Correlation between serum markers and transjugular intrahepatic portosystemic shunt prognosis in patients with cirrhotic ascites

BACKGROUND

Individuals with refractory ascites in the context of liver cirrhosis typically face an adverse prognosis. The transjugular intrahepatic portosystemic shunt (TIPS) is an efficacious intervention, but there is a lack of reliable tools for postoperative prognosis assessment. Previously utilized clinical biochemical markers, such as the serum albumin concentration (Alb), sodium (Na+) concentration, and serum creatinine (Scr), have limited predictive value. Therefore, the quest for novel, specific biomarkers to evaluate the post-TIPS prognosis in patients with liver cirrhosis and refractory ascites holds significant practical importance.

AIM

To investigate the associations between the Child-Pugh score, model for end-stage liver disease (MELD) score, and serum cystatin C (Cys C) level and post-TIPS prognosis in patients with liver cirrhosis and refractory ascites.

METHODS

A retrospective analysis was conducted on 75 patients with liver cirrhosis and refractory ascites who underwent TIPS at our institution from August 2019 to August 2021. These patients were followed up regularly for two years, and the death toll was meticulously documented. The patients were allocated into a survival group (n = 45 patients) or a deceased group (n = 30 patients) based on their prognosis status. The clinical data of the two groups were collected, and Child-Pugh scores and MELD scores were calculated for analysis. Spearman correlation analysis was carried out to evaluate the correlation of prognosis with Child-Pugh grade, MELD score, and Cys C level. Additionally, a multiple-factor analysis utilizing the Cox proportional hazard model was used to identify independent risk factors affecting the post-TIPS prognosis of patients with liver cirrhosis and refractory ascites. The receiver operating characteristic curve (ROC) ascertained the predictive value of the Cys C concentration, Child-Pugh grade, and MELD score for the prognosis of liver cirrhosis with refractory ascites in post-TIPS patients.

RESULTS

During a 2-year follow-up period, among 75 patients with liver cirrhosis and refractory ascites who underwent TIPS treatment, 30 patients (40.00%) passed away. The deceased cohort exhibited heightened aspartate aminotransferase, alanine aminotransferase, total bilirubin, Scr, prothrombin time, Cys C, international normalized ratio, Child-Pugh, and MELD scores compared to those of the survival cohort, while Alb and Na+ levels were attenuated in the deceased group (P < 0.05). Spearman analysis revealed moderate to high positive correlations between prognosis and Child-Pugh score, MELD score, and Cys C level (r = 0.709, 0.749, 0.671, P < 0.05). Multivariate analysis using the Cox proportional hazard model demonstrated that the independent risk factors for post-TIPS prognosis in patients with liver cirrhosis and refractory ascites were Cys C (HR = 3.802; 95%CI: 1.313-11.015), Child-Pugh (HR = 3.030; 95%CI: 1.858-4.943), and MELD (HR = 1.222; 95%CI: 1.073-1.393) scores. ROC analysis confirmed that, compared to those of the classic prognostic models for Child-Pugh and MELD scores, the predictive accuracy of Cys C for post-TIPS prognosis in patients with liver cirrhosis and refractory ascites was slightly lower. This analysis yielded sensitivity and specificity values of 83.33% and 82.22%, respectively. The area under the curve value at this juncture was 0.883, with an optimal cutoff value set at 1.95 mg/L.

CONCLUSION

Monitoring the serum Cys C concentration is valuable for assessing the post-TIPS prognosis in patients with liver cirrhosis and refractory ascites. Predictive models based on serum Cys C levels, as opposed to Scr levels, are more beneficial for evaluating the condition and prognosis of patients with ascites due to cirrhosis.

Lymphatic drainage dysfunction via narrowing of the lumen of cisterna chyli and thoracic duct after luminal dilation

BACKGROUND

The chronological pattern of extrahepatic lymphatic vessel progression in the course of chronic liver disease has not been clarified. This study aimed to clarify the chronological changes in lymphatic vessels with liver disease progression.

METHODS

This was a prospective cross-sectional study that enrolled a total of 199 patients. The maximum diameter of the cisterna chyli (CC) or terminal thoracic duct (tTD) was measured using computed tomography or ultrasonography, respectively. Changes in the maximum diameters of the CC and tTD were evaluated with patients with chronic liver disease as the pilot set (n = 138). Subsequently, we examined whether CC/tTD could be used to re-allocate unclassified patients by the Baveno-VII criteria to appropriately diagnose clinically significant portal hypertension (CSPH) in the pilot and validation sets.

RESULTS

In the pilot set, a scatter-plot showed that both CC and tTD were narrowed as terminal features in chronic liver disease after dilation. Because there was a significant correlation between the CC diameter and hepatic venous pressure gradient (r = 0.724) in unclassified patients, the diagnostic value of CC and tTD for CSPH was good (AUC: 0.961 and 0.913, respectively). After re-allocation, 68 and 27 unclassified patients were reduced to 4 and 5 in the pilot and validation sets, respectively.

CONCLUSION

Both the CC and tTD narrow in the course of liver disease after dilation. Moreover, the maximum diameter of the CC and tTD can be used to re-allocate patients who are unclassified according to the Baveno-VII criteria.

CLINICAL TRIAL NUMBER

UMIN trial no. 000044857.

Prevalence and risk factors of lymphatic dysfunction in cirrhosis patients with refractory ascites: An often unconsidered mechanism

BACKGROUND

The lymphatic system is crucial in maintaining the body fluid homeostasis. A dysfunctional lymphatic system may contribute to the refractoriness of ascites and edema in cirrhosis patients. Therefore, assessment of lymphatic dysfunction in cirrhosis patients with refractory ascites (RA) can be crucial as it would call for using different strategies for fluid mobilization.

AIM

To assessing the magnitude, spectrum, and clinical associations of lymphatic dysfunction in liver cirrhosis patients with RA.

METHODS

This observational study included 155 consecutive cirrhosis patients with RA. The presence of clinical signs of lymphedema, such as peau d'orange appearance and positive Stemmer sign, intestinal lymphangiectasia (IL) on duodenal biopsy seen as dilated vessels in the lamina propria with strong D2-40 immunohistochemistry, and chylous ascites were used to diagnose the overt lymphatic dysfunctions.

RESULTS

A total of 69 (44.5%) patients out of 155 had evidence of lymphatic dysfunction. Peripheral lymphedema, found in 52 (33.5%) patients, was the most common manifestation, followed by IL in 42 (27.0%) patients, and chylous ascites in 2 (1.9%) patients. Compared to patients without lymphedema, those with lymphedema had higher mean age, median model for end-stage liver disease scores, mean body mass index, mean ascitic fluid triglyceride levels, and proportion of patients with hypoproteinemia (serum total protein < 5 g/dL) and lymphocytopenia (< 15% of total leukocyte count). Patients with IL also had a higher prevalence of lymphocytopenia and hypoproteinemia (28.6% vs. 9.1%, P = 0.004). Seven (13%) patients with lymphedema had lower limb cellulitis compared to none in those without it. On multivariate regression analysis, factors independently associated with lymphatic dysfunction included obesity [odds ratio (OR): 4.2, 95% confidence intervals (95%CI): 1.1-15.2, P = 0.027], lymphocytopenia [OR: 6.2, 95%CI: 2.9-13.2, P < 0.001], and hypoproteinemia [OR: 3.7, 95%CI: 1.5-8.82, P = 0.003].

CONCLUSION

Lymphatic dysfunction is common in cirrhosis patients with RA. Significant indicators of its presence include hypoproteinemia and lymphocytopenia, which are likely due to the loss of lymphatic fluid from the circulation. Future efforts to mobilize fluid in these patients should focus on methods to improve lymphatic drainage.

Effect of different infusion approaches on safety and efficacy of terlipressin: Current controversies

Terlipressin, a synthetic analog of vasopressin, has been widely used to treat acute variceal bleeding, hepatorenal syndrome, and other complications of cirrhosis. However, among different infusion approaches of terlipressin, its safety and efficacy are also heterogeneous. Previous studies have demonstrated that continuous infusion of terlipressin is more effective with a lower incidence of adverse events than intermittent intravenous infusion. This paper aims to review the relevant literature and summarize the data regarding the safety and effectiveness of different infusion approaches of terlipressin to guide clinical practice.

Partial vasopressin 1a receptor agonism reduces portal hypertension and hyperaldosteronism and induces a powerful diuretic and natriuretic effect in rats with cirrhosis and ascites

The vasopressin system has emerged as a therapeutic focus for lowering portal hypertension and reducing splanchnic vasodilation in patients with refractory ascites. Clinically available vasopressin agonists are limited by preferential selectivity for V1 receptors that also have steep concentration-response curves with potential risks of excess vasoconstriction and/or complete antidiuretic effects. OCE-205 is a novel, selective, partial V1a receptor agonist with mixed agonist/antagonist activity and no V2 receptor activation at therapeutic doses. We carried out two studies assessing the in vivo effects of OCE-205 in different rat models of cirrhosis and ascites. In a carbon tetrachloride rat cirrhosis model, OCE-205 administration produced a marked reduction in portal hypertension and hyperaldosteronism, along with robust diuretic and natriuretic effects. These effects were accompanied by marked decreases in ascites volume, with three of five animals experiencing total mobilization of ascites. There was no evidence of fluid overload or sodium or water retention, confirming OCE-205's lack of V2 receptor activity. In a second, corroborative study using a bile duct ligation rat model of ascites, OCE-205 produced significant decreases in ascites volume and body weight and a significant increase in urine volume versus vehicle. Urine sodium excretion increased significantly after the first administration of OCE-205 relative to vehicle; however, repeat administration over 5 days did not lead to hyponatremia. Thus, in separate in vivo models, the mixed agonist/antagonist OCE-205 demonstrated relevant and expected endpoint findings consistent with its known mechanism of action and in vitro pharmacology without apparent unwanted effects or nonspecific toxicities.

