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Xu X, Ding H, Jia J, Wei L, Duan Z, Tang C, Linghu E, Nan Y, Han Y, Xu J, Zhuang H. Chinese guidelines on the management of ascites in cirrhosis : Chinese Society of Hepatology, Chinese Medical Association. Hepatol Int 2024; 18:1071-1089. [PMID: 38980598 DOI: 10.1007/s12072-024-10697-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/03/2024] [Indexed: 07/10/2024]
Abstract
In 2023, Chinese Society of Hepatology of Chinese Medical Association convened a panel of experts to update the Chinese guidelines on the management of ascites and associated complications in cirrhosis which was launched in 2017 and renamed this guidelines as "Guidelines on the Management of Ascites in Cirrhosis." This comprehensive resource offers essential recommendations for the diagnosis and treatment of cirrhotic ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome.
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Affiliation(s)
- Xiaoyuan Xu
- Department of Gastroenterology, Peking University First Hospital, No. 8, Xishiku St. Xicheng District, Beijing, China.
| | - Huiguo Ding
- Liver Disease and Digestive Center, Beijing Youan Hospital, Capital Medical University, No. 8, West Headline Outside You'anmen, Fengtai District, Beijing, China
| | - Jidong Jia
- Liver Disease Center, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong'an Road, Xicheng District, Beijing, China
| | - Lai Wei
- Hepatobiliary and Pancreatic Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, No. 168, Litang Road, Changping District, Beijing, China
| | - Zhongping Duan
- Liver Disease Center, Beijing Youan Hospital, Capital Medical University, No. 8, West Headline Outside You'anmen, Fengtai District, Beijing, China
| | - Chengwei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, Sichuan Province, China
| | - Enqiang Linghu
- Digestive Department, First Medical Center of Chinese, PLA General Hospital, No. 28, Fuxing Road, Haidian District, Beijing, China
| | - Yuemin Nan
- Department of Integrated Traditional Chinese and Western Medicine for Liver Diseases, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang, Hebei Province, China
| | - Ying Han
- Liver Disease and Digestive Center, Beijing Youan Hospital, Capital Medical University, No. 8, West Headline Outside You'anmen, Fengtai District, Beijing, China
| | - Jinghang Xu
- Department of Infectious Diseases, Peking University First Hospital, No. 8, Xishiku St. Xicheng District, Beijing, China
| | - Hui Zhuang
- Department of Pathogenic Biology, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, China
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2
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Nadim MK, Kellum JA, Forni L, Francoz C, Asrani SK, Ostermann M, Allegretti AS, Neyra JA, Olson JC, Piano S, VanWagner LB, Verna EC, Akcan-Arikan A, Angeli P, Belcher JM, Biggins SW, Deep A, Garcia-Tsao G, Genyk YS, Gines P, Kamath PS, Kane-Gill SL, Kaushik M, Lumlertgul N, Macedo E, Maiwall R, Marciano S, Pichler RH, Ronco C, Tandon P, Velez JCQ, Mehta RL, Durand F. Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting. J Hepatol 2024; 81:163-183. [PMID: 38527522 PMCID: PMC11193657 DOI: 10.1016/j.jhep.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 03/27/2024]
Abstract
Patients with cirrhosis are prone to developing acute kidney injury (AKI), a complication associated with a markedly increased in-hospital morbidity and mortality, along with a risk of progression to chronic kidney disease. Whereas patients with cirrhosis are at increased risk of developing any phenotype of AKI, hepatorenal syndrome (HRS), a specific form of AKI (HRS-AKI) in patients with advanced cirrhosis and ascites, carries an especially high mortality risk. Early recognition of HRS-AKI is crucial since administration of splanchnic vasoconstrictors may reverse the AKI and serve as a bridge to liver transplantation, the only curative option. In 2023, a joint meeting of the International Club of Ascites (ICA) and the Acute Disease Quality Initiative (ADQI) was convened to develop new diagnostic criteria for HRS-AKI, to provide graded recommendations for the work-up, management and post-discharge follow-up of patients with cirrhosis and AKI, and to highlight priorities for further research.
