Current treatment options of refractory ascites in liver cirrhosis – A systematic review and meta-analysis

Abstract

Background: Refractory ascites is a severe complication of liver cirrhosis and treatment options consist in large volume paracentesis, transjugular intrahepatic portosystemic shunt, alfapump®, peritoneovenous shunt and permanent indwelling peritoneal catheter. Aim: Our aim was to assess the efficacy, mortality and complications of each treatment. Methods: We performed a systematic review using Pubmed and Embase. Frequencies were summarized with Comprehensive Meta-Analysis Software. Results: Seventy-seven studies were included. In patients with transjugular intrahepatic portosystemic shunt, 1-year mortality was 33% (95% CI 0.29-0.39, I 2 = 82.1; τ 2 = 0.37; p < 0.001) with lower mortality in newer studies (26% vs. 44%). At 6 months, mortality in patients with alfapump® was 24% (95% CI 0.16-0.33, I 2 = 0.0 0; τ 2 = 0.0 0; p = 0.83), 31% developed acute kidney injury (95% CI 0.18-0.48, I 2 = 44.0; τ 2 = 0.22; p = 0.15). Mortality at 12 months was 44% (95% CI 32%-58%, I 2 = 76.7, τ 2 = 0.44, p < 0.001) in peritoneovenous shunts and 45% (95% CI 38%-53%, I 2 = 61.4, τ 2 = 0.18, p = 0.003) in large volume paracentesis, respectively. Overall mortality in patients with permanent indwelling catheters was 66% (95% CI 33%-89%, I 2 = 82.5, τ 2 = 1.57, p = 0.001).Discussion: Mortality in patients with transjugular intrahepatic portosystemic shunt was lower in newer studies, probably due to a better patient selection. Acute kidney injury was frequent in patients with alfapump®. Permanent indwelling catheters seemed to be a good option in a palliative setting.

Postoperative chylous ascites after total gastrectomy successfully treated using peritoneovenous (Denver) shunt: a case report

“…Upon identifying the leakage, suture ligation of the lymphatic vessels may help resolve the leak. PVS is considered an option for patients who are poor candidates for surgery [ 15 ]. Although we considered a surgical treatment in our patient, we decided against it.…”

“…PVS is primarily accepted as a treatment for refractory cirrhotic or malignant ascites [ 15 , 16 ], and is also indicated in CA [ 15 ]. PVS can provide immediate relief from symptoms.…”

Management of refractory ascites

“…11,62 Clearance of ascites with TIPS is associated with improved quality of life, 63 better nitrogen balance, 64 significant muscle gain, 65 and improved survival. 48,66,67 A recently validated Freiburg Index of Post-TIPS survival (FIPS) included age, bilirubin, albumin, and creatinine in its prediction of high risk for mortality post-TIPS. Patients in the high-risk category had a median post-TIPS survival of 5 months vs. 48 months in the low-risk group (P<0.001).…”

“…75,80 The effects of the alfapump on the survival of these patients has not been formally studied but has been shown to be at least the same as patients who undergo regular LVP. 66…”

“…Various academic societies have recommended against placing a TIPS in patients who are older than 70 years of age, with a MELD score of >18, who have had spontaneous HE ≥ grade 2, or the presence of cardiac failure, pulmonary hypertension, liver cancer, sepsis, or occlusive portal vein thrombosis [ 11 , 62 ]. Clearance of ascites with TIPS is associated with improved quality of life [ 63 ], better nitrogen balance [ 64 ], significant muscle gain [ 65 ], and improved survival [ 48 , 66 , 67 ]. A recently validated Freiburg Index of Post-TIPS survival (FIPS) included age, bilirubin, albumin, and creatinine in its prediction of high risk for mortality post-TIPS.…”