Changes in Coagulation and Fibrinolytic Factors in Patients With Cirrhotic Refractory Ascites Undergoing Cell-free and Concentrated Ascites Reinfusion Therapy: A Retrospective Observational Study in Japan

BACKGROUND/AIM

The management of refractory ascites is critical for the treatment of patients with decompensated cirrhosis. This study aimed to evaluate the feasibility and safety of cell-free and concentrated ascites reinfusion therapy (CART) in patients with cirrhosis and refractory ascites, with a focus on changes in coagulation and fibrinolytic factors in ascitic fluid following CART.

PATIENTS AND METHODS

This was a retrospective cohort study including 23 patients with refractory ascites undergoing CART. Serum endotoxin activity (EA) before and after CART and the levels of coagulation and fibrinolytic factors and proinflammatory cytokines in original and processed ascitic fluid were measured. The Ascites Symptom Inventory-7 (ASI-7) scale was used for subjective symptom assessment before and after CART.

RESULTS

Body weight and waist circumference significantly decreased after CART, whereas serum EA did not significantly change after CART. Similar to the previous reports, ascitic fluid concentrations of total protein, albumin, high-density lipoprotein cholesterol, γ-globulin, and immunoglobulin G levels were significantly increased after CART; mild elevations in body temperature and interleukin 6 and tumor necrosis factor-alpha levels in ascitic fluid were also observed. Importantly, the levels of antithrombin-III, factor VII, and X, which are useful for patients with decompensated cirrhosis, were markedly increased in the reinfused fluid during CART. Finally, the total ASI-7 score was significantly lower following CART, compared with the pre-CART score.

CONCLUSION

CART is an effective and safe approach for the treatment of refractory ascites that allows the intravenous reinfusion of coagulation and fibrinolytic factors in the filtered and concentrated ascites.

Reduction of portosystemic gradient during transjugular intrahepatic portosystemic shunt achieves good outcome and reduces complications

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is placed important role in the therapy of complications of portal hypertension, there is still no suitable criterion for a reduction in portosystemic gradient (PSG), which can both reduce PSG and maximize clinical results and minimize hepatic encephalopathy (HE).

AIM

To compare the clinical outcomes and incidence of HE after one-third PSG reduction during TIPS in patients with variceal bleeding and refractory ascites.

METHODS

A total of 1280 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2016 to January 2019 were analyzed retrospectively. Patients were divided into group A (variceal hemorrhage and PSG reduced by one third, n = 479); group B (variceal hemorrhage and PSG reduced to < 12 mmHg, n = 412); group C (refractory ascites and PSG reduced by one third, n = 217); and group D (refractory ascites and PSG reduced to < 12 mmHg of PSG, plus medication, n = 172). The clinical outcomes were analyzed.

RESULTS

By the endpoint of follow-up, recurrent bleeding was no different between groups A and B (χ² = 7.062, P = 0.374), but recurrent ascites did differ significantly between groups C and D (χ² = 14.493, P = 0.006). The probability of total hepatic impairment within 3 years was significantly different between groups A and B (χ² = 11.352, P = 0.005) and groups C and D (χ² = 13.758, P = 0.002). The total incidence of HE differed significantly between groups A and B (χ² = 7.932, P = 0.016), groups C and D (χ² = 13.637, P = 0.007). There were no differences of survival rate between groups A and B (χ² = 3.376, P = 0.369, log-rank test), but did differ significantly between groups C and D (χ² = 13.582, P = 0.014, log-rank test).

CONCLUSION

The PSG reduction by one third may reduce the risk of HE, hepatic function damage and achieve good clinical results.

Hepatic sinusoidal obstruction syndrome induced by tacrolimus following liver transplantation: Three case reports

BACKGROUND

Hepatic sinusoidal obstruction syndrome (HSOS) is a rare complication in solid organ transplant recipients, especially in liver transplantation recipients. However, the consequences of HSOS occurrence are pernicious, which could result in severe liver or renal failure, and even death. In addition to previously reported azathioprine and acute rejection, tacrolimus is also considered as one predisposing factor to induce HSOS after liver transplantation, although the underlying mechanism remains unclear.

CASE SUMMARY

In this study, we reported three cases of tacrolimus-related HSOS after liver transplantation. The diagnosis of HSOS was firstly based on the typical symptoms including ascites, painful hepatomegaly and jaundice. Furthermore, the features of patchy enhancement on portal vein and delayed phase of abdominal enhanced computed tomography were suspected of HSOS and ultimately confirmed by liver biopsy and histological examination in two patients. A significant decrease in ascites and remission of clinical symptoms of abdominal distention and pain were observed after withdrawal of tacrolimus.

CONCLUSION

Tacrolimus-induced HSOS is a scarce but severe complication after liver transplantation. It lacks specific symptoms and diagnostic criteria. Timely diagnosis of HSOS is based on clinical symptoms, radiological and histological examinations. Discontinuation of tacrolimus is the only effective treatment. Transplantation physicians should be aware of this rare complication potentially induced by tacrolimus.

Transjugular Intrahepatic Portosystemic Shunt Outcomes in the Elderly Population: A Systematic Review and Meta-Analysis

Background

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure typically utilized to treat refractory ascites and variceal bleeding. However, TIPS can lead to significant complications, most commonly hepatic encephalopathy (HE). Advanced age has been described as a risk factor for HE, as the elderly population tends to have decreased cognitive reserve and increased sarcopenia. We conducted a systematic review and meta-analysis of the available literature to summarize the association between advanced age and risk of adverse events after undergoing TIPS.

Methods

A comprehensive search strategy to identify reports of specific outcomes (HE, 30-day and 90-day mortality, and 30-day readmission due to HE) in elderly patients after undergoing TIPS was developed in Embase (Embase.com, Elsevier). We compared outcomes and performed separate data analyses for patients aged < 70 vs. > 70 years and patients aged < 65 vs. > 65 years.

Results

Six studies with a total of 1,591 patients met our inclusion criteria and were included in the final meta-analysis. Three studies divided patients by age < 65 vs. > 65 years, with a total of 816 patients who were 54% male. The remaining three studies divided patients by age < 70 vs. > 70 years, with a total of 775 patients who were 63% male. Results demonstrated a significantly lower risk of post-TIPS HE (risk ratio (RR): 0.42, confidence interval (CI): 0.185 - 0.953, P = 0.03, I² = 49%), 30-day mortality (RR: 0.37, CI: 0.188 - 0.74, P = 0.005, I² = 0%), and 90-day mortality (RR: 0.35, CI: 0.24 - 0.49, P = 0.001, I² = 0%) in patients aged > 70 vs. < 70 years, as well as a trend towards lower risk of 30-day readmission due to HE. There was no significant difference in post-TIPS HE, 30-day or 90-day mortality, or 30-day readmission due to HE between patients aged < 65 vs. > 65 years.

Conclusion

Age > 70 years is associated with significantly higher rates of HE and 30-day and 90-day mortality rates in patients after undergoing TIPS, as well as a trend towards higher 30-day readmission due to HE.

Efficacy and safety of heparin plus dexamethasone after partial splenic embolization for liver cirrhosis with massive splenomegaly

PURPOSE

The aim of this study was to investigate the efficacy and safety of the combination of low-molecular-weight heparin + dexamethasone after partial splenic embolization in cirrhotic patients with massive splenomegaly.

METHODS

This study included 116 patients with liver cirrhosis complicated with massive splenomegaly who underwent PSE in Union Hospital from January 2016 to December 2019, and they met the criteria. They were divided into two groups: PSE + Hep + Dex group (N = 54) and PSE group (N = 62). We conducted a retrospective study to analyze the efficacy and safety of the two groups of patients.

RESULTS

The volume of splenic embolization was 622.34 ± 157.06 cm³ in the PSE + Hep + DEX group and 587.62 ± 175.33 cm³ in the PSE group (P = 0.306). There was no statistically difference in the embolization rate of the spleen between the two groups (P = 0.573). WBC peaked 1 week after PSE and PLT peaked 1 month after PSE in both groups; it gradually decreased later, but was significantly higher than the preoperative level during the 12-month follow-up period. The incidences of abdominal pain (46.3% vs 66.1%, P = 0.039), fever (38.9% vs 75.8%, P < 0.001), PVT (1.9% vs 12.9%, P = 0.026), refractory ascites (5.6% vs 19.4%, P = 0.027) were lower in the PSE + Hep + DEX group than in the PSE group. The VAS score of abdominal pain in PSE group was higher than that in PSE + Hep + DEX group on postoperative days 2-8 (P < 0.05). Splenic abscess occurred in 1(1.6%) patient in the PSE group and none (0.0%) in the PSE + Hep + DEX group (P = 0.349).

CONCLUSIONS

The combined use of dexamethasone and low-molecular-weight heparin after PSE is a safe and effective treatment strategy that can significantly reduce the incidence of complications after PSE (such as post-embolization syndrome, PVT, refractory ascites).