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Affiliation(s)
- Mitra K Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lui Forni
- School of Medicine, University of Surrey and Critical Care Unit, Royal Surrey Hospital Guildford UK
| | - Claire Francoz
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, Paris, France
| | | | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, UK
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jody C Olson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University and Hospital of Padova, Padova, Italy
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Columbia University, New York, NY, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Divisions of Critical Care Medicine and Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, University and Teaching Hospital of Padua, Italy
| | - Justin M Belcher
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Scott W Biggins
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Akash Deep
- Pediatric Intensive Care Unit, King's College Hospital, London, UK
| | - Guadalupe Garcia-Tsao
- Digestive Diseases Section, Yale University School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Yuri S Genyk
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Division of Abdominal Organ Transplantation at Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Pere Gines
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi-Sunyer and Ciber de Enfermedades Hepàticas y Digestivas, Barcelona, Catalonia, Spain
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Nuttha Lumlertgul
- Excellence Centre in Critical Care Nephrology and Division of Nephrology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Etienne Macedo
- Division of Nephrology, Department of Medicine, University of California San Diego, CA, USA
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Raimund H Pichler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza-Italy
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Juan-Carlos Q Velez
- Department of Nephrology, Ochsner Health, New Orleans, LA, USA; Ochsner Clinical School, The University of Queensland, Brisbane, QLD, Australia
| | - Ravindra L Mehta
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - François Durand
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, Paris, France; University Paris Cité, Paris, France.
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3
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Tiwari N, Shlomovitz E, Capel J, Wong F. Innovative Management of a Difficult Case of Hepatic Hydrothorax. ACG Case Rep J 2024; 11:e01372. [PMID: 38854808 PMCID: PMC11161277 DOI: 10.14309/crj.0000000000001372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 04/22/2024] [Indexed: 06/11/2024] Open
Abstract
Hepatic hydrothorax affects 5%-15% of decompensated cirrhosis patients, with up to 26% being refractory to standard treatments. For those ineligible for transjugular intrahepatic systemic shunts or liver transplants, alternatives to repeated thoracentesis are limited but can include the insertion of an indwelling pleural catheter. We present the first case of the use of an automatic low-flow ascites pump (alfapump) to manage nonmalignant pleural effusion in an elderly patient with cirrhosis.
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Affiliation(s)
- Neha Tiwari
- Department of Medicine, Division of Gastroenterology & Hepatology, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Eran Shlomovitz
- Joint Medical Imaging Department, Toronto General Hospital, University of Toronto, Toronto, Canada
| | | | - Florence Wong
- Department of Medicine, Division of Gastroenterology & Hepatology, Toronto General Hospital, University of Toronto, Toronto, Canada
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Adebayo D, Wong F. Review article: Recent advances in ascites and acute kidney injury management in cirrhosis. Aliment Pharmacol Ther 2024; 59:1196-1211. [PMID: 38526023 DOI: 10.1111/apt.17972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/08/2024] [Accepted: 03/14/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Better understanding of disease pathophysiology has led to advances in managing ascites and its associated complications including hepatorenal syndrome-acute kidney Injury (HRS-AKI), especially medicinal and interventional advances. AIM To review the latest changes in the management of ascites and HRS-AKI. METHODS A literature search was conducted in Pubmed, using the keywords cirrhosis, ascites, renal dysfunction, acute kidney injury, hepatorenal syndrome, beta-blockers, albumin, TIPS and vasoconstrictors, including only publications in English. RESULTS The medicinal advances include earlier treatment of clinically significant portal hypertension to delay the onset of ascites and the use of human albumin solution to attenuate systemic inflammation thus improving the haemodynamic changes associated with cirrhosis. Furthermore, new classes of drugs such as sodium glucose co-transporter 2 are being investigated for use in patients with cirrhosis and ascites. For HRS-AKI management, newer pharmacological agents such as vasopressin partial agonists and relaxin are being studied. Interventional advances include the refinement of TIPS technique and patient selection to improve outcomes in patients with refractory ascites. The development of the alfa pump system and the study of outcomes associated with the use of long-term palliative abdominal drain will also serve to improve the quality of life in patients with refractory ascites. CONCLUSIONS New treatment strategies emerged from better understanding of the pathophysiology of ascites and HRS-AKI have shown improved prognosis in these patients. The future will see many of these approaches confirmed in large multi-centre clinical trials with the aim to benefit the patients with ascites and HRS-AKI.
