Systematic review with meta‐analysis: automated low‐flow ascites pump therapy for refractory ascites

Abstract

Summary Background Few effective treatments are available for patients with cirrhosis and refractory ascites. New treatment modalities are needed for these patients. Aim To synthesise the available evidence on the efficacy and safety of automated low‐flow ascites pump therapy in patients with cirrhosis and refractory ascites. Methods Electronic databases were searched for trials evaluating automated low‐flow ascites pump therapy in patients with refractory ascites. Results Nine studies were included. Eight were case series, one was a randomised controlled trial. Pooled estimate rates were 0.62 (95% CI = 0.49‐0.74) for the absence of requirement of large volume paracentesis (LVP) after pump insertion, 0.30 (95% CI = 0.17‐0.47) for acute kidney injury, 0.27 (95% CI = 0.13‐0.49) for bacterial peritonitis and 0.20 (95% CI = 0.09‐0.37) for urinary tract infection. There was high heterogeneity between studies which was often reduced or eliminated in sensitivity analyses by excluding studies of patients with a mean or median model for end‐stage liver disease (MELD) score > 15. Results of sensitivity analyses were similar to those of overall analyses. Mean increase in serum creatinine level after pump insertion was 23 µmol/L (95% CI = 10‐35) with no heterogeneity between studies. The pooled estimate rate for pump‐related side effects was 0.77 (95% CI = 0.64‐0.87) with low heterogeneity between studies. Conclusion This meta‐analysis demonstrates that most patients treated with automated low‐flow ascites pump therapy do not require LVP after pump insertion. Acute kidney injury occurs in 30% of patients and creatinine levels increase by a mean of 23 µmol/L after pump insertion. Bacterial peritonitis and urinary tract infection occur in 27% and 20% of patients respectively.

Transjugular intrahepatic portosystemic shunt and alfapump® system for refractory ascites in liver cirrhosis: Outcomes and complications

“…Indeed, the renal function of alfapump® patients, evaluated as CKD‐EPI‐eGFR, decreased about 22 ml/min in the first six months in our study. This corroborates a meta‐analysis indicating a rise in creatinine of 23 μmol/l in patients with alfapump® 21 . We observed a trend towards a higher rate of bacterial infection in alfapump® vs TIPS (55% versus 26%, p = 0.07), which might have contributed to the higher AKI and HRS rate.…”

“…Contrary to AKI, we observed a higher rate of ileus in patients with TIPS, especially in patients with umbilical hernias. HE was frequent in both groups, more frequent than reported elsewhere for TIPS 23 as well for alfapump V R , 21 without differences among treatment. As HE is a clinical diagnosis, the assessment of HE often varies between different studies.…”

“…This corroborates a meta-analysis indicating a rise in creatinine of 23 lmol/ l in patients with alfapump V R . 21 We observed a trend towards a higher rate of bacterial infection in alfapump V R vs TIPS (55% versus 26%, p ¼ 0.07), which might have contributed to the higher AKI and HRS rate. As our patients only received albumin in cases of LVP with more than 5 l extracted, the loss of proteins through the urinary output might also have led to the high rate of HRS and pre-renal impairment as well as the worsening eGFR, which had already been suggested by Sola`et al 9 In contrast to alfapump V R patients, the eGFR increased in patients with TIPS.…”

HEP-Net opinion on the management of ascites and its complications in the setting of decompensated cirrhosis in the resource constrained environment of Pakistan

“…However long term studies with larger patient populations are ongoing which will further establish main concerns about such a system, especially pump dysfunction (pump failure and bladder and peritoneal catheter related problems), infection, ascitic fluid leakage through wounds, bladder perforation and renal impairment. [68][69][70][71][72][73] Recommendations: The incidence of SBP in cirrhotic patients in Pakistan averages 27-38 % of all patients admitted to hospitals, as noted in various studies. [74][75][76][77][78] Up to 10% of asymptomatic patients with cirrhosis presenting for routine outpatient checkups have been found to have SBP.…”

Tunnelled Peritoneal Catheter for Malignant Ascites—An Open-Label, Prospective, Observational Trial

“…This procedure leads to a reduction in the number of paracenteses and an improvement of quality of life. However, this procedure is rather expensive and associated with a number of complications, such as renal failure, infections and dysfunction of the pump system [4]. The implantation of peritoneovenous shunts is another option, but contraindicated for ascites due to gastrointestinal malignancies.…”