Refractory ascites after laparoscopic cholecystectomy: a case report

BACKGROUND

Laparoscopic cholecystectomy is a common surgical option for gallstone disease with minimal trauma and rapid recovery. Ascites is a relatively uncommon complication after laparoscopic cholecystectomy and is more frequently observed in patients with preoperative abnormal liver function. However, patients without underlying liver disease develop refractory ascites after laparoscopic cholecystectomy are rare. We report a case of massive ascites caused by lymphatic injury after laparoscopic cholecystectomy.

CASE PRESENTATION

A 63-year-old woman complained of abdominal discomfort and distension at the twelfth day after a laparoscopic cholecystectomy for gallbladder stones. Subsequently, the patient developed spontaneous bacterial peritonitis and a decreased output of urine. Abdominal computed tomography (CT) identified abdominal effusion. The patient received abdominocentesis and the volume of slightly turbid yellow ascites averaged 1500-2000 ml per day. The results of laboratory analysis of ascitic fluid showed the following: serum-ascites albumin-gradient (SAAG), 11-12 g/L; albumin, 11-14 g/L; triglycerides, 0.91 mmol/L. After the diuretic therapy, repeated large-volume paracentesis with albumin supplementation, administration of antibiotics and renal vasodilating medications, the patient's symptoms did not relieve. Lymphoscintigraphy found a small amount of radioactive filling in the abdominal cavity. The patient finally received surgery with detection and ligation of the lymphatic leak. The ascites disappeared and the patient recovered well.

CONCLUSIONS

For patients with atypical characteristics of chylous ascites, lymphoscintigraphy could help to localize and qualify the diagnosis. Surgical treatment could be considered when conservative treatment fails.

Transjugular intrahepatic porto-systemic shunt in cirrhotic patients with hepatorenal syndrome - chronic kidney disease: Impact on renal function

BACKGROUND AND AIMS

Transjugular intrahepatic porto-systemic shunt (TIPS) ameliorates renal function in type-2 hepatorenal syndrome (HRS). Available evidence is based on 'old' HRS diagnostic criteria, and not on the current definition of HRS - chronic kidney disease (HRS-CKD). Among patients who underwent TIPS for refractory ascites over the last 12 years, we investigated clinical and renal function evolution of those with HRS-CKD.

METHODS

among 212 patients, 41 with HRS-CKD were included. Renal function was evaluated for 12 months after TIPS, along with management of ascites and transplant-free survival (TFS).

RESULTS

renal function significantly improved already one week after TIPS [serum creatinine (sCr): 1.37 ± 0.23 vs 1.94 ± 0.54 mg/dl, p< 0.001]; the amelioration was maintained during the whole follow-up and was observed in every CKD stage, defined according to baseline estimated Glomerular Filtration Rate (eGFR). sCr and eGFR became comparable between different CKD stages after only one week, whilst significantly different at baseline. TIPS led to a remarkable improvement in the control of ascites in all CKD stages and no significant differences in TFS were recorded.

CONCLUSIONS

TIPS led to an early, substantial and persistent improvement in renal function in patients with HRS-CKD, irrespective of their baseline CKD stage.

Alfapump® implantable device in management of refractory ascites: An update

Refractory ascites (RA) is a frequent and life-threatening complication of cirrhosis. In selected patients with RA, transjugular intrahepatic portosystemic shunt (TIPS) placement and liver transplantation (LT) are currently considered the best therapeutic alternatives to repeated large volume paracentesis. In patients with a contraindication to TIPS or LT, the alfapump^® system (Sequana Medical, Ghent, Belgium) has been developed to reduce the need for iterative paracentesis, and consequently to improve the quality of life and nutritional status. We report here recent data on technical progress made since the first implantation, the efficacy and tolerance of the device, the position of the pump in the therapeutic arsenal for refractory ascites, and the grey areas that remain to be clarified regarding the optimal selection of patients who are potential candidates for this treatment.

Spontaneous bacterial empyema in cirrhosis: A systematic review and meta-analysis

BACKGROUND

Spontaneous bacterial empyema (SBE) occurs when a hepatic hydrothorax becomes infected and runs a course similar to spontaneous bacterial peritonitis (SBP). It remains underdiagnosed as patients with cirrhosis do not routinely undergo diagnostic thoracentesis. Current understanding is limited by small cohorts, while studies reporting its association with ascites/SBP are conflicting.

AIM

To explore the incidence of SBE, to determine its association with ascites, and to summarize what is known regarding treatment and outcomes for patients with SBE.

METHODS

Major databases were searched until June 2021. Outcomes include the incidence of SBE in pleural effusions, SBP in peritoneal fluid, and SBE in patients without ascites within our cohort of patients with cirrhosis. We performed a meta-analysis using a random-effects model with pooled proportions and 95% confidence intervals (CI). We assessed heterogeneity using I² and classic fail-safe to determine bias.

RESULTS

Eight studies with 8899 cirrhosis patients were included. The median age ranged between 41.2 to 69.7 years. The majority of the patients were Child-Pugh B and C. Mean MELD score was 18.6 ± 8.09. A total of 1334 patients had pleural effusions and the pooled incidence of SBE was 15.6% (CI 12.6-19; I² 50). Amongst patients diagnosed with SBE, the most common locations included right (202), left (64), and bilateral (8). Amongst our cohort, a total of 2636 patients had ascites with a pooled incidence of SBP of 22.2% (CI 9.9-42.7; I² 97.8). The pooled incidence of SBE in patients with cirrhosis but without concomitant ascites was 9.5% (CI 3.6-22.8; I² 82.5).

CONCLUSION

SBE frequently occurs with concurrent ascites/SBP; our results suggest high incidence rates of SBE even in the absence of ascites. The pleura can be an unrecognized nidus and our findings support the use of diagnostic thoracentesis in patients with decompensated cirrhosis after exclusion of other causes of pleural effusion. Thoracentesis should be considered particularly in patients without ascites and when there is a high suspicion of infection. The need for diagnostic thoracentesis will continue to be important as rates of multi-drug resistant bacterial infections increase and antibiotic susceptibility information is required for adequate treatment.

Effects and safety of natriuretic peptides as treatment of cirrhotic ascites: A systematic review and meta-analysis

BACKGROUND

Natriuretic peptides are involved in the cascade of pathophysiological events occurring in liver cirrhosis, counterbalancing vasoconstriction and anti-natriuretic factors. The effects of natriuretic peptides as treatment of cirrhotic ascites have been investigated only in small studies, and definitive results are lacking.

AIM

To examine the effects and safety of natriuretic peptides in cirrhosis patients with ascites.

METHODS

We searched MEDLINE, Web of Science, Scopus, Cochrane Library and Embase for all available studies applying intravenous administration of any natriuretic peptide to patients suffering from cirrhotic ascites. Inclusion was not limited by treatment duration or dose, or by follow-up duration. Both randomised controlled trials and non-randomised studies were eligible for inclusion. The primary outcome was change in renal sodium excretion. Secondary outcomes included safety measures and changes in renal water excretion, plasma aldosterone concentration, and plasma renin activity.

RESULTS

Twenty-two studies were included. Atrial natriuretic peptide (ANP) was the only intensively studied treatment. Sodium excretion increased in response to continuous ANP infusion and was more pronounced when infusion rates of > 30 ng/kg/min were administered compared with ≤ 30 ng/kg/min (P < 0.01). Moreover, natriuresis was significantly higher in study subgroups with mild/moderate ascites compared with moderate/severe and refractory ascites (P < 0.01). ANP infusions increased renal water excretion, although without reaching a statistically significant dose-response gradient. Plasma aldosterone concentration and plasma renin activity were significantly lower at baseline in study subgroups achieving a negative sodium balance in response to an ANP administration compared with treatment non-responders (P < 0.01). Blood pressure decreases occurred less frequently when ANP doses ≤ 30 ng/kg/min were applied. The quality of evidence for a natriuretic response to ANP was low, mainly due to small sample sizes and considerable between-study heterogeneity. Data were sparse for the other natriuretic peptides; B-type natriuretic peptide and urodilatin.

CONCLUSION

Intravenous ANP infusions increase sodium excretion in patients with cirrhotic ascites. Continuous infusion rates > 30 ng/kg/min are the most effective. However, safety increases with infusion rates ≤ 30 ng/kg/min.

Consensus care recommendations for alfapump® in cirrhotic patients with refractory or recurrent ascites

Background

The alfapump^® is an implantable class III medical device that pumps ascitic fluid from the peritoneal space to the urinary bladder from where it is excreted. The pump reduces or abrogates the need for repeated paracentesis in patients with recurrent or refractory ascites.

Aims

To improve outcomes for alfapump^® implantation and pre- and post-implant patient management in both clinical trial and real-world settings by development of consensus recommendations.

Methods

The alfapump^® working group consisting of hepatologists and surgeons with extensive experience in implantation of the alfapump^® and patient management met on two occasions: (1) to determine the key areas where recommendations should be made; and (2) to discuss the experiences of the working group within those areas and formulate draft statements. Developed statements were submitted to the group and consensus sought on relevance and wording through a collaborative iterative approach in order to consolidate the recommendations into consensus statements. Only recommendations agreed upon unanimously were included.

Results

Twenty-three consensus recommendations were developed in the areas of pre-implantation procedure, (three statements), surgical implant procedure (11 statements), immediate post-implant care (three statements) and long-term management (six statements).

Conclusions

The consensus statements are a valuable reference resource for physicians managing patients with the alfapump^® and for those considering management strategies for patients with refractory ascites.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02173-5.

