The North American Study for the Treatment of Refractory Ascites

Sanyal, Arun J.; Genning, Chris; Reddy, K. Rajender; Wong, Florence; Kowdley, Kris V.; Benner, Kent G.; McCashland, Timothy M.

doi:10.1053/gast.2003.50088

Cited by 403 publications

(283 citation statements)

References 23 publications

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“…9 Sinusoidal portal hypertension is clearly important in the pathogenesis of cirrhotic ascites, [1][2][3] as demonstrated by the resolution or improvement of ascites after TIPS insertion. [4][5][6][7][8] However, we believe this subtle sodium retention in these patients is not solely related to the presence of portal hypertension because the functioning TIPS normalizessinusoidal portal pressure.…”

Section: Discussionmentioning

confidence: 77%

“…However, it is clear that sinusoidal portal hypertension plays a pathogenetic role, [1][2][3] as reduction in sinusoidal portal pressure using a transjugular intrahepatic portosystemic stent shunt (TIPS) in patients with cirrhosis and refractory ascites resulted in either resolution or reduction of ascites. [4][5][6][7][8] However, other mechanisms are also likely to be involved, because post-TIPS ascites-free patients with cirrhosis continue to demonstrate a degree of sodium retention when challenged with a sodium load despite a normal portal-systemic gradient. 9 This occurs despite an adequately filled effective arterial blood volume (EABV) as shown by normal plasma renin activity, plasma aldosterone, and norepinephrine (PNE) levels, 9 suggesting that it is not underfilling of the EABV as described by the Peripheral Arterial Vasodilatation Hypothesis 10 that is responsible for the sodium retention on sodium challenge in these patients.…”

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confidence: 99%

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The effect of single oral low-dose losartan on posture-related sodium handling in post-TIPS ascites-free cirrhosis

et al. 2006

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Post-TIPS ascites-free patients with cirrhosis and previous refractory ascites demonstrate subtle sodium retention when challenged with a high sodium load. This is also observed in pre-ascitic patients with cirrhosis. This phenomenon is dependent on an intrarenal angiotensin II (ANG II) mechanism related to the assumption of erect posture. We investigated whether similar mechanisms were involved in post-TIPS ascites-free patients, by studying 10 patients with functioning TIPS and no ascites. We measured the effect of changing from supine to erect posture on sodium excretion at baseline and after single oral low dose losartan (7.5 mg) which has been shown to blunt proximal and distal tubular sodium reabsorption in pre-ascites. At baseline, the assumption of erect posture produced a reduction in sodium excretion (from 0.30 ؎ 0.06 to 0.13 ؎ 0.02 mmol/min, P ‫؍‬ .05), which was mainly due to an increase in proximal tubular reabsorption of sodium (PTRNa) (69.7 ؎ 3.1% to 81.1 ؎ 1.8%, P ‫؍‬ .003). The administration of losartan resulted in a blunting of PTRNa (supine 69.7 ؎ 3.1% to 63.9 ؎ 3.9%, P ‫؍‬ .01 and erect 81.1 ؎ 1.8% to 73.8 ؎ 2.4%, P ‫؍‬ .01), accompanied by an increased distal tubular reabsorption of sodium in both postures, with no overall improvement in sodium excretion on standing. In conclusion, post-TIPS ascitesfree patients with cirrhosis exhibit erect posture-induced sodium retention. We speculate that (1) this effect is partly mediated by the effect of ANG II on PTRNa and (2) that the inability of low dose losartan to block the erect posture-induced sodium retention may be related to the erect posture-induced rise in aldosterone which is unmodified by losartan. (HEPATOLOGY 2006;44:640-649.)

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Section: Discussionmentioning

confidence: 77%

mentioning

confidence: 99%

The effect of single oral low-dose losartan on posture-related sodium handling in post-TIPS ascites-free cirrhosis

et al. 2006

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“…Numerosi trials controllati hanno comparato l'efficacia della TIPS con la terapia medica ed endoscopica nella profilassi del sanguinamento da varici e nel trattamento dell'ascite refrattaria, che rimangono le principali indicazioni, univocamente condivise [1][2][3][4][5][6][7]; le linee guida alla procedura sono state tracciate sulla base di aspetti tecnici angiografici, fattori prognostici clinico-laboratoristici ed incidenza di complicanze. Indicazioni più rare ed oggetto di studi non controllati condotti su piccoli gruppi di pazienti, alcune delle quali non uniformemente accettate sono: la trombosi portale, la sindrome di Budd-Chiari, l'ascite pleurica [8][9][10], la sindrome epato-polmonare (HPS) [11], la sindrome epato-renale (HRS) [3,[12][13][14][15][16][17], la profilassi del sanguinamento intraoperatorio in pazienti cirrotici con ipertensione portale candidati ad interventi di chirurgia addominale maggiore [8,18,19] e la tutela della pervietà portale pre-trapianto epatico (OLT) [20,21].…”