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Affiliation(s)
- Danielle Adebayo
- Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Florence Wong
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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5
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Lan T, Chen M, Tang C, Deltenre P. Recent developments in the management of ascites in cirrhosis. United European Gastroenterol J 2024; 12:261-272. [PMID: 38340308 PMCID: PMC10954428 DOI: 10.1002/ueg2.12539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/05/2023] [Indexed: 02/12/2024] Open
Abstract
In recent years, advances have been made for treating ascites in patients with cirrhosis. Recent studies have indicated that several treatments that have been used for a long time in the management of portal hypertension may have beneficial effects that were not previously identified. Long-term albumin infusion may improve survival in patients with cirrhosis and ascites while beta-blockers may reduce ascites occurrence. Transjugular intrahepatic porto-systemic shunt (TIPS) placement may also improve survival in selected patients in addition to the control with ascites. Low-flow ascites pump insertion can be another option for some patients with intractable ascites. In this review, we summarize the latest data related to the management of ascites occurring in cirrhosis. There are still unanswered questions, such as the optimal use of albumin as a long-term therapy, the place of beta-blockers, and the best timing for TIPS placement to improve the natural history of ascites, as well as the optimal stent diameter to reduce the risk of shunt-related side-effects. These issued should be addressed in future studies.
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Affiliation(s)
- Tian Lan
- Lab of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Chen
- Lab of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Chengwei Tang
- Lab of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Pierre Deltenre
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
- Department of Gastroenterology and Hepatology, Clinique St Luc, Bouge, Belgium
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6
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Wong F. Innovative approaches to the management of ascites in cirrhosis. JHEP Rep 2023; 5:100749. [PMID: 37250493 PMCID: PMC10220491 DOI: 10.1016/j.jhepr.2023.100749] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/20/2023] [Accepted: 03/15/2023] [Indexed: 05/31/2023] Open
Abstract
Standard of care for the treatment of ascites in cirrhosis is to administer a sodium-restricted diet and diuretic therapy. The progression of cirrhosis will eventually lead to the development of refractory ascites, at which point diuretics will no longer be able to control the ascites. Second-line therapies such as a transjugular intrahepatic portosystemic shunt (TIPS) placement or repeat large volume paracentesis are then required. There is some evidence that regular infusions of albumin may delay the onset of refractoriness and improve survival, especially if given at an early stage in the natural history of ascites and for a long enough duration. The use of TIPS can eliminate ascites, but its insertion is associated with complications, especially cardiac decompensation and worsening of hepatic encephalopathy. New information is now available regarding how to best select patients for TIPS, what type of cardiac investigations are needed and how under-dilating the TIPS at the time of insertion may help. The use of a non-absorbable antibiotics, such as rifaximin, starting in the pre-TIPS period may also reduce the likelihood of post-TIPS hepatic encephalopathy. In patients who are not suitable for TIPS, the use of an alfapump to remove the ascites via the bladder can improve quality of life without significantly altering survival. In the future it may be possible to use metabolomics to help refine the management of patients with ascites, e.g. to assess their response to non-selective beta-blockers or to predict the development of other complications such as acute kidney injury.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Division of Gastroenterology & Hepatology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Abraldes JG, Caraceni P, Ghabril M, Garcia-Tsao G. Update in the Treatment of the Complications of Cirrhosis. Clin Gastroenterol Hepatol 2023; 21:2100-2109. [PMID: 36972759 PMCID: PMC11097249 DOI: 10.1016/j.cgh.2023.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/17/2023] [Accepted: 03/07/2023] [Indexed: 03/29/2023]