Simultaneous muscular hemorrhages in two regions three years after successfully controlling refractory ascites using transjugular intrahepatic portosystemic shunt treatment: a case report

INTRODUCTION

Various therapies and drugs have been developed to extend the life expectancy of patients with liver cirrhosis. The prolonged prognosis of cirrhotic patients may change the final cause of death in the future. Deep bleeding into the muscle is an uncommon but potentially life-threatening complication of liver cirrhosis.

CASE REPORT

A 53-year-old man had undergone transjugular intrahepatic portosystemic shunt treatment for refractory ascites, which successfully controlled it for three years. However, he had started drinking again and experienced acute-on-chronic liver failure. He also had severe back pain. Abdominal computed tomography showed hyperdensities in the retroperitoneum and right pleural cavity. Despite blood infusion, he died from acute-on-chronic liver failure. A pathological autopsy revealed bleeding from the iliopsoas and right diaphragmatic muscle simultaneously, evident from the presence of red blood cells located between the muscle sheaths. Disruption of the small vessels in the skeletal muscle fibers was inferred.

CONCLUSION

This is a critical case that underscores the significance of improving available knowledge based on the cause of final death of the patients with cirrhosis, who now have a good long-term prognosis owing to the latest medical developments.

Granulocyte colony stimulating factor: A potential therapeutic rescue in severe alcoholic hepatitis and decompensated cirrhosis

Liver cirrhosis accounts for over 2 million deaths annually worldwide. A subset of these patients - those with alcoholic hepatitis and decompensated cirrhosis, have abysmal short-term survival. Liver transplant is the only intervention of proven survival benefit; however organ availability is a major limitation. It is thus imperative to assess potential benefit of experimental therapies as a bridge to transplant. Stem cell therapies have shown some promise in patients with end-stage liver disease. Of these, bone-marrow derived hematopoietic stem cells have generated the most interest. Animal as well as human data suggest biological plausibility of stem cell translocation from bone marrow to liver, giving credence to cytokine therapies based on bone marrow stimulation. Granulocyte colony stimulating factor has been the most frequently used cytokine for this purpose. This intervention has shown encouraging results in terms of safety as well as survival benefits in small clinical trials. The evidence, however, is sparse and heterogeneous. In this review we describe the biological plausibility, mechanisms of action, and clinical evidence of the use of cytokine based stem cell therapy in patients with end-stage liver disease.

Liver stiffness measured by virtual touch quantification predicts the occurrence of posthepatectomy refractory ascites in patients with hepatocellular carcinoma

PURPOSE

This study assessed the significance of measuring liver stiffness using virtual touch quantification before hepatectomy to predict posthepatectomy refractory ascites.

METHODS

A total of 267 patients with hepatocellular carcinoma who underwent hepatectomy were prospectively analyzed. Liver stiffness was defined as the median value of the virtual touch quantification (Vs; m/s) by acoustic radio-force-impulse-based virtual touch.

RESULTS

A multivariate analysis showed that Vs and the aspartate aminotransferase-to-platelet ratio index were independent risk factors for postoperative refractory ascites (odds ratio = 3.27 and 3.08, respectively). The cutoff value for Vs was 1.52 m/s (sensitivity: 59.5%, specificity: 88.6%) as determined by the analysis of the receiver-operating characteristic curve, and the area under the receiver-operating characteristic curve was 0.79. The cutoff value for the aspartate aminotransferase-to-platelet ratio was 0.952 (sensitivity: 65.5%, specificity: 82.9%), and the area under the receiver-operating characteristic curve was 0.75.

CONCLUSIONS

Vs is an independent risk factor for refractory ascites after hepatectomy. The measurement of liver stiffness by virtual touch quantification before hepatectomy can help estimate the risk of postoperative refractory ascites. Nonsurgical treatments should be considered for the management of patients who are at high risk for refractory ascites.

Transjugular intrahepatic portosystemic shunt (TIPS) placement at index portal hypertensive decompensation (anticipant TIPS) in cirrhosis and the role of early intervention in variceal bleeding and ascites

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) placement improves survival in patients with refractory/recurrent acute variceal bleeding (RAVB) and refractory ascites/hydrothorax. Recently, early TIPS was shown to reduce rebleeding and improve survival compared to the conventional TIPS. We aimed to study outcomes in patients with cirrhosis undergoing TIPS at first significant portal hypertensive (PHT) decompensation (termed anticipant TIPS) compared to those undergoing TIPS for recurrent or persistent PHT complications (conventional) and compared the former to matched controls on standard medical management (SMT).

METHODS

We retrospectively analyzed the clinical, biochemical, and liver disease severity parameters and survival at baseline and post-intervention in cirrhosis patients at two major hepatobiliary intervention centers undergoing anticipant (n = 27) or conventional TIPS (n = 30) and compared the former group to matched historical controls on SMT (n = 35).

RESULTS

Baseline parameters were comparable between both the groups, including the Child-Pugh class and model for end-stage liver disease (MELD) scores. Length of stay in the intensive care unit, post-procedure admission rates, and sepsis events were higher among patients undergoing conventional TIPS (p < 0.05). Post-TIPS, at 1 year, overall and sub-grouped survivals were   better in patients undergoing anticipant TIPS. On further sub-group analysis, based on the PHT events and stratified based on Child-Pugh and MELD scores, a higher proportion of patients survived after anticipant TIPS at 1 year. Compared to SMT, patients undergoing anticipant TIPS had significantly lesser hospitalizations, recurrence of varices, and ascites at 1 year, reducing hospital visits and financial burden.

CONCLUSIONS

Anticipant TIPS at the first significant PHT event could improve liver-related events and survival compared to   standard medical management and conventional TIPS, respectively.

β-blockers in advanced cirrhosis: More friend than enemy

Nonselective beta-adrenergic blocker (NSBB) therapy for the prevention of initial and recurrent gastrointestinal bleeding in cirrhotic patients with gastroesophageal varices has been used for the past four decades. NSBB therapy is considered the cornerstone of treatment for varices, and has become the standard of care. However, a 2010 study from the group that pioneered β-blocker therapy suggested a detrimental effect of NSBBs in decompensated cirrhosis, especially in patients with refractory ascites. Since then, numerous additional studies have incompletely resolved whether NSBBs are deleterious, although more recent evidence weighs against a harmful effect. The possibility of a "therapeutic window" has also been raised. We aimed to review the literature to analyze the pros and cons of using NSBBs in patients with cirrhosis, not only with respect to bleeding or mortality but also to other potential benefits and risks. β-blockers are highly effective in preventing first bleeding and recurrent bleeding. Furthermore, NSBBs improve congestion/ischemia of the gut mucosa, decrease intestinal permeability, and therefore indirectly alleviate systemic inflammation. β-blockers shorten the electrocardiographic prolonged QTc interval and may also decrease the incidence of hepatocellular carcinoma. On the other hand, the possibility of deleterious effects in cirrhosis has not been completely eliminated. NSBBs may be associated with an increased risk of portal vein thrombosis, although this could be correlational artifact. Overall, we conclude that β-blockers in cirrhosis are much more of a friend than enemy.

ACR Appropriateness Criteria® Radiologic Management of Portal Hypertension

Cirrhosis is a heterogeneous disease that cannot be studied as a single entity and is classified in two main prognostic stages: compensated and decompensated cirrhosis. Portal hypertension, characterized by a pathological increase of the portal pressure and by the formation of portal-systemic collaterals that bypass the liver, is the initial and main consequence of cirrhosis and is responsible for the majority of its complications. A myriad of treatment options exists for appropriately managing the most common complications of portal hypertension, including acute variceal bleeding and refractory ascites. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Lymphatic dysfunction in advanced cirrhosis: Contextual perspective and clinical implications

The lymphatic system plays a very important role in body fluid homeostasis, adaptive immunity, and the transportation of lipid and waste products. In patients with liver cirrhosis, capillary filtration markedly increases, primarily due to a rise in hydrostatic pressure, leading to enhanced production of lymph. Initially, lymphatic vasculature expansion helps to prevent fluid from accumulating by returning it back to the systemic circulation. However, the lymphatic functions become compromised with the progression of cirrhosis and, consequently, the lymphatic compensatory mechanism gets overwhelmed, contributing to the development and eventual worsening of ascites and edema. Neurohormonal changes, low-grade chronic inflammation, and compounding effects of predisposing factors such as old age, obesity, and metabolic syndrome appear to play a significant role in the lymphatic dysfunction of cirrhosis. Sustained portal hypertension can contribute to the development of intestinal lymphangiectasia, which may rupture into the intestinal lumen, resulting in the loss of protein, chylomicrons, and lymphocyte, with many clinical consequences. Rarely, due to high pressure, the rupture of the subserosal lymphatics into the abdomen results in the formation of chylous ascites. Despite being highly significant, lymphatic dysfunctions in cirrhosis have largely been ignored; its mechanistic pathogenesis and clinical implications have not been studied in depth. No recommendation exists for the diagnostic evaluation and therapeutic strategies, with respect to lymphatic dysfunction in patients with cirrhosis. This article discusses the perspectives and clinical implications, and provides insights into the management strategies for lymphatic dysfunction in patients with cirrhosis.

Long-term clinical outcome and survival predictors in patients with cirrhosis after 10-mm-covered transjugular intrahepatic portosystemic shunt

BACKGROUND AND AIMS

Transjugular intrahepatic portosystemic shunts (TIPS) are successfully used in the management of portal hypertension (PH)-related complications. Debate surrounds the diameter of the dilation. The aim was to analyse the outcomes of and complications deriving from TIPS in patients with cirrhosis and identify predictors of survival.

