Current management of refractory ascites in patients with cirrhosis

Liver cirrhosis is a health problem worldwide, and ascites is its principal symptom. Refractory ascites is intractable and occurs in 5%–10% of all patients with ascites due to cirrhosis. Refractory ascites leads to a poor quality of life and high mortality rate. Ascites develops as a result of portal hypertension, which leads to water–sodium retention and renal failure. Various therapeutic measures can be used for refractory ascites, including large-volume paracentesis, transjugular intrahepatic portosystemic shunt, vasoconstrictive drugs, and an automated low-flow ascites pump system. However, ascites generally can be resolved only by liver transplantation. Because not all patients can undergo liver transplantation, traditional approaches are still used to treat refractory ascites. The choice of treatment modality for refractory ascites depends, among other factors, on the condition of the patient.

Download Full-text

Automated low-flow ascites pump for the treatment of cirrhotic patients with refractory ascites

Therapeutic Advances in Gastroenterology ◽

10.1177/1756283x16684688 ◽

2017 ◽

Vol 10 (2) ◽

pp. 283-292 ◽

Cited By ~ 18

Author(s):

Guido Stirnimann ◽

Vanessa Banz ◽

Federico Storni ◽

Andrea De Gottardi

Keyword(s):

Low Flow ◽

Refractory Ascites ◽

Organ Shortage ◽

Efficacy And Safety ◽

Novel Treatments ◽

Intrahepatic Portosystemic Shunt ◽

Cirrhotic Patients ◽

Large Volume Paracentesis ◽

Volume Controlled ◽

Automated Low Flow

Cirrhotic patients with refractory ascites (RA) can be treated with repeated large volume paracentesis (LVP), with the insertion of a transjugular intrahepatic portosystemic shunt (TIPS) or with liver transplantation. However, side effects and complications of these therapeutic options, as well as organ shortage, warrant the development of novel treatments. The automated low-flow ascites pump (alfapump®) is a subcutaneously-implanted novel battery-driven device that pumps ascitic fluid from the peritoneal cavity into the urinary bladder. Ascites can therefore be aspirated in a time- and volume-controlled mode and evacuated by urination. Here we review the currently available data about patient selection, efficacy and safety of the alfapump and provide recommendations for the management of patients treated with this new method.

Download Full-text

Translating Our Current Understanding of Ascites Management into New Therapies for Patients with Cirrhosis and Fluid Retention

Digestive Diseases ◽

10.1159/000456595 ◽

2017 ◽

Vol 35 (4) ◽

pp. 402-410 ◽

Cited By ~ 13

Author(s):

Elisa Pose ◽

Andres Cardenas

Keyword(s):

Liver Transplantation ◽

Fluid Retention ◽

Current Understanding ◽

Low Flow ◽

Initial Assessment ◽

Refractory Ascites ◽

Term Outcome ◽

Pump System ◽

Long Term Outcome ◽

Portosystemic Shunts

Ascites is the most common complication associated with cirrhosis resulting in poor quality of life, high risk of development of other complications of cirrhosis, increased morbidity and mortality associated with surgical interventions, and poor long-term outcome. Patients with cirrhosis and a first onset of ascites, have a probability of survival of 85% during the first year and 56% at 5 years without liver transplantation. Ascites is caused due to increased renal sodium retention as a result of increased activity of the renin-angiotensin-aldosterone system in response to marked vasodilation of the splanchnic circulation. The practical management of ascites involves the proper evaluation of a patient with a thorough history and physical exam. In addition, complete laboratory, ascitic fluid, and radiological tests should be performed. One of the most important steps in the initial assessment of patients with ascites is to refer the appropriate candidates for liver transplantation, as it offers a definitive cure for cirrhosis and its complications. While the initial management of uncomplicated ascites with low sodium diet and diuretic treatment is straightforward in a majority of patients, approximately 10% of patients fail to respond to diuretics and become a real therapeutic challenge. The initial treatment of choice in patients with refractory ascites is large-volume paracentesis (LVP) associated with intravenous albumin; some patients also benefit from transjugular intrahepatic portosystemic shunts (TIPS). When repeated LVP or TIPS cannot be performed, other approaches using vasoconstrictors such as midodrine can be considered although data are scarce. A newly designed automated low flow pump system (Alfapump), which is designed to move ascites from the peritoneal cavity to the urinary bladder where it is eliminated spontaneously through diuresis is promising, but the data are also limited and safety is still a matter of concern. This article focuses on the practical aspects of the evaluation and treatment of patients with ascites and cirrhosis and also discusses how to translate our current understanding of ascites pathophysiology into new treatment methods for patients with fluid retention.