Abstract
Cirrhosis consists of 2 main stages: compensated and decompensated, the latter defined by the development/presence of ascites, variceal hemorrhage, and hepatic encephalopathy. The survival rate is entirely different, depending on the stage. Treatment with nonselective β-blockers prevents decompensation in patients with clinically significant portal hypertension, changing the previous paradigm based on the presence of varices. In patients with acute variceal hemorrhage at high risk of failure with standard treatment (defined as those with a Child-Pugh score of 10-13 or those with a Child-Pugh score of 8-9 with active bleeding at endoscopy), a pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) improves the mortality rate and has become the standard of care in many centers. In patients with bleeding from gastrofundal varices, retrograde transvenous obliteration (in those with a gastrorenal shunt) and/or variceal cyanoacrylate injection have emerged as alternatives to TIPS. In patients with ascites, emerging evidence suggests that TIPS might be used earlier, before strict criteria for refractory ascites are met. Long-term albumin use is under assessment for improving the prognosis of patients with uncomplicated ascites and confirmatory studies are ongoing. Hepatorenal syndrome is the least common cause of acute kidney injury in cirrhosis, and first-line treatment is the combination of terlipressin and albumin. Hepatic encephalopathy has a profound impact on the quality of life of patients with cirrhosis. Lactulose and rifaximin are first- and second-line treatments for hepatic encephalopathy, respectively. Newer therapies such as L-ornithine L-aspartate and albumin require further assessment.
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Affiliation(s)
- Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Paolo Caraceni
- Istituto di Ricerca e Cura a Carattere Scientifico Azienda Ospedaliera-Universitaria di Bologna, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Veterans Administration - Connecticut Healthcare System, West Haven, Connecticut.
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Abstract
Ascites is the most common complication of cirrhosis, with 5-year mortality reaching 30%. Complications of ascites (ie, spontaneous bacterial peritonitis, hepatorenal syndrome, recurrent/refractory ascites, and hepatic hydrothorax) further worsen survival. The development of ascites is driven by portal hypertension, systemic inflammation, and splanchnic arterial vasodilation. Etiologic treatment and nonselective beta-blockers can prevent ascites in compensated cirrhosis. The treatment of ascites is currently based on the management of fluid overload (eg, diuretics, sodium restriction, and/or paracenteses). In selected patients, long-term albumin use, norfloxacin prophylaxis, and transjugular intrahepatic portosystemic shunt reduce the risk of further decompensation and improve survival.
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Deltenre P, Zanetto A, Saltini D, Moreno C, Schepis F. The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions. Hepatology 2023; 77:640-658. [PMID: 35665949 DOI: 10.1002/hep.32596] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 01/28/2023]
Abstract
In selected patients with cirrhosis and ascites, transjugular intrahepatic portosystemic shunt (TIPS) placement improves control of ascites and may reduce mortality. In this review, we summarize the current knowledge concerning the use of TIPS for the treatment of ascites in patients with cirrhosis, from pathophysiology of ascites formation to hemodynamic consequences, patient selection, and technical issues of TIPS insertion. The combination of these factors is important to guide clinical decision-making and identify the best strategy for each individual patient. There is still a need to identify the best timing for TIPS placement in the natural history of ascites (recurrent vs. refractory) as well as which type and level of renal dysfunction is acceptable when TIPS is proposed for the treatment of ascites in cirrhosis. Future studies are needed to define the optimal stent diameter according to patient characteristics and individual risk of shunt-related side effects, particularly hepatic encephalopathy and insufficient cardiac response to hemodynamic consequences of TIPS insertion.