METHODS

This was a retrospective single-centre study, which included patients with cirrhosis who had a TIPS procedure for PH from 2009 to October 2018. Demographic, clinical and radiological data were collected. The Kaplan-Meier method was used to measure survival and predictors of survival were identified with the Cox regression model.

RESULTS

A total of 98 patients were included (78.6% male), mean age was 58.5 (SD±/-9.9) and the median MELD was 13.3 (IQR 9.5-16). The indications were refractory ascites (RA), variceal bleeding (VB) and hepatic hydrothorax (HH). Median survival was 72 months (RA 46.4, VB 68.5 and HH 64.7) and transplant-free survival was 26 months. Clinical and technical success rates were 70.5% and 92.9% respectively. Age (HR 1.05), clinical success (HR 0.33), sodium (HR 0.92), renal failure (HR 2.46) and albumin (HR 0.35) were predictors of survival. Hepatic encephalopathy occurred in 28.6% of patients and TIPS dysfunction occurred in 16.3%.

CONCLUSIONS

TIPS with 10-mm PTFE-covered stent is an effective and safe treatment for PH-related complications in patients with cirrhosis. Age, renal failure, sodium, albumin and clinical success are independent predictors of long-term survival.

Perforation of the ascending colon during implantation of an indwelling peritoneal catheter: a case report

Background

Tunneled peritoneal drainage catheters are described as an effective and relatively safe method in the management of malignant and non-malignant refractory ascites. Therapeutic advantages, linked to their use, are self-management of ascites and palliative care at home. Complications occur rarely. We describe an ascending colon perforation after implantation of a peritoneal drainage in a patient with refractory ascites due to liver cirrhosis.

Case presentation

The 68-year-old male was admitted to the intensive care unit due to severe community acquired pneumonia. The ascites drainage was inserted in order to reduce the intra-abdominal pressure and enable appropriate ventilation. A few hours later, bowel content could be detected in the tube and an abdominal computed tomography confirmed the intestinal perforation. Notably, there was no pneumoperitoneum and peritonitis had not yet set in. The catheter was removed during an emergency laparotomy and sutured closure of both perforation sites was performed.

Conclusion

Patients with septated ascites and intraperitoneal adhesions are at potential higher risk of bowel perforation during implantation of an indwelling peritoneal catheter. A mini-laparotomy is, therefore, necessary in order to ensure safe implantation and positioning of the catheter in those cases.

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Combined treatment of refractory ascites with an alfapump® plus hernia repair in the same surgical session: A retrospective, multicentre, European pilot study in cirrhotic patients

INTRODUCTION

The treatment of symptomatic hernia in cirrhotic patients with refractory ascites is critical but challenging. The objective of this study was to assess the feasibility and safety of the implantation of alfapump® combined with concomitant hernia repair in cirrhotic patients with refractory ascites.

METHODS

Using data from six European centres, we retrospectively compared patients treated with alfapump® system implantation and concomitant hernia repair [the combined treatment group (CT group, n=12)] or with intermittent paracentesis hernia repair [the standard treatment group (ST group, n=26)]. Some patients of the ST group had hernia repair in an elective setting (STel group) and others in emergency (STem group). The endpoints were requirement of peritoneal drainage, the rate of infectious complications, the in-hospital mortality, the length of stay, paracentesis-free survival.

RESULTS

Postoperatively, none of the patients in the CT group and 21 patients (80%) in the ST group underwent peritoneal drainage for the evacuation of ascites fluid (P<0.0001). The overall incidence of infectious complications was not different between groups but there were fewer infections in the CT group than in the STem group (33% vs. 81%; P=0.01). There was no difference for in-hospital mortality. The length of stay was shorter in the CT group (P=0.03). Paracentesis-free survival was significantly better (P=0.0003) in the CT group than in the ST group.

CONCLUSION

Implantation of alfapump combined with concomitant hernia repair seems feasible and safe in cirrhotic patients; however, larger and randomized study are required.

Pathophysiology and Prevention of Paracentesis-induced Circulatory Dysfunction: A Concise Review

Annually, 10% of cirrhotic patients with ascites develop refractory ascites for which large-volume paracentesis (LVP) is a frequently used therapeutic procedure. LVP, although a safe method, is associated with circulatory dysfunction in a significant percentage of patients, which is termed paracentesis-induced circulatory dysfunction (PICD). PICD results in faster reaccumulation of ascites, hyponatremia, renal impairment, and shorter survival. PICD is diagnosed through laboratory results, with increases of >50% of baseline plasma renin activity to a value ≥4 ng/mL/h on the fifth to sixth day after paracentesis. In this review, we discuss the pathophysiology and prevention of PICD.

Impact of cardiac function, refractory ascites and beta blockers on the outcome of patients with cirrhosis listed for liver transplantation

BACKGROUND & AIMS

Whether non-selective beta blockers (NSBBs) are deleterious in patients with end-stage cirrhosis and refractory ascites has been widely debated. We hypothesized that only the subset of patients on the liver transplant waiting list who had impaired cardiac performance would be at increased risk of mortality if receiving NSBBs.

METHODS

This study included 584 consecutive patients with cirrhosis evaluated for transplantation between 1999 and 2014. All patients had right heart catheterization with hemodynamic measurements at evaluation. Fifty percent received NSBBs. Refractory ascites was present in 33%. Cardiac performance was assessed by left ventricular stroke work index (LVSWI). Waiting list mortality without liver transplantation was explored using competing risk analysis.

RESULTS

LVSWI was significantly lower in patients with refractory ascites. In multivariate analysis using competing risk, refractory ascites, NSBBs and LVSWI were associated with waiting list mortality in the whole population, with a statistically significant interaction between NSBBs and LVSWI. The most discriminant value of LVSWI was 64.1 g-m/m². In the final model, refractory ascites (subdistribution hazard ratio 1.52; 95% CI1.01-2.28; p = 0.0083) and treatment by NSBBs with LVSWI <64.1 g-m/m² (subdistribution hazard ratio 1.96; 95% CI 1.32-2.90; p = 0.0009) were significantly associated with waiting list mortality, taking into account serum sodium and the model for end-stage liver disease score.

CONCLUSIONS

This study suggests that compromised cardiac performance is more common in patients with refractory ascites and that NSBBs are deleterious in cirrhotic patients with compromised cardiac performance. These results highlight the prognostic value of cardiac function in patients with end-stage cirrhosis.

LAY SUMMARY

There are still controversies concerning the impact of non-selective beta blockers on outcomes in patients with decompensated cirrhosis, especially in those with refractory ascites. In this study of 584 cirrhotic patients evaluated for liver transplantation, who underwent right heart catheterization, we have shown that global cardiac performance measured by left ventricular stroke work index is lower in patients with refractory ascites. Administration of non-selective beta blockers in patients with compromised cardiac performance may increase waiting list mortality. These results highlight the prognostic value of global cardiac performance in patients with end-stage cirrhosis.

Management of refractory ascites attenuates muscle mass reduction and improves survival in patients with decompensated cirrhosis

BACKGROUND

This study investigated time-course changes in skeletal muscle volume per year with tolvaptan in patients with refractory ascites that was unresponsive to loop diuretics and aldosterone antagonists.

METHODS

This retrospective study included 42 patients who received tolvaptan for refractory ascites and/or hepatic edema and underwent computed tomography (CT) before and ≥ 3 months after initiating tolvaptan. The time-course changes in skeletal muscle index per year [ΔSMI (%)] was calculated as follows: ΔSMI (%) = (SMI at final CT scan - SMI at initial CT scan)/SMI at initial CT scan × 100/years between CT scans.

RESULTS

Eligible patients were 23 men and 19 women of median age of 71 years (range 21-94 years). The median follow-up period was 22.7 (range 3.5-54.6) months. ΔSMI (%) was significantly higher in the responders group than in the nonresponder group. Multivariate analysis showed the response to tolvaptan was an independent and significant factor associated with an increase in muscle mass [odds ratio (OR) 20.364; 95% CI 2.327-178.97; P = 0.006]. Overall survival with tolvaptan was significantly higher in the responder group than in the nonresponder group. Multivariate analysis showed that the response to tolvaptan treatment was a significant contributor to good prognosis (OR 3.884; 95% CI 1.264-11.931; P = 0.018). A significant negative correlation was observed between the dosage of furosemide and ΔSMI (%) (P = 0.014).

CONCLUSIONS

Treatment of refractory ascites with tolvaptan may attenuate the progression of sarcopenia and improve the prognosis in patients with decompensated cirrhosis.

Rifaximin improves survival in cirrhotic patients with refractory ascites: A real-world study

BACKGROUND

Rifaximin has been shown to reduce the incidence of hepatic encephalopathy and other complications in patients with cirrhosis. However, few studies have investigated the effect of rifaximin in cirrhotic patients with refractory ascites.

AIM

To evaluate the effects of rifaximin in the treatment of refractory ascites and to preliminarily explore its possible mechanism.

METHODS

A total of 75 cirrhotic patients with refractory ascites were enrolled in the study (50 in a rifaximin and 25 in a control group). Patients in the rifaximin group were divided into two subgroups according to the presence of spontaneous bacterial peritonitis and treatment with or without other antibiotics (19 patients treated with rifaximin and 31 patients treated with rifaximin plus intravenous antibiotics). All patients received conventional treatment for refractory ascites, while patients in the rifaximin group received oral rifaximin-α 200 mg four times daily for at least 2 wk. The ascites grade, fasting weight, liver and kidney function, and inflammatory factors in the plasma were evaluated before and after treatment. In addition, the gut microbiota was determined by metagenomics sequencing to analyse the changes in the characteristics of the gut microbiota before and after rifaximin treatment. The patients were followed for 6 mo.

