Ascites after liver transplantation

Abstract

Massive ascites after liver transplantation, although uncommon, usually represents a serious adverse event. The pathogenesis of this complication has not been adequately investigated. To determine the incidence, characteristics, and pathogenic factors of massive ascites after liver transplantation (ascitic fluid G 500 mL/d for G10 days), the charts of 378 liver transplant recipients were reviewed. Massive ascites occurred in 25 patients (7%). Mean ascitic fluid production was 960 mL/d (range, 625 to 2,350 mL/d), and the duration of ascites was 77 days (range, 15 to 223 days). The ascitic fluid had a high protein content (36 ؎ 7 g/L; range, 25 to 50 g/L). When patients who did and did not develop massive ascites were compared, significant differences were found in receptor sex (men, 88% v 60%, respectively; P F .01) and surgical technique (inferior vena cava preservation with piggyback technique, 72% v 41%; P F .01). Significantly increased wedged and free hepatic venous pressures and gradients between hepatic vein and right atrial pressures were found in patients who developed ascites, suggesting a difficulty in graft blood outflow. Massive ascites was associated with renal impairment, increased incidence of abdominal infection, prolonged hospitalization, and a tendency toward reduced survival. In conclusion, massive ascites after liver transplantation is relatively uncommon but associated with increased morbidity and mortality and is predominantly related to difficulties of hepatic venous drainage. Measurement of hepatic vein and atrial pressures to detect a significant gradient and correct possible alterations in hepatic vein outflow should be the first approach in the management of these patients.

Report of the first international liver transplantation society expert panel consensus conference on renal insufficiency in liver transplantation

“…It has been shown that the piggyback technique does not compromise renal outflow at any time, maintaining normal kidney function 170. The anastomosis of the donor liver to the vena cava is performed at the junction of the 3 hepatic veins, with care taken to avoid compromising vena cava flow 171, 172. It has been argued that preserving the vena cava is the most “physiological” method of removing the diseased liver.…”

The need for venovenous bypass in liver transplantation

“…Nonetheless, some centers still use VVB in such patients because of partial venous obstruction resulting from side‐clamping of the IVC 15 . In fact, the unwillingness to use PLTx without VVB or temporary passive shunt at some small transplant centers is mainly due to their fear of venous complications without the use of VVB 61 62 . Moreover, they believe that with the use of meticulous approaches, e.g.…”

Splenic artery embolization for the treatment of refractory ascites after liver transplantation

“…Refractory ascites (RA) is a rare complication after adult orthotopic liver transplantation; its incidence ranges from 5% to 7% 1. The most common causes of posttransplant RA are hepatic inflow and outflow obstructions, acute or chronic rejection, recurrent hepatitis, and heart failure.…”

“…The most common causes of posttransplant RA are hepatic inflow and outflow obstructions, acute or chronic rejection, recurrent hepatitis, and heart failure. Recurrent intraperitoneal infections, renal insufficiency, electrolyte imbalances, and a failure to thrive are commonly associated with this condition 1‐3…”