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Affiliation(s)
- Pierre Deltenre
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Department of Gastroenterology and Hepatology , CHU UCL Namur, Université Catholique de Louvain , Yvoir , Belgium.,Department of Gastroenterology and Hepatology , Clinique St Luc , Bouge , Belgium
| | - Alberto Zanetto
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy.,Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology , Padova University Hospital , Padova , Italy
| | - Dario Saltini
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Laboratory of Experimental Gastroenterology , Université Libre de Bruxelles , Brussels , Belgium
| | - Filippo Schepis
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
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Abstract
The development of refractory ascites in approximately 10% of patients with decompensated cirrhosis heralds the progression to a more advanced stage of cirrhosis. Its pathogenesis is related to significant hemodynamic changes, initiated by portal hypertension, but ultimately leading to renal hypoperfusion and avid sodium retention. Inflammation can also contribute to the pathogenesis of refractory ascites by causing portal microthrombi, perpetuating the portal hypertension. Many complications accompany the development of refractory ascites, but renal dysfunction is most common. Management starts with continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesisinduced circulatory dysfunction. Albumin infusions independent of paracentesis may have a role in the management of these patients. The insertion of a covered, smaller diameter, transjugular intrahepatic porto-systemic stent shunt (TIPS) in the appropriate patients with reasonable liver reserve can bring about improvement in quality of life and improved survival after ascites clearance. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites should be referred for liver transplant, as their prognosis is poor. In patients with refractory ascites and concomitant chronic kidney disease of more than stage 3b, assessment should be referred for dual liver-kidney transplants. In patients with very advanced cirrhosis not suitable for any definitive treatment for ascites control, palliative care should be involved to improve the quality of life of these patients.
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Affiliation(s)
- Florence Wong
- Division of Gastroenterology and Hepatology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada,Corresponding author : Florence Wong Division of Gastroenterology and Hepatology, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto Ontario M5G2C4, Canada Tel: +1-416-3403834, Fax: +1-416-3405019, E-mail:
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11
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Stirnimann G, Berg T, Spahr L, Zeuzem S, McPherson S, Lammert F, Storni F, Banz V, Babatz J, Vargas V, Geier A, Engelmann C, Herber A, Trepte C, Capel J, De Gottardi A. Final safety and efficacy results from a 106 real-world patients registry with an ascites-mobilizing pump. Liver Int 2022; 42:2247-2259. [PMID: 35686702 PMCID: PMC9543940 DOI: 10.1111/liv.15337] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 05/02/2022] [Accepted: 05/16/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhotic refractory ascites ineligible for transjugular intrahepatic shunt (TIPSS) have limited treatment options apart from repeated large volume paracentesis. The alfapump® is an implantable device mobilizing ascites from the peritoneal cavity to the bladder, from where it can be excreted. The aim of this observational cohort study was to prospectively investigate safety and efficacy of the device in a real-world cohort with cirrhotic refractory ascites and contraindications for TIPSS. METHODS A total of 106 patients received an implant at 12 European centres and were followed up for up to 24 months. Complications, device deficiencies, frequency of paracentesis, clinical status and survival were recorded prospectively. RESULTS Approximately half of the patients died on-study, about a quarter was withdrawn because of serious adverse events leading to explant, a sixth were withdrawn because of liver transplant or recovery, and nine completed follow-up. The most frequent causes of on-study death and complication-related explant were progression of liver disease and infection. The device reduced the requirement for large-volume paracentesis significantly, with more than half of patients not having required any post-implant. Survival benefits were not observed. Device-related reinterventions were predominantly caused by device deficiencies. A post-hoc comparison of the first 50 versus the last 50 patients enrolled revealed a decreased reintervention rate in the latter, mainly related to peritoneal catheter modifications. CONCLUSIONS The device reduced paracentesis frequency in a real-world setting. Technical complications were successfully decreased by optimization of management and device modification (NCT01532427).