RESULTS

Compared with the control group, the fasting weight of patients significantly decreased and the ascites significantly subsided after treatment with rifaximin (P = 0.011 and 0.009, respectively). The 6-mo survival rate of patients in the rifaximin group was significantly higher than that in the control group (P = 0.048). The concentration of interferon-inducible protein 10 decreased significantly in the rifaximin group compared with that in the control group (P = 0.024). The abundance of Roseburia, Haemophilus, and Prevotella was significantly reduced after rifaximin treatment, while the abundance of Lachnospiraceae_noname, Subdoligranulum, and Dorea decreased and the abundance of Coprobacillus increased after treatment with rifaximin plus intravenous antibiotics. The gene expression of virulence factors was significantly reduced after treatment in both subgroups treated with rifaximin or rifaximin plus intravenous antibiotics.

CONCLUSION

Rifaximin mitigates ascites and improves survival of cirrhotic patients with refractory ascites. A possible mechanism is that rifaximin regulates the structure and function of intestinal bacteria, thus improving the systemic inflammatory state.

Constrictive pericarditis as a cause of refractory ascites after liver transplantation: A case report

BACKGROUND

Refractory ascites is a rare complication following orthotopic liver transplantation (OLT). The broad spectrum of differential diagnosis often leads to delay in diagnosis. Therapy depends on recognition and treatment of the underlying cause. Constrictive pericarditis is a condition characterized by clinical signs of right-sided heart failure. In the advanced stages of the disease, hepatic congestion leads to formation of ascites. In patients after OLT, cardiac etiology of ascites is easily overlooked and it requires a high degree of clinical suspicion.

CASE SUMMARY

We report a case of a 55-year-old man who presented with a refractory ascites three months after liver transplantation for alcoholic cirrhosis. Prior to transplantation the patient had a minimal amount of ascites. The transplant procedure and the early postoperative course were uneventful. Standard post-transplant work up failed to reveal any typical cause of refractory post-transplant ascites. The function of the graft was good. Apart from atrial fibrillation, cardiac status was normal. Eighteen months post transplantation the patient developed dyspnea and severe fatigue with peripheral edema. Ascites was still prominent. The presenting signs of right-sided heart failure were highly suggestive of cardiac etiology. Diagnostic paracentesis was suggestive of cardiac ascites, and further cardiac evaluation showed typical signs of constrictive pericarditis. Pericardiectomy was performed followed by complete resolution of ascites. On the follow-up the patient remained symptom-free with no signs of recurrent ascites and with normal function of the liver graft.

CONCLUSION

Refractory ascites following liver transplantation is a rare complication with many possible causes. Broad differential diagnosis needs to be considered.

[CCI clinical practice guidelines: management of TIPS for portal hypertension (2019 edition)]

Portal hypertension(PH) is one of the main complications of cirrhosis.Transjugular intrahepatic portosystemic shunt(TIPS) is the percutaneous creation of a conduit from the hepatic vein to the portal vein that is used to manage consequences of PH (i.e., variceal bleeding and refractory ascites) and used as a bridging therapy to liver transplant for decompensated cirrhosis. The following Clinical Practice Guidelines (CPGs) presents profession associational recommendations of the Chinese College of Interventionalists(CCI) on TIPS for PH. The CPGs was written by more than 30 experts in the field of TIPS in China (including interventional radiologists, liver surgeons, hepatologists and gastroenterologist, et al.). The panel of experts, produced these CPGs using evidence from PubMed and Cochrane database searches and combined with relevant expert consensuses and high quality clinical researches in China providing up to date guidance on TIPS for PH with the only purpose of improving clinical practice.

Refractory ascites-the contemporary view on pathogenesis and therapy

Refractory ascites (RA) refers to ascites that cannot be mobilized or that has an early recurrence that cannot be prevented by medical therapy. Every year, 5–10% of patients with liver cirrhosis and with an accumulation of fluid in the peritoneal cavity develop RA while undergoing standard treatment (low sodium diet and diuretic dose up to 400 mg/day of spironolactone and 160 mg/day of furosemide). Liver cirrhosis accounts for marked alterations in the splanchnic and systemic hemodynamics, causing hypovolemia and arterial hypotension. The consequent activation of renin-angiotensin and sympathetic systems and increased renal sodium re-absorption occurs during the course of the disease. Cirrhotic patients with RA have poor prognoses and are at risk of developing serious complications. Different treatment options are available, but only liver transplantation may improve the survival of such patients.

Intraperitoneal Chemotherapy: A Strategy for the Treatment of Refractory Ascites in Recurrent Endometrial Cancer Patients - Three Case Reports and Review of the Literature

BACKGROUND

Endometrial cancer currently represents the most frequent gynecologic malignancy in Western countries, and the seventh most common cancer in women. For advanced-stage disease, the recurrence risk is high, and the site of the relapse is heterogeneous with localized or spread peritoneal disease. There are few therapeutic strategies, and the quality of life is poor.

CASES PRESENTATION

We present 3 cases of peritoneal-spread recurrences of endometrial cancer in patients with advanced stage at diagnosis. The patients had been subjected to multiple lines of chemotherapy including re-challenging with platinum regimens, pegylated liposomal doxorubicin, and taxane, with progression of disease. These patients came to us with abdominal distension, dyspnea, elevated CA 125, and presence of ascites. After paracentesis with a single administration of intraperitoneal chemotherapy based on carboplatin, all 3 patients showed improvement in their quality of life and breathing as well as reduction of fatigue and anorexia. No complications occurred.

CONCLUSION

Although only 3 cases are reported, the exceptional results and the absence of side effects observed strongly warrant future trials to investigate the role intraperitoneal chemotherapy can have both as palliative treatment of refractory ascites and as salvage therapy in advanced endometrial cancer.

Prognosis of surgical hernia repair in cirrhotic patients with refractory ascites

BACKGROUND

Abdominal wall hernias are common in patients with ascites. Elective surgical repair is recommended for the treatment of abdominal wall hernias. However, surgical hernia repair in cirrhotic patients with refractory ascites is controversial. In this study, we aimed to evaluate the outcomes of elective surgical hernia repair in patients with liver cirrhosis with and without refractory ascites.

METHOD

From January 2005 to June 2018, we retrospectively reviewed the records of consecutive patients with liver cirrhosis who underwent a surgical hernia repair.

RESULTS

This study included 107 patients; 31 patients (29.0%) had refractory ascites. Preoperatively, cirrhotic patients with refractory ascites had a higher median model for end-stage liver disease (MELD) score (13.0 vs 11.0, P = 0.001) than those without refractory ascites. The 30-day mortality rate (3.2% vs 0%, P = 0.64) and the risk of recurrence (hazard ratio 0.410; 95% CI 0.050-3.220; P = 0.39) did not differ significantly between cirrhotic patients with refractory ascites and cirrhotic patients without refractory ascites. Among cirrhotic patients with refractory ascites, albumin (P = 0.23), bilirubin (P = 0.37), creatinine (P = 0.97), and sodium levels (P = 0.35) did not change significantly after surgery.

CONCLUSION

In advanced liver cirrhosis patients with refractory ascites, hernias can be safely treated with elective surgical repair. Mortality rate within 30 days did not differ by the presence or absence of refractory ascites. Elective hernia repair might be beneficial for treatment of abdominal wall hernia in cirrhotic patients with refractory ascites.

[Refractory ascites caused by lymphatic flow disorder after stem cell transplantation for acute myeloid leukemia]

In allogeneic hematopoietic stem cell transplantation (HSCT), ascites may develop owing to several causes, including sinusoidal obstruction syndrome, infections, malignancies, and malnutrition. However, it is often difficult to determine its precise cause. Here, a 59-year-old male developed chylous ascites three months post allogeneic bone marrow transplantation for relapsed acute myeloid leukemia. None of the attempted treatments resulted in improvement. Lymphangioscintigraphy revealed a lymphatic flow disorder at the level of the cisterna chyli. Autopsy revealed no leukemic cell infiltration or graft-versus-host disease of the liver or pancreas. The pancreatic specimen revealed parenchymal fibrosis and infiltration of plasma cells, suggesting chronic inflammation in addition to pathological changes caused by acute pancreatitis. These findings indicate that acute or chronic pancreatitis caused a lymphatic flow disorder that developed into refractory ascites. Although we could not diagnose pancreatitis while the patient was alive, it is important to recognize that asymptomatic pancreatitis can develop after HSCT. Furthermore, one should attempt to make an accurate diagnosis as early as possible.

Long-term clinical outcomes in patients with viral hepatitis related liver cirrhosis after transjugular intrahepatic portosystemic shunt treatment. Virol J. 2018;15:151. [PMID: 30285813 PMCID: PMC6167830 DOI: 10.1186/s12985-018-1067-7]

Background

Transjugular intrahepatic portosystemic shunt (TIPS) procedure has played a vital role in management of portal hypertension. Thus, we aimed to investigate the natural history, long-term clinical outcome, predictors of survival in viral hepatitis related cirrhotic patients post-TIPS.

Method

A total of 704 patients with complete followed-up data were enrolled, and clinical characteristics of patients were collected and analyzed. Kaplan-Meier method was used to calculate survival, and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model.

