TIPS & REFRACTORY ASCITES

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Dig Dis Sci. 2003

TIPS for management of refractory ascites: response and survival are both unpredictable.Thuluvath PJ, Bal JS, S, Lund G, Venbrux A.Department of Medicine, The s Hopkins University School of MedicineRefractory ascites is a serious complication of advanced cirrhosis with a 1-year transplant-free survival of 20-50%. The aim of our study was to investigate the short- and long-term effects of transjugular intrahepatic portosystemic shunt (TIPS) in the management of refractory ascites. In all 65 patients (39 M, 26 F; Child B 55%, Child C 45%, mean MELD score 14.8 +/- 6.6) with liver disease (alcoholic 40%, cryptogenic 20%, HCV 14%, others 26%) and refractory ascites were included in this study. Forty-eight (74%) patients had no signs of hepatic encephalopathy (HE), 16 (24%) had mild and 1 (2%) had moderate HE before TIPS; 28 (43%) had mild (> 1.2 and < 2.4 mg/dl) and 6 patients (9%) had moderate (> 2.4 mg/dl) renal dysfunction. Mean follow-up was 55.5 +/- 70.2 weeks. Treatment success, defined as complete response, partial response, and no response, and survival was determined at 3 weeks, and 3, 6, 12, 24, and 36 months after TIPS. TIPS was successful in all patients. Mean portal venous pressure gradient improved significantly after TIPS (24 +/- 8 to 10 +/- 4). During follow-up, 40 (58%) patients died and 17 (27%) patients had liver transplantation (OLT); 20 (31%) patients had 38 shunt revisions due to lack of initial response or recurrence of ascites. The response was assessed in patients who were alive, without OLT, at each time point. Complete response was seen in 10%, 23%, 17%, 11%, 22% and 33%; partial response was seen in 46%, 46%, 40%, 44%, 28%, and 8%; and no response was seen in 44%, 31%, 43%, 41 %, 39%, and 50% at 3 weeks, and 3, 6, 12, 24, and 36 months respectively. There were no pre-TIPS variables that could predict the response at 3 weeks, 3 months, or 6 months. Mild HE was seen in 8 (12%) patients and severe HE was seen in 16 (25%) immediately after TIPS. The mortality at 3 weeks, and 3, 6, 12, 24, and 36 months was 26%, 38%, 46%, 51%, 57%, and 58%, respectively. Three-week (P = 0.01) and 3-month (P = 0.04) mortality was higher in Child C patients compared to Child B. However, there were no independent predictors of survival on multivariate analysis at 3 or 6 months. Child-Pugh score 3 weeks after TIPS was a strong predictor of mortality. In conclusion, in patients with refractory ascites, TIPS was associated with a high mortality and morbidity. The response and the mortality were both unpredictable on the basis of pretransplant variables.

Barb here - ANYONE CARE TO COMMENT ON THESE RESULTS?

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TJ & Barb Henshaw writes:

>Dig Dis Sci. 2003

>

>TIPS for management of refractory ascites: response and survival are

>both unpredictable.

>

> In conclusion, in patients with refractory ascites, TIPS was

>associated with a high mortality and morbidity. The response and the

>mortality were both unpredictable on the basis of pretransplant

>variables.

>

>Barb here - ANYONE CARE TO COMMENT ON THESE RESULTS?

I'm not great at reading medicalese. But this study makes it sound to me

like the results from TIPS for refractory ascites are not good enough. Is

refractory ascites the usual horrible water retention in the abdomen and

legs that leads to such things as 6 liters of water can be drained with

paracenteisis (not sure the spelling) that plagues PSC patients in advanced

end stage liver disease.

TIPS was recommended for my husband, Colin at UCLA, as his MELD scores were

holding at 21 or less, despite having had encepalopathy and varices and

severe ascites. The TIPS procedure was not successful. They couldn't get

through. I think they described it as fibrotic veins blocked the

passageway. So he was hospitalized at ULCA for 2 weeks altogether. Then,

after being told that his MELD scores were not high enough, they suddenly

gave him a liver transplant without ever telling us why he suddenly

qualified. We're happy! Reading this article, I'm glad the TIPS didn't

work, and perhaps it would have delayed the liver transplant.

Janet, wife of Colin, dx PSC 1990, liver tx April, 2003, UCLA