Section: Da Oltre 20 Anni Lo Shunt Intraepatico Porto-sistemico (Tipsunclassified

“…A number of controlled trials have compared the efficacy of TIPS versus medical and endoscopic treatment in preventing variceal bleeding and treating refractory ascites, to date the universally accepted indications for TIPS [1][2][3][4][5][6][7]. Guidelines for the procedure have been established on the basis of technical angiographic aspects, clinical and laboratory prognostic factors and complication rate.…”

Section: Introductionmentioning

confidence: 99%

Fifteen years’ experience with transjugular intrahepatic portosystemic shunt (TIPS) using bare stents: retrospective review of clinical and technical aspects

et al. 2008

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Purpose. The authors present a retrospective analysis of a large series of patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement. Materials and methods. Between March 1992 and December 2006, 658 patients were referred to our centre for TIPS placement. Indications for the procedure were digestive tract bleeding (52.8%), refractory ascites (35.3%), preservation of portal vein patency prior to liver transplantation (3.0%) and thrombosis of the suprahepatic veins (2.3%). Other indications (6.6%) included pleural ascites, portal thrombosis and hepatorenal and hepatopulmonary syndromes. All patients were evaluated with colour Doppler ultrasonography and in a few cases with computed tomography. The portal system was punctured under sonographic guidance. Wallstent, Palmaz and Nitinol thermosensitive stents were used. Embolisation of persistent varices was performed in 6.8% of cases. Results. Technical success was 98.9%. During a 1,500-day follow-up, the cumulative incidence of stent revision was 25.7% (Nitinol), 32.9% (Wallstent) and 1.8% (Palmaz). Mortality rates were 31.1%, 38.5% and 56.4%, respectively. The technical complications included six cases of heart failure, six of haematobilia, three of stent migration, two of intrahepatic haematoma and one of haemoperitoneum. Eight patients with severe portosystemic encephalopathy (PSE) were treated with a reduction stent. Riassunto

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“…The purpose of TIPS is to decompress the portal system and therefore treat the complications of portal hypertension. TIPS has been proven to be an effective treatment for secondary prevention of variceal bleeding, as well as refractory cirrhotic ascites, with controlled trials (2)(3)(4)(5). Besides these, TIPS has been used in a variety of different clinical conditions, including Budd-Chiari syndrome (BCS).…”

Section: Transjugular Intrahepatic Portosystemic Shunt (Tips)mentioning

confidence: 99%

Transjugular intrahepatic portosystemic shunt: Where are we?

Altun

Yıldırım²,

Öcal³

et al. 2014

Turk J Gastroenterol

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Background/Aims: The purpose of this study was to evaluate the technical/hemodynamic success, complications, and biochemical/ hematologic consequences of transjugular intrahepatic portosystemic shunt (TIPS) created with 10-mm bare stents in our patients. Materials and Methods: Data of 27 cirrhotic patients (18 men and 9 women; mean age, 39.7±18.7 years) with a median MELD score 14 (range 7-31) treated with TIPS between January 2000 and August 2010 were evaluated retrospectively. Results: The indications were refractory bleeding varices in 48.2%, refractory ascites in 22.2%, and Budd-Chiari syndrome in 29.6% of the patients. Technical and hemodynamic success rates were 96.3% and 92.3%, respectively. Mean portosystemic pressure gradient decreased from 21.5±5.3 mm Hg to 9±2.7 mm Hg (p<0.05). The rate of primary stent patency was 76.9% 1 year after the procedure. No statistically significant difference in shunt dysfunction was found between the groups of patients treated for Budd-Chiari syndrome and other indications (p>0.05). One patient (3.7%) had shunt dysfunction due to thrombosis within 24 hours. New and/or worsening hepatic encephalopathy occurred in 34.6% of patients. Increased age (≥40 years) was significantly related to hepatic encephalopathy in both univariate and multivariate analyses (p<0.05). Thirty-day mortality rate and 1-year transplant-free survival rate were 0% and 80.7%, respectively. Conclusion: Transjugular intrahepatic portosystemic shunt procedure is a safe treatment for many patients with cirrhosis, but post-procedure hepatic encephalopathy and shunt dysfunction are still problems. Especially, patient age should be taken into consideration in predicting hepatic encephalopathy risk.

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The North American Study for the Treatment of Refractory Ascites

Cited by 403 publications

References 23 publications

The effect of single oral low-dose losartan on posture-related sodium handling in post-TIPS ascites-free cirrhosis

The effect of single oral low-dose losartan on posture-related sodium handling in post-TIPS ascites-free cirrhosis

Fifteen years’ experience with transjugular intrahepatic portosystemic shunt (TIPS) using bare stents: retrospective review of clinical and technical aspects

Transjugular intrahepatic portosystemic shunt: Where are we?

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