Ascites becomes refractory to medical treatment in nearly 10% of cirrhotic patients, who then require repeated large-volume paracentesis. In this prospective study we evaluated the use of transjugular intrahepatic
portosystemic shunt (
TIPS) in 30 patients with refractory
ascites.
TIPS was successful in all and resulted in a 54% reduction in portacaval gradient (from 22.8 +/- 0.8 to 10.4 +/- 0.6 mm Hg).
Ascites became easily controlled with
diuretics in 26 patients following
TIPS.
Ascites recurrence associated with shunt
stenosis was observed during follow-up in eight patients; revision could be undertaken in five of them and resulted in good control of
ascites. In responders, a marked decrease in plasma
aldosterone and
renin activity, a reduction in serum
creatinine, and a rise in urinary
sodium excretion were observed.
Creatinine and
inulin clearances improved significantly; PAH clearance remained unchanged. However, new-onset or worsening
hepatic encephalopathy was seen in 14 patients. Severe disabling
chronic encephalopathy occurred in five patients; it could be reversed successfully by balloon occlusion of the shunt in three. The cumulative survival rate was 41 and 34% at 1 and 2 years, respectively. In summary,
TIPS can control refractory
ascites in a majority of patients but is associated with a high rate of chronic disabling HE. In addition, the survival rate is poor. Randomized trials are needed to evaluate the exact role of
TIPS in the management of refractory
ascites. It is unlikely to improve survival but can ameliorate quality of life in nontransplant candidates and be useful as a bridge to
transplantation, in particular, to improve denutrition associated with longstanding tense
ascites.