Outcomes and Mortality of Grade 1 Ascites and Recurrent Ascites in Patients With Cirrhosis

Abstract

This article has an accompanying continuing medical education activity, also eligible for MOC credit, on page exx. Learning Objective-Upon completion of this activity, successful learners will be able to evaluate the grade of ascites in patients with cirrhosis and to identify the correct treatment according to the different classifications. BACKGROUND & AIMS:Ascites has been classified according to quantity and response to medical therapy. Despite its precise definitions, little is known about the effects of grade 1 ascites or recurrent ascites (i.e.ascites that recurs at least on 3 occasions within a 12-month period despite dietary sodium restriction and adequate diuretic dosage) on patient outcome. We studied progression of grade 1 ascites and recurrent ascites in a large cohort of outpatients with cirrhosis. METHODS:We performed a post-hoc analysis of data from 547 outpatients with cirrhosis (259 without ascites, 54 patients with grade 1 ascites, 234 with grade 2 or 3 ascites) who participated a care management program study in Italy from March 2003 through September 2017. We collected demographic, clinical, and laboratory data and patients were evaluated at least every 6 months.Patients received abdominal ultrasound analysis at study inclusion and at least twice a year. Number and volume of paracentesis were collected, when available. Patients were followed until death, liver transplantation, or March 2018. The median follow-up time was 29 months. Primary outcomes were mortality and development of complications of cirrhosis. RESULTS:There was no significant difference in 60-month transplant-free survival between patients with grade 1 vs grade 2 or 3 ascites (36% vs 43%) but survival was significantly lower when both groups were compared with patients without ascites (68%; P < .001 for both comparisons). However, the grade of systemic inflammation and the rate of complications were significantly greater in patients with grade 1 ascites than in patients without ascites, but significantly lower than in patients with grade 2 or 3 ascites. Development of grade 2 or 3 ascites did not differ significantly between patients with no ascites vs grade 1 ascites (10% vs 14%). There was no significant difference in 36-month transplant-free survival between patients with ascites responsive to medical treatment vs recurrent ascites (78% vs 62%), whereas patients with refractory ascites had significantly lower survival than patients with responsive or recurrent ascites (23%; responsive vs refractory ascites P<.001; recurrent vs refractory ascites P [ .022). CONCLUSIONS:In an analysis of data from a large cohort of outpatients with cirrhosis, we found that grade 1 ascites is associated with systemic inflammation, more complications, and increased mortality compared with no ascites. Mortality does not differ significantly between patients with recurrent ascites vs ascites responsive to medical treatment.

Towards a new definition of decompensated cirrhosis

“…Finally, the concept (and current definition) of AD does not apply to patients who develop decompensation in a progressive way, as in the case of the many patients who present with slow and progressive ascites formation or mild grade 1 or 2 hepatic encephalopathy or jaundice. 31 Unpublished data from a multicentre European database including 1,858 consecutive patients with We propose that decompensation of cirrhosis may be characterised by an acute onset (AD) or by a progressive, nonacute onset (NAD). AD is defined as any first or recurrent grade 2 or 3 ascites within less than 2 weeks, first or recurrent acute hepatic encephalopathy in patients with previous normal consciousness, acute gastrointestinal bleeding, and any type of acute bacterial infection.…”

New clinical and pathophysiological perspectives defining the trajectory of cirrhosis

“…32 Therefore further decompensation are also needed in these patients, for whom watchful follow-up is currently recommended. [33][34][35] Current understanding of the pathophysiologic basis of decompensated cirrhosis, AD and its limitations…”

“…Journal of Hepatology 2021 vol. 75 j S14-S26 Review ascites, 35 grade 1 hepatic encephalopathy 85,86 or CSPH with or without varices. 17 Thus, the CANONIC and PREDICT studies focus on a set of patients at higher risk of acute decompensation and therefore mortality.…”

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

“…Thus, currently available data (Table 2 ) suggest that TIPS should be considered early in patients with difficult-to-treat ascites (not necessarily fulfilling the criteria of RA) having a stable underlying liver disease with relatively preserved renal function. However, a recent observational study on outcomes and mortality of patients with cirrhosis with recurrent ascites found that mortality does not differ significantly between patients with recurrent ascites and patients with ascites responsive to medical treatment and that recurrent ascites is not necessarily a sign of worsening of the liver disease, implying that these patients should not be prioritized for TIPS or liver transplant[ 104 ]. Further large multicentre prospective RCTs are needed to assess the role of “early TIPS” in ascites.…”