Download Full-text

Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation

CVIR Endovascular ◽

10.1186/s42155-019-0096-7 ◽

2020 ◽

Vol 3 (1) ◽

Author(s):

Osman Ahmed ◽

Abhijit L. Salaskar ◽

Steven Zangan ◽

Anjana Pillai ◽

Talia Baker

Keyword(s):

Liver Transplantation ◽

Portal Vein ◽

Splenic Vein ◽

Portosystemic Shunt ◽

Refractory Ascites ◽

Hepatic Veins ◽

Sonographic Guidance ◽

Portosystemic Shunts ◽

Intrahepatic Portosystemic Shunt ◽

End To End

Abstract Background Percutaneous trans-splenic portal vein recanalization (PVR) has been reported for facilitation of transjugular intrahepatic portosystemic shunts (TIPS), however has not been applied to patients undergoing direct intrahepatic portosystemic shunt (DIPS). We report the utilization of trans-splenic-PVR with DIPS creation in a patient with chronic portal and hepatic vein occlusions undergoing liver transplantation evaluation. Case presentation A 48-year-old male with decompensated alcoholic cirrhosis complicated by refractory ascites, hepatic encephalopathy, and variceal bleeding underwent CT that demonstrated chronic occlusion of the hepatic veins (HV), extrahepatic portal vein (PV), and superior mesenteric vein (SMV). Due to failed attempts at TIPS at outside institutions, interventional radiology was consulted for portal vein recanalization (PVR) with TIPS to treat the portal hypertension and ascites and also facilitate an end-to-end PV anastomosis at transplantation. After an initial hepatic venogram confirmed chronic HV occlusion, a DIPS with trans-splenic PVR was planned. The splenic vein was accessed under sonographic guidance using a micropuncture set and subsequently upsized to a 6 French sheath over a stiff guidewire. A splenic venogram via this access confirmed occlusion of the PV with drainage of the splenic vein (SV) through gastric varices. The thrombosed PV was then recanalized and angioplastied to restore PV flow via the transsplenic approach. A transjugular liver access kit with a modified 21-gauge needle was advanced into the IVC through the internal jugular vein (IJV) sheath and directed towards the target snare in PV. The needle was used to subsequently puncture the PV through the caudate lobe and facilitate placement of a wire into the SV. The initial portosystemic gradient (PSG) was 20 mmHg. The IJV sheath was advanced through the hepatic parenchymal tract into the main-PV and a stent-graft was placed across the main PV and into the IVC. A portal venogram demonstrated brisk blood flow through the DIPS, resolution of varices and a PSG of 8 mmHg. One month after the procedure, the patient had a significant reduction in ascites and MELD-NA score. Patient is currently listed and awaiting transplantation. Conclusions In the setting of chronically occluded portal and hepatic veins, trans-splenic PVR DIPS may serve as an effective bridge to liver transplantation by facilitating an end to end portal vein anastomosis.

Download Full-text

MELD Score Less Than 15 Predicts Prolonged Survival After Transjugular Intrahepatic Portosystemic Shunt for Refractory Ascites After Liver Transplantation

Transplantation Journal ◽

10.1097/tp.0b013e31820e014e ◽

2011 ◽

pp. 1 ◽

Cited By ~ 1

Author(s):

Eyob Feyssa ◽

Jorge Ortiz ◽

Kevin Grewal ◽

Ashaur Azhar ◽

Afshin Parsikia ◽

...

Keyword(s):

Liver Transplantation ◽

Transjugular Intrahepatic Portosystemic Shunt ◽

Meld Score ◽

Portosystemic Shunt ◽

Prolonged Survival ◽

Refractory Ascites ◽

Intrahepatic Portosystemic Shunt

Download Full-text

Hemodynamic Evaluation of Nonselective β-Blockers in Patients with Cirrhosis and Refractory Ascites

Gastroenterology Research and Practice ◽

10.1155/2018/4098210 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Alberto Ferrarese ◽

Valerie Tikhonoff ◽

Edoardo Casiglia ◽

Paolo Angeli ◽

Silvano Fasolato ◽

...

