Peritoneo-venous shunting in patients with cirrhotic ascites and end-stage renal failure

Peritoneal Dialysis for Patients with End-Stage Renal Disease and Liver Cirrhosis

End-stage renal disease patients with cirrhosis represent a therapeutic dilemma, with several difficulties associated with hemodialysis as a renal replacement therapy modality. Peritoneal dialysis is a feasible option for these patients, despite the confounders of associated infection risk, malnutrition, ascites management, and mechanical complications. This review covers the existing data on the outcomes and complications associated with the use of peritoneal dialysis in the cirrhotic patient.

Transjugular intrahepatic portosystemic shunts in hemodialysis-dependent patients and patients with advanced renal insufficiency: safety, caution, and encephalopathy

PURPOSE

To retrospectively determine the acute safety and chronic outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with hemodialysis-dependent end-stage renal disease for control of bleeding and refractory ascites.

MATERIALS AND METHODS

Four dialysis-dependent patients and one renal transplant recipient (glomerular filtration rate, 27 mL/min) underwent TIPS creation for treatment of refractory ascites (n = 3) and recurrent portal hypertensive bleeding (n = 1). A sixth patient developed unrelated renal failure 3 years after initial TIPS formation and presented with encephalopathy at that time. All had nearly normal liver function test results and no previous baseline encephalopathy. Three dialysis recipients underwent dialysis immediately after the TIPS procedure in an intensive care unit; one did not.

RESULTS

There were no complications of fluid overload or pulmonary edema after TIPS creation in the patients who immediately underwent dialysis. The one patient in whom dialysis was delayed developed respiratory failure and shock liver (ie, ischemic hepatitis). Ascites resolved in all three patients, and no recurrent variceal bleeding occurred during a mean follow-up of 17 months. Severe, grade 2-4 hepatic encephalopathy developed in all patients; in one patient, its onset was delayed until the onset of renal failure 3 years after the original TIPS procedure. Shunt reduction was required in four cases and competitive variceal embolization was required in one to reduce portosystemic diversion. No less than grade 1 episodic baseline encephalopathy was present in all patients despite continued use of the maximum prescribed medical therapy thereafter.

CONCLUSIONS

TIPS creation is effective in controlling ascites and bleeding in functionally anephric patients, but at the cost of marked and disproportionate hepatic encephalopathy. Prompt, acute postprocedural dialysis and fluid management is critical for safe creation of a TIPS in dialysis-dependent patients.

Direct Infusion of Ascites into the Blood Circuit during Hemodiafiltration in Uremic Patients with Cirrhosis

Two chronic dialysis patients with massive ascites caused by cirrhosis were treated by infusion of their ascites directly into the blood circuit. This stabilized their hemodynamics during dialysis, facilitating the control of weight gain and ascites, and thus markedly improving their general condition. Long-term use of this therapy was able to prevent the accumulation of ascitic fluid. Interestingly, fever occurred when this therapy was performed with hemodialysis, but not with hemofiltration or hemodiafiltration, suggesting that a pyrogen in the ascites was removed by filtration.

Management of ascites in cirrhosis

Ascites is one of the earliest and most common complications of patients with cirrhosis. A typical circulatory dysfunction characterized by arterial vasodilation, high cardiac output and stimulation of vasoactive systems is commonly present in these patients and is associated with a poor prognosis. The treatment of ascites has been based on the combination of a low-sodium diet and the administration of diuretics. The reintroduction of paracentesis and the recent introduction of the transjugular intrahepatic portosystemic shunt (TIPS) are the most relevant innovations in the treatment of ascites during the past two decades, although controlled trials in large series of patients are needed to delineate whether TIPS is a safe and useful treatment for these patients.

Hemodynamic effects of peritoneovenous shunts in hemodialysis patients with ascites

Ascites in hemodialysis patients has been reported in association with systemic diseases, such as cirrhosis or congestive heart failure, and as an idiopathic form. Regardless of the etiology, these patients often are refractory to treatment with intradialytic ultrafiltration because of recurrent hypotensive episodes. In this report we describe the hemodynamic effects of peritoneovenous shunts (PVSs) in three hemodialysis patients with ascites refractory to conventional treatment. One patient had idiopathic ascites and the other two had associated liver disease. Patients were monitored for lowest blood pressure, number of intradialytic hypotensive episodes, number of grams of albumin infused to treat hypotensive episodes, interdialytic weight gain, and hemodynamic stability (defined as the difference between the predialysis mean arterial pressure and the lowest intradialytic mean arterial pressure). In all three patients the hemodynamic parameters stabilized after PVS placement despite equal or greater ultrafiltration during dialysis (due to a significant increase in the lowest measured intradialytic blood pressure). The total number of hypotensive episodes decreased from 219 prior to PVS placement to zero after shunt placement. The need for albumin infusion during hemodialysis (for blood pressure support) decreased (significantly in two patients), as did the volume of ascites in all three patients. One patient required PVS replacement secondary to infection, which was the only complication. We believe that refractory ascites in end-stage renal disease patients can be successfully treated by placement of a PVS, which often results in relief of the ascites and significant improvement in intradialytic hemodynamic stability.

Peritoneal dialysis in end-stage renal disease patients with preexisting chronic liver disease and ascites

PURPOSE

Hemodialysis in patients with chronic liver disease and ascites may be complicated by intradialytic hypotension, limiting the amount of ultrafiltration and resulting in massive ascites. Successful maintenance peritoneal dialysis (PD) has not been previously reported as an alternative to hemodialysis in this population.

PATIENTS AND METHODS

Nine patients with chronic renal failure, chronic liver disease, and tense ascites prior to beginning PD are described. All chronic PD catheters were placed percutaneously by the nephrology staff. Seven patients were maintained primarily on continuous ambulatory peritoneal dialysis, whereas two were on intermittent peritoneal dialysis.

RESULTS

PD catheters were placed without serious hemorrhage or bowel injury. PD provided adequate clearance and volume maintenance for each patient. Fifteen episodes of peritonitis occurred in 18 patient-years of PD. All episodes of peritonitis were successfully treated with intraperitoneal antibiotics without catheter removal. Only one patient had a decline in the serum albumin level of 0.5 g/dL or more during the course of chronic PD. Three of the nine patients are still alive and on PD for durations of 18 to 24 months. One patient insidiously developed sclerosing peritonitis after 8 years on PD and is now on hemodialysis, and another patient switched to hemodialysis because she was no longer able to care for herself or to manage her PD. Four patients died while maintained on PD; three deaths were due to complications of liver failure within the first 4 months of PD and the fourth was due to empyema after 4 years of PD.

CONCLUSION

PD can be used successfully to treat chronic renal failure in patients with chronic liver disease and ascites when the liver disease itself is not rapidly fatal. PD may be better tolerated than hemodialysis and perhaps should be the renal replacement treatment of choice in these patients.