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Affiliation(s)
- Guido Stirnimann
- University Clinic for Visceral Surgery and Medicine, Inselspital University HospitalUniversity of BernBernSwitzerland
| | - Thomas Berg
- Division of Hepatology, Department of Medicine IILeipzig University Medical CenterLeipzigGermany
| | - Laurent Spahr
- Department of Medical Specialties, Service of GastroenterologyGeneva University HospitalsGenevaSwitzerland
| | - Stefan Zeuzem
- Department of MedicineUniversity HospitalFrankfurtGermany
| | - Stuart McPherson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Translational and Clinical Research InstituteNewcastle UniversityNewcastleUK
| | - Frank Lammert
- Department of Medicine IISaarland University Medical CenterHomburgGermany,Medizinische Hochschule HannoverHannoverGermany
| | - Federico Storni
- University Clinic for Visceral Surgery and Medicine, Inselspital University HospitalUniversity of BernBernSwitzerland
| | - Vanessa Banz
- University Clinic for Visceral Surgery and Medicine, Inselspital University HospitalUniversity of BernBernSwitzerland
| | - Jana Babatz
- Medizinische Klinik IUniversitätsklinikum Carl Gustav CarusDresdenGermany
| | - Victor Vargas
- Liver Unit, Hospital Vall d'HebronUniversitat Autònoma Barcelona, CIBERehdBarcelonaSpain
| | - Andreas Geier
- Division of Hepatology, Department of Medicine IIUniversity Hospital WürzburgWürzburgGermany
| | - Cornelius Engelmann
- Division of Hepatology, Department of Medicine IILeipzig University Medical CenterLeipzigGermany,Medical Department, Division of Hepatology and GastroenterologyCharité—Universitätsmedizin BerlinBerlinGermany
| | - Adam Herber
- Division of Hepatology, Department of Medicine IILeipzig University Medical CenterLeipzigGermany
| | | | | | - Andrea De Gottardi
- University Clinic for Visceral Surgery and Medicine, Inselspital University HospitalUniversity of BernBernSwitzerland,Servizio di Gastroenterologia e Epatologia, Ente Ospedaliero CantonaleLuganoSwitzerland,Facoltà di Scienze BiomedicheUniversità della Svizzera ItalianaLuganoSwitzerland
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12
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Rogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, Kanwal F. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology 2022; 76:819-853. [PMID: 35103995 PMCID: PMC9942270 DOI: 10.1002/hep.32378] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Shari S. Rogal
- Departments of Medicine and Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare Center, Pittsburgh, Pennsylvania, USA
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, Oregon, USA
| | - Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Nneka N. Ufere
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Christopher D. Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Fasiha Kanwal
- Sections of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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13
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Weil-Verhoeven D, Di Martino V, Stirnimann G, Cervoni JP, Nguyen-Khac E, Thévenot T. Alfapump ® implantable device in management of refractory ascites: An update. World J Hepatol 2022; 14:1344-1356. [PMID: 36158913 PMCID: PMC9376776 DOI: 10.4254/wjh.v14.i7.1344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/30/2022] [Accepted: 06/27/2022] [Indexed: 02/06/2023] Open
Abstract
Refractory ascites (RA) is a frequent and life-threatening complication of cirrhosis. In selected patients with RA, transjugular intrahepatic portosystemic shunt (TIPS) placement and liver transplantation (LT) are currently considered the best therapeutic alternatives to repeated large volume paracentesis. In patients with a contraindication to TIPS or LT, the alfapump® system (Sequana Medical, Ghent, Belgium) has been developed to reduce the need for iterative paracentesis, and consequently to improve the quality of life and nutritional status. We report here recent data on technical progress made since the first implantation, the efficacy and tolerance of the device, the position of the pump in the therapeutic arsenal for refractory ascites, and the grey areas that remain to be clarified regarding the optimal selection of patients who are potential candidates for this treatment.