Results

TIPS implatantion significantly decreased portal vein pressure with 9.77 cmH₂O reduction, without influencing long-term liver functions. The total incidence rate of major complication post-TIPS, including HE and re-bleeding/bleeding, was 37.9% and 15.5%, respectively. Patients in Child-Pugh C stage revealed higher overt hepatic encephalopathy (HE) occurrence (65.6%), while patients receiving covered, 6 mm in diameter stents indicated notably lower incidence of HE in comparison with other groups (6.4%). The median survival was > 60 months, 27.0 months, and 11.5 months in cirrhotic patients with variceal bleeding, refractory ascites, and both complications, respectively. The cumulative 5-year survival was significantly higher in patients with variceal bleeding (75.6%) in comparison with either that in patients with refractory ascites (12.5%) or that in patients with both complications (1.96%) (P < 0.0001). Covered stents usage, baseline model for end-stage liver disease (MELD) score, and baseline Child-Pugh classification were predictive of survival (P < 0.001). Other variables including age, male gender, and pre-TIPS PVP were not emerged as significant predictors (P > 0.05).

Conclusion

TIPS was an effective and safe therapeutic method for decompression of portal hypertension and for treatment of its complications. Careful selection of patients with minimal liver dysfunction for TIPS implantation was essential for better long-term outcomes.

[New therapeutic paradigm and concepts for patients with cirrhotic refractory ascites]

The activation of renin-angiotensin-aldosterone-vasopressin system is a key factor in the formation of ascites due to splanchnic vasodilation in cirrhosis. In theory, aldosterone antagonists, contraction of blood vessels, vasopressin V2 receptor, and angiotensin receptor antagonists are important targets for the prevention and treatment of cirrhotic ascites. The 15%-20% of patients with cirrhotic ascites that show no response to at least one week's treatment with potent diuretics (spironolactone 160 mg/d combined with furosemide 80 mg/d) are considered to have refractory ascites. At present, effective treatments for refractory ascites include tolvaptan, large-volume paracentesis (4000-6000 ml/time/day) combined with albumin (4 g/L ascites), ascites ultrafiltration and reinfusion, transjugular intrahepatic portosystemic shunt, and liver transplantation. In the future, with the development of vasoactive drugs, rifaximin, ascites drainage pump, and other new therapies, the treatment of refractory ascites may be more effective to reduce the need for liver transplantation.

Survival Benefit of Tolvaptan for Refractory Ascites in Patients with Advanced Cirrhosis

AIMS

The study aimed to evaluate the effects of tolvaptan treatment on survival of patients with decompensated liver cirrhosis with refractory ascites.

METHODS

This multicenter, retrospective, observational study included patients with cirrhosis who were treated with tolvaptan for hepatic ascites refractory to conventional diuretics. Patients who could and could not decrease accompanying diuretics within 1 month after tolvaptan administration were defined as the "Decreased" and "Not-decreased" groups, respectively.

RESULTS

Median body weight change 1 week after tolvaptan treatment was -1.95 kg, with the 50% of patients experiencing a 2 kg/week reduction. Spot urinary sodium was found to be a better predictor of tolvaptan response than liver function and liver fibrosis markers. Median survival was significantly longer (not reached versus 116 days, p = 0.005) and serum creatinine concentrations 12 weeks after tolvaptan administration significantly lower (0.99 vs. 1.55 mg/dL, p < 0.05) in the Decreased than in the Not-decreased group. Multivariate analysis showed that the presence of viable hepatocellular carcinoma (hazards ratio [HR] 2.14, p = 0.02) and a decrease in diuretics were independently prognostic of survival (HR 0.36, p < 0.01).

CONCLUSIONS

The maintenance of renal function is essential in enhancing survival of patients with cirrhosis. Doses of diuretics should be adjusted appropriately during tolvaptan treatment.

large volume paracentesis for refractory ascites: A multicenter randomized controlled study

BACKGROUND AND AIMS

Patients with refractory ascites (RA) require repeated large volume paracenteses (LVP), which involves frequent hospital visits and is associated with a poor quality-of-life. This study assessed safety and efficacy of an automated, low-flow pump (alfapump® [AP]) compared with LVP standard of care [SoC].

METHODS

A randomized controlled trial, in seven centers, with six month patient observation was conducted. Primary outcome was time to first LVP. Secondary outcomes included paracentesis requirement, safety, health-related quality-of-life (HRQoL), and survival. Nutrition, hemodynamics, and renal injury biomarkers were assessed in a sub-study at three months.

RESULTS

Sixty patients were randomized and 58 were analyzed (27 AP, 31 SoC, mean age 61.9years, mean MELD 11.7). Eighteen patients were included in the sub-study. Compared with SoC, median time to first LVP was not reached after six months in the AP group, meaning a significant reduction in LVP requirement for the AP patients (AP, median not reached; SoC, 15.0days (HR 0.13; 95%CI 13.0-22.0; p<0.001), and AP patients also showed significantly improved Chronic Liver Disease Questionnaire (CLDQ) scores compared with SoC patients (p<0.05 between treatment arms). Improvements in nutritional parameters were observed for hand-grip strength (p=0.044) and body mass index (p<0.001) in the sub-study. Compared with SoC, more AP patients reported adverse events (AEs; 96.3% vs. 77.4%, p=0.057) and serious AEs (85.2 vs. 45.2%, p=0.002). AEs consisted predominantly of acute kidney injury in the immediate post-operative period, and re-intervention for pump related issues, and were treatable in most cases. Survival was similar in AP and SoC.

CONCLUSIONS

The AP system is effective for reducing the need for paracentesis and improving quality of life in cirrhotic patients with RA. Although the frequency of SAEs (and by inference hospitalizations) was significantly higher in the AP group, they were generally limited and did not impact survival. Lay summary: The alfapump® moves abdominal fluid into the bladder from where it is then removed by urination. Compared with standard treatment, the alfapump reduces the need for large volume paracentesis (manual fluid removal by needle) in patients with medically untreatable ascites. This can improve life quality for these patients. www.clinicaltrials.gov#NCT01528410.

Cirrhotic cardiomyopathy is less prevalent in patients with Budd-Chiari syndrome than cirrhosis of liver

BACKGROUND AND AIM

Cirrhotic cardiomyopathy (CCM) is associated with high mortality after transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation in patients with cirrhosis. There is no data about the prevalence or impact of CCM in Budd-Chiari syndrome (BCS). We assessed the prevalence of CCM in patients with BCS and its impact on outcome after radiological intervention.

METHODS

Thirty-three consecutive patients with BCS (15 men) and 33 controls with hepatitis B-related cirrhosis (18 men, matched for Child-Pugh score) were evaluated with baseline electrocardiography (ECG), echocardiography (ECHO) and dobutamine stress ECHO, and ECG (DSE). The two groups were compared for prevalence of CCM. Patients with BCS with and without CCM were assessed for development of heart failure, duration of intensive care unit (ICU) stay, and in-hospital mortality immediately after radiological intervention.

RESULTS

Fewer patients with BCS had CCM (7/21 vs. 21/33; p = 0.001, OR-0.16, CI [0.05-0.5]), diastolic dysfunction (DD) (0/33 vs. 6/33; p = 0.01, OR-0.06, CI [0.00-1.1]), and prolonged QTc interval (5/33 vs.17/33; p = 0.001, OR-0.16, CI [0.05-0.5]) despite correction for age. Patients with BCS had lower end-systolic and end-diastolic volumes of left and right ventricles. None of the 19 patients (five with CCM) with BCS undergoing radiological intervention (12 TIPS, 4 inferior vena cava, and 3 hepatic vein stenting) developed heart failure or had prolonged ICU stay. There was no in-hospital mortality.

CONCLUSION

Patients with BCS have lower frequency of CCM as compared to patients with cirrhosis. CCM may not adversely affect outcomes after radiological interventions.

Post-hepatectomy Refractory Ascites in Cirrhotic Patients with Hepatocellular Carcinoma: Risk Factor Analysis to Overcome this Problematic Complication

BACKGROUND

Refractory ascites is a serious post-hepatectomy complication in cirrhotic patients with hepatocellular carcinoma (HCC). In order to avoid this complication, surgeons should preserve as much liver parenchyma as possible in performing hepatectomy in such patients. However, we still occasionally encounter refractory ascites even after limited or small hepatectomy. The aim of this study was to identify risk factors for post-hepatectomy refractory ascites in cirrhotic patients, focusing on limited or small hepatectomy.

PATIENTS AND METHODS

The data of 73 cirrhotic patients with HCC who underwent limited or small hepatectomy were analyzed. Limited or small hepatectomy was defined as hepatectomy equal to or of less than subsegmentectomy. We compared the clinicopathological factors between patients with and without postoperative refractory ascites.

RESULTS

Fourteen cirrhotic patients suffered postoperative refractory ascites. Total cholesterol, duration of operation, duration of Pringle maneuver, resection of segment VII, intraoperative blood loss, and intraoperative blood transfusion were found to be significant risk factors for postoperative refractory ascites in univariate analyses. Multivariate analysis revealed that resection of segment VII was an independent risk factor.

CONCLUSION

Resection of segment VII necessitates extensive dissection of the right triangular or coronary ligaments, which could explain that it was an independent risk factor for post-hepatectomy refractory ascites. Surgeons should avoid extensive dissection of these ligaments in order to avoid this detrimental complication.

Transjugular intrahepatic portosystemic shut vs total paracentesis for treatment of refractory ascites in patients with cirrhosis: A meta-analysis

AIM

To evaluate the efficacy and safety of transjugular intrahepatic portosystemic (TIPS) vs total paracentesis (TP) in the treatment of refractory ascites in patients with cirrhosis.

