procedure requires the constant assistance of a clinical engineer or/and the use of an expensive equipment for the multi‐purpose blood processing. Therefore, we developed a CART specialized equipment (mobility CART [M‐CART]) that could be used safely with various safety measures and automatic functions such as automatic washing of clogged filtration filter and self‐regulation of the concentration ratio. Downsizing, lightning of the weight, and automatic processing in M‐CART required the use of newly developed multi‐ring‐type roller pump units. This equipment was approved under Japanese regulations in 2018. In performing 41 sessions of CART (for malignant ascites, 22 sessions; and hepatic ascites, 19 sessions) using this equipment in 17 patients, no serious adverse event occurred. An average of 4494 g of ascites was collected and the total amount of ascites was processed in all the sessions without any trouble. The mean weight of the processed ascites was 560 g and the mean concentration ratio was 8.0. The ascites were processed at a flow rate of 50 mL/min. The mean ascites processing time was 112.5 minutes and a 106.5‐minutes (95.2%) ascites processing was performed automatically. The operator responded to alarms or support information 3.2 times on average (3.1 minutes, 2.1% of ascites processing time). Human errors related to ascites processing were detected by M‐CART at 0.4 times per session on average and were appropriately addressed by the operator. The frequencies of automatic washing of clogged filtration filter and self‐regulation of the concentration ratio were 31.7% and 53.7%, respectively. The mean recovery rates (recovery dose) of protein, albumin, and immunoglobulin G were 72.9%, 72.9%, and 71.2% (65.9 g, 34.9 g, and 13.2 g), respectively. Steroids were administered in 92.7% of the sessions to prevent fever and the mean increase in body temperature was 0.53°C. M‐CART is a compact and lightweight automatic CART specialized equipment that can safely and easily process a large quantity of ascites without the constant assistance of an operator.

• automatic ascites processing
• cell-free and concentrated ascites reinfusion therapy
• refractory ascites

• cell-free and concentrated ascites reinfusion therapy
• liver cirrhosis
• refractory ascites
• tolvaptan

• Aged
• Aged, 80 and over
• Antidiuretic Hormone Receptor Antagonists/therapeutic use
• Ascites/blood
• Ascites/etiology
• Ascites/therapy
• Ascitic Fluid
• Diuretics/therapeutic use
• Female
• Fluid Therapy/methods
• Furosemide/therapeutic use
• Humans
• Liver Cirrhosis/complications
• Male
• Middle Aged
• Product Surveillance, Postmarketing
• Serum Albumin
• Spironolactone/therapeutic use
• Tolvaptan/therapeutic use

• Diuretics
• Liver crirrhosis
• Paracentesis
• Refractory ascites
• Treatment

• Adult
• Aged
• Ascites/complications
• Ascites/surgery
• Female
• Humans
• Liver Cirrhosis/complications
• Liver Cirrhosis/surgery
• Liver Transplantation
• Living Donors
• Male
• Middle Aged
• Paracentesis/methods
• Prospective Studies

Cell-free and concentrated ascites reinfusion therapy (CART) is frequently used to treat refractory ascites in Japan. However, its efficacy remains unclear. This controlled cohort study verified the serum albumin elevating effect of CART by comparisons with simple paracentesis. Ascites patients receiving CART (N = 88) or paracentesis (N = 108) at our hospital were assessed for the primary outcome of change in serum albumin level within 3 days before and after treatment. A significantly larger volume of ascites was drained in the CART group. The change in serum albumin level was +0.08 ± 0.25 g/dL in the CART group and −0.10 ± 0.30 g/dL in the paracentesis group (P < 0.001). The CART – paracentesis difference was +0.26 g/dL (95%CI +0.18 to +0.33, P < 0.001) after adjusting for potential confounders by multivariate analysis. The adjusted difference increased with drainage volume. In the CART group, serum total protein, dietary intake, and urine volume were significantly increased, while hemoglobin and body weight was significantly decreased, versus paracentesis. More frequent adverse events, particularly fever, were recorded for CART, although the period until re-drainage was significantly longer. This study is the first demonstrating that CART can significantly increase serum albumin level as compared with simple paracentesis. CART represents a useful strategy to manage patients requiring ascites drainage.

• Adult
• Aged
• Ascites/epidemiology
• Ascites/etiology
• Female
• Graft Survival
• Humans
• Incidence
• Liver Transplantation/adverse effects
• Liver Transplantation/mortality
• Living Donors
• Male
• Middle Aged
• Multivariate Analysis
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Retrospective Studies
• Risk Factors
• Severity of Illness Index

• Ascites
• Cell-free and concentrated ascites reinfusion therapy
• Human mercaptalbumin
• Human non-mercaptalbumin
• L-cysteine

• Ascites
• Cancer
• Filtration
• Proteins
• Therapy

• Cirrhosis
• TIPS
• inflammation
• liver transplantation
• refractory ascites
• sodium retention

• Advanced ovarian cancer
• Ascites tumor cells
• Body temperature
• Cell-free and concentrated ascites reinfusion therapy

• TAFRO syndrome
• ascites
• corticosteroid
• hemodialysis
• rituximab
• thrombocytopenia

• Ascites/drug therapy
• Drug Therapy, Combination
• Edema/diagnosis
• Edema/drug therapy
• Female
• Fever/diagnosis
• Glucocorticoids/therapeutic use
• Humans
• Immunologic Factors/therapeutic use
• Lymphadenopathy/diagnosis
• Lymphadenopathy/drug therapy
• Middle Aged
• Primary Myelofibrosis/diagnosis
• Primary Myelofibrosis/drug therapy
• Remission Induction
• Renal Dialysis
• Renal Insufficiency/diagnosis
• Renal Insufficiency/therapy
• Rituximab/therapeutic use
• Syndrome
• Thrombocytopenia/diagnosis
• Thrombocytopenia/drug therapy
• Withholding Treatment