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Affiliation(s)
- Delphine Weil-Verhoeven
- Service d’Hépatologie Et Soins Intensifs Digestifs, CHRU Jean Minjoz, Besançon 25030, France
- EA 4266 EPILAB, Université de Bourgogne Franche-Comté, Besançon 25030, France
| | - Vincent Di Martino
- Service d’Hépatologie Et Soins Intensifs Digestifs, CHRU Jean Minjoz, Besançon 25030, France
- EA 4266 EPILAB, Université de Bourgogne Franche-Comté, Besançon 25030, France
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital University Hospital and University of Bern, Bern 3010, Switzerland
| | - Jean Paul Cervoni
- Service d’Hépatologie Et Soins Intensifs Digestifs, CHRU Jean Minjoz, Besançon 25030, France
| | - Eric Nguyen-Khac
- Service d’Hépato-Gastroentérologie, CHU Amiens-Picardie, Amiens 80080, France
| | - Thierry Thévenot
- Service d’Hépatologie Et Soins Intensifs Digestifs, CHRU Jean Minjoz, Besançon 25030, France
- EA 4266 EPILAB, Université de Bourgogne Franche-Comté, Besançon 25030, France
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14
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Aagaard NK, Malago M, De Gottardi A, Thomas M, Sauter G, Engelmann C, Aranovich D, Cohen M, Thévenot T, Ehmann T, Capel J, Angeli P, Jalan R, Stirnimann G. Consensus care recommendations for alfapump ® in cirrhotic patients with refractory or recurrent ascites. BMC Gastroenterol 2022; 22:111. [PMID: 35260086 PMCID: PMC8905806 DOI: 10.1186/s12876-022-02173-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/04/2022] [Indexed: 12/26/2022] Open
Abstract
Background The alfapump® is an implantable class III medical device that pumps ascitic fluid from the peritoneal space to the urinary bladder from where it is excreted. The pump reduces or abrogates the need for repeated paracentesis in patients with recurrent or refractory ascites.
Aims To improve outcomes for alfapump® implantation and pre- and post-implant patient management in both clinical trial and real-world settings by development of consensus recommendations.
Methods The alfapump® working group consisting of hepatologists and surgeons with extensive experience in implantation of the alfapump® and patient management met on two occasions: (1) to determine the key areas where recommendations should be made; and (2) to discuss the experiences of the working group within those areas and formulate draft statements. Developed statements were submitted to the group and consensus sought on relevance and wording through a collaborative iterative approach in order to consolidate the recommendations into consensus statements. Only recommendations agreed upon unanimously were included. Results Twenty-three consensus recommendations were developed in the areas of pre-implantation procedure, (three statements), surgical implant procedure (11 statements), immediate post-implant care (three statements) and long-term management (six statements). Conclusions The consensus statements are a valuable reference resource for physicians managing patients with the alfapump® and for those considering management strategies for patients with refractory ascites. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02173-5.
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Affiliation(s)
- Niels Kristian Aagaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Massimo Malago
- Hepato-Pancreatic-Biliary and Liver Transplantation Surgery, Royal Free Hospital, University College London, London, UK
| | - Andrea De Gottardi
- Servizio di Gastroenterologia e Epatologia, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Michael Thomas
- Department of General, Visceral, Tumour and Transplant Surgery, University Hospital of Cologne, Cologne, Germany
| | - Gerd Sauter
- Department of Internal Medicine II, LMU University Hospital, Munich, Germany
| | - Cornelius Engelmann
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - David Aranovich
- Hepatology and Bile Duct Surgery Service, Surgery B Department, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Michal Cohen
- The Liver Institute, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel
| | - Thierry Thévenot
- Service d'Hépatologie, Hôpital Universitaire Jean Minjoz, Besançon, France
| | - Thomas Ehmann
- Department of General and Visceral Surgery, St. Josef Krankenhaus Haan, Haan, Germany
| | | | - Paolo Angeli
- Facoltà di Medicina e Chirurgia, Università degli Studi di Padova, Padova, Italy
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Royal Free Campus, London, UK
| | - Guido Stirnimann
- University Clinic for Visceral Surgery and Medicine, University Hospital Inselspital Bern and University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.