METHODS

PubMed, Web of Science Medline, EMBASE, CNKI, WanFang Database, and Chinese BioMedical Literature Database were searched to retrieve randomized controlled trials (RCTs) that compared TIPS vs TP in the treatment of refractory ascites in patients with cirrhosis. The quality assessment of RCTs and data extraction were conducted by two reviewers independently. Meta-analysis was performed using RevMan5.2 software.

RESULTS

Six studies involving 390 patients (192 cases of TIPS and 198 cases of TP) were included. The meta-analysis showed that compared with TP, TIPS significantly improved liver transplantation-free (LTF) survival (HR = 0.61, P = 0.0009); reduced recurrent ascites (RR = 0.61, P < 0.0001); decreased the levels of renin [weighted mean difference (WMD) = -5.41, P < 0.00001] and aldosterone (WMD = -23.72, P = 0.02) and provided better control of water-sodium retention; and reduced the incidence rate of hepatorenal syndrome (RR = 0.38, P = 0.03). However, TIPS increased the risk of hepatic encephalopathy (RR = 1.81, P = 0.007). No significant differences were found in overall mortality, hospitalization days, the rates of gastrointestinal bleeding and spontaneous bacterial peritonitis, or the effects of treatment on renal and liver function between the two groups.

CONCLUSION

Compared with traditional paracentesis therapy, TIPS increased the risk of hepatic encephalopathy. However, TIPS significantly improved LTF survival, decreased the risk of recurrent ascites, provided better control of water-sodium retention, and prevented the occurrence of hepatorenal syndrome.

Bile Duct Perforation due to Inspissated Bile Presenting as Refractory Ascites

Non hepatic origin of refractory ascites is not a rarity. Hemolytic anemias are known to cause inspissated bile and biliary obstruction. Distal biliary obstruction can lead to biliary perforation. The authors report a case of hereditary spherocytosis leading to inspissated bile causing bile duct perforation and biliary ascites. A high index of suspicion for biliary ascites should be kept in a child with refractory ascites in the setting of progressive ascites with decreasing bilirubin. Ascitic fluid bilirubin analysis will clinch the diagnosis. Surgical repair is the optimal management.

Characteristics of Patients and Their Ascites Who Underwent Repeated Cell-Free and Concentrated Ascites Reinfusion Therapy

Novel cell-free and concentrated ascites reinfusion therapy (KM-CART) is easy to use, safe and applicable for refractory ascites. We can get the full amount of ascites, filtrate, and concentrate in a short time. KM-CART can be applied as palliative care for dying patients including patients with massive malignant ascites. Some patients who underwent repeated KM-CART survived longer than those who did not repeat the therapy. The aim of this study was to identify the type of patients with ascites for whom KM-CART would be effective and candidates for repeated KM-CART. In this retrospective cohort observational study, we examined 123 CART processes performed on 58 patients with refractory ascites. Data were collected before and after processing of the ascites. We compared two groups; patients who underwent KM-CART ≥ 5 times and those who underwent this process ≤ 4 times. Age, disease, benign or malignant status of the disease, the amount of ascites, concentrations of total protein (TP) and albumin (Alb) and their amounts in the original ascites and the filtered and concentrated ascitic fluid and the recovery ratio of TP and Alb were determined. No significant difference was observed between the two groups in age, disease, amount of ascites, and the recovery ratio of TP and Alb. Significant differences were observed in the amounts of TP and Alb in the original ascites and the filtered and concentrated ascitic fluid. Patients who underwent KM-CART ≥ 5 times had higher Alb levels in the original ascites than those who underwent this therapy ≤ 4 times. Patients with higher Alb concentrations in the original ascites could be candidates for repeated KM-CART.

Permanent catheters for recurrent ascites-a critical and systematic review of study methodology

PURPOSE

Management of refractory ascites traditionally includes medical treatment with diuretics or intermittent paracentesis. Patients with recurrent ascites may benefit from the use of permanent intra-abdominal catheters with more frequent drainage without hospitalization. The objective was to systematically asses the methodology of factors and endpoints reported in studies investigating permanent catheters for recurrent ascites treatment.

METHODS

Using a systematic search strategy, we critically assessed the methodology when treating refractory ascites using a permanent catheter. Studies critically assessed included both retro- and prospective studies.

RESULTS

A total of 715 unique articles were found via PubMed, The Cochrane Library and Embase. Twenty-nine studies (tunnelled catheter = 12, peritoneal ports = 6 and peritoneovenous shunts = 11) with three distinct types of permanent catheters fulfilled the inclusion criteria. Only three studies reported technical success less than 100 %. Data on complications and treatment were not available in all papers; peritonitis (48 %), cellulitis (41 %), prophylactic antibiotics (48 %) and complications to catheter insertion were difficult to distinguish from advanced co-morbidity of patients. Thirteen studies (45 %) reported some type of evaluating patient experience or functional outcome, but only three studies used validated reproducible scales when assessing outcomes. Fifteen of the 29 studies included 30 patients or less.

CONCLUSION

Knowledge is limited because complications and outcomes are poorly defined. The expected increase in catheter treatment of refractory ascites necessitates comparative studies, using validated patient-related outcomes, and the reporting of unambiguous complications. A proposal of variables to include in future studies is presented.

Efficacy of octreotide for treatment of cirrhosis with refractory ascites: A meta-analysis

AIM: To evaluate the efficacy and safety of octreotide in the treatment of cirrhosis with refractory ascites.

METHODS: PubMed, EMBASE, CBM, CNKI, VIP and Wanfang Database were searched to retrieved studies evaluating the efficacy of octreotide in the treatment of cirrhosis with refractory ascites. All the related data that met our standards were extracted. The quality of the included trials was evaluated according to the Jadad score. RevMan 5.2 software was used for meta-analysis.

RESULTS: A total of 9 randomized controlled trials involving 696 patients were included. The results of meta-analysis showed that the octreotide group was superior to the control group in treatment efficiency (OR = 3.18, 95%CI: 2.03-4.97, P < 0.00001), weight reduction (MD = -8.75, 95%CI: -11.25--6.25, P < 0.00001), ascites reduction (SMD = -31.8, 95%CI: -35.23--28.37, P < 0.00001), decreased abdominal girth (SMD = -8.75, 95%CI: -11.55--5.95, P < 0.00001), increased blood urea nitrogen (BUN) (MD = -1.18, 95%CI: -2.31--0.06, P = 0.04) and 24 h urine volume (SMD = 8.18, 95%CI: 3.69-12.67, P = 0.0004), but there was no statistical difference in serum creatinine (sCr) or portal vein trunk diameter (PVD).

CONCLUSION: Current evidence suggests that octreotide could improve treatment efficiency in terms of weight reduction, ascites reduction, decreased abdominal girth, increased BUN and 24 h urine volume.

Efficacy of tolvaptan in patients with refractory ascites in a clinical setting

AIM: To elucidate the efficacies of tolvaptan (TLV) as a treatment for refractory ascites compared with conventional treatment.

METHODS: We retrospectively enrolled 120 refractory ascites patients between January 1, 2009 and September 31, 2014. Sixty patients were treated with oral TLV at a starting dose of 3.75 mg/d in addition to sodium restriction (> 7 g/d), albumin infusion (10-20 g/wk), and standard diuretic therapy (20-60 mg/d furosemide and 25-50 mg/d spironolactone) and 60 patients with large volume paracentesis in addition to sodium restriction (less than 7 g/d), albumin infusion (10-20 g/wk), and standard diuretic therapy (20-120 mg/d furosemide and 25-150 mg/d spironolactone). Patient demographics and laboratory data, including liver function, were not matched due to the small number of patients. Continuous variables were analyzed by unpaired t-test or paired t-test. Fisher’s exact test was applied in cases comparing two nominal variables. We analyzed factors affecting clinical outcomes using receiver operating characteristic curves and multivariate regression analysis. We also used multivariate Cox’s proportional hazard regression analysis to elucidate the risk factors that contributed to the increased incidence of ascites.

RESULTS: TLV was effective in 38 (63.3%) patients. The best cut-off values for urine output and reduced urine osmolality as measures of refractory ascites improvement were > 1800 mL within the first 24 h and > 30%, respectively. Multivariate regression analysis indicated that > 25% reduced urine osmolality [odds ratio (OR) = 20.7; P < 0.01] and positive hepatitis C viral antibodies (OR = 5.93; P = 0.05) were positively correlated with an improvement of refractory ascites, while the total bilirubin level per 1.0 mg/dL (OR = 0.57; P = 0.02) was negatively correlated with improvement. In comparing the TLV group and controls, only the serum sodium level was significantly lower in the TLV group (133 mEq/L vs 136 mEq/L; P = 0.02). However, there were no significant differences in the other parameters between the two groups. The cumulative incidence rate was significantly higher in the control group with a median incidence time of 30 d in the TLV group and 20 d in the control group (P = 0.01). Cox hazard proportional multivariate analysis indicated that the use of TLV (OR = 0.58; P < 0.01), uncontrolled liver neoplasms (OR = 1.92; P < 0.01), total bilirubin level per 1.0 mg/dL (OR = 1.10; P < 0.01), and higher sodium level per 1.0 mEq/L (OR = 0.94; P < 0.01) were independent factors that contributed to incidence.

CONCLUSION: Administration of TLV results in better control of refractory ascites and reduced the incidence of additional invasive procedures or hospitalization compared with conventional ascites treatments.