Keyword(s):

Liver Transplantation ◽

Negative Inotropic Effect ◽

Plasma Renin ◽

Primary Prophylaxis ◽

Refractory Ascites ◽

Hemodynamic Effects ◽

Peripheral Vascular ◽

Increasing Trend ◽

Β Blockers ◽

Large Volume Paracentesis

Background. Nonselective β-blockers (NSBB) have been associated with increased incidence of paracentesis-induced circulatory dysfunction (PICD) and reduced survival in patients with cirrhosis and refractory ascites. Aim. To prospectively evaluate a hemodynamic response to NSBB in cirrhotics listed for liver transplantation with refractory ascites undergoing large volume paracentesis (LVP). Methods. Patients with cirrhosis and refractory ascites, with an indication to start NSBB in primary prophylaxis for variceal bleeding, were enrolled. During two consecutive LVP, while being, respectively, off and on NSBB, cardiac output (CO), systemic vascular resistances (SVR), peripheral vascular resistances (PVR), and plasma renin activity (PRA) were noninvasively assessed. Results. Seventeen patients were enrolled, and 10 completed the study. Before NSBB introduction, SVR (1896 to 1348 dyn·s·cm−5; p=0.028) and PVR (47 to 30 mmHg·min·dl·ml−1; p=0.04) significantly decreased after LVP, while CO showed an increasing trend (3.9 to 4.5 l/m; p=0.06). After NSBB introduction, LVP was not associated with a significant increase in CO (3.4 to 3.8 l/m; p=0.13) nor with a significant decrease in SVR (2002 versus 1798 dyn·s·cm−5; p=0.1). Incidence of PICD was not increased after NSBB introduction. Conclusion. The negative inotropic effect of NSBB was counterbalanced by a smaller decrease of vascular resistances after LVP, probably due to splanchnic β2-blockade. This pilot study showed that NSBB introduction may be void of detrimental hemodynamic effects after LVP in cirrhotics with refractory ascites.

Download Full-text

Faculty Opinions recommendation of Automated low flow pump system for the treatment of refractory ascites: a multi-center safety and efficacy study.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.717976415.793470830 ◽

2013 ◽

Author(s):

Philip Rosenthal

Keyword(s):

Low Flow ◽

Refractory Ascites ◽

Efficacy Study ◽

Pump System ◽

Safety And Efficacy ◽

Automated Low Flow ◽

Flow Pump

Download Full-text

Transjugular Intrahepatic Portosystemic Shunt in Ascites: Updates

Digestive Disease Interventions ◽

10.1055/s-0037-1609042 ◽

2017 ◽

Vol 01 (04) ◽

pp. 254-258

Author(s):

Harry Trieu ◽

Stephen Kee ◽

Edward Lee

Keyword(s):

Transjugular Intrahepatic Portosystemic Shunt ◽

American Association ◽

Survival Rates ◽

Covered Stent ◽

Portosystemic Shunt ◽

Refractory Ascites ◽

Covered Stents ◽

Significant Survival ◽

Intrahepatic Portosystemic Shunt ◽

Large Volume Paracentesis

AbstractThe 2009 update of the American Association for the Study of Liver Diseases (practice guidelines recommends transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of refractory ascites in patients who do not tolerate repeated large volume paracentesis (LVP). It also stated uncertain survival benefit and possible increase in the risk of hepatic encephalopathy (HE). Since this update was published, new studies concerning TIPS as therapy for refractory ascites have emerged. Five studies reported a significant survival improvement in patients who underwent TIPS compared with LVP for refractory ascites, while a single study noted improved survival rates in covered stent TIPS recipients. Three studies found a significantly greater prevalence of severe HE in TIPS recipients compared with LVP recipients; however, only one study reported a significant association between TIPS and increased development of HE of all grades. Based on our review of the current literature, we recommend TIPS over LVP for the treatment of refractory ascites. Further, covered stents should be used for TIPS creation whenever possible.

Download Full-text