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15
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Zaccherini G, Tufoni M, Iannone G, Caraceni P. Management of Ascites in Patients with Cirrhosis: An Update. J Clin Med 2021; 10:5226. [PMID: 34830508 PMCID: PMC8621554 DOI: 10.3390/jcm10225226] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 12/16/2022] Open
Abstract
Ascites represents a critical event in the natural history of liver cirrhosis. From a prognostic perspective, its occurrence marks the transition from the compensated to the decompensated stage of the disease, leading to an abrupt worsening of patients' life expectancy. Moreover, ascites heralds a turbulent clinical course, characterized by acute events and further complications, frequent hospitalizations, and eventually death. The pathophysiology of ascites classically relies on hemodynamic mechanisms, with effective hypovolemia as the pivotal event. Recent discoveries, however, integrated this hypothesis, proposing systemic inflammation and immune system dysregulation as key mechanisms. The mainstays of ascites treatment are represented by anti-mineralocorticoids and loop diuretics, and large volume paracentesis. When ascites reaches the stage of refractoriness, however, diuretics administration should be cautious due to the high risk of adverse events, and patients should be treated with periodic execution of paracentesis or with the placement of a trans-jugular intra-hepatic portosystemic shunt (TIPS). TIPS reduces portal hypertension, eases ascites control, and potentially modify the clinical course of the disease. Further studies are required to expand its indications and improve the management of complications. Long-term human albumin administration has been studied in two RCTs, with contradictory results, and remains a debated issue worldwide, despite a potential effectiveness both in ascites control and long-term survival. Other treatments (vaptans, vasoconstrictors, or implantable drainage systems) present some promising aspects but cannot be currently recommended outside clinical protocols or a case-by-case evaluation.
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Affiliation(s)
- Giacomo Zaccherini
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.Z.); (G.I.)
| | - Manuel Tufoni
- IRCCS AOU di Bologna—Policlinico di S. Orsola, 40138 Bologna, Italy;
| | - Giulia Iannone
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.Z.); (G.I.)
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.Z.); (G.I.)
- IRCCS AOU di Bologna—Policlinico di S. Orsola, 40138 Bologna, Italy;
- Center for Biomedical Applied Research, University of Bologna, 40126 Bologna, Italy
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16
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Storni F, Stirnimann J, Banz V, De Gottardi A, Stirnimann G. Treatment of refractory ascites with an automated low flow ascites pump in patients awaiting liver transplantation. JOURNAL OF LIVER TRANSPLANTATION 2021. [DOI: 10.1016/j.liver.2021.100037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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17
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Garcia-Pagan JC, Francoz C, Montagnese S, Senzolo M, Mookerjee RP. Management of the major complications of cirrhosis: Beyond guidelines. J Hepatol 2021; 75 Suppl 1:S135-S146. [PMID: 34039484 DOI: 10.1016/j.jhep.2021.01.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/17/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023]
Abstract
Along with a growing understanding of the pathophysiology of cirrhosis and its complications, new therapies and management strategies have emerged in recent years. Many of these advances have helped inform the current EASL clinical practice guidelines1 on the management of some of the key complications of cirrhosis, such as ascites, variceal bleeding and infection. However, there are still some aspects of management where the evidence base is less clear, and/or where opinions amongst practitioners remain divided. Some of these more controversial areas are explored in this section, wherein we present evidence culminating in a suggested management approach based on expert opinion and extending beyond the current guidelines.
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Affiliation(s)
- Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain
| | - Claire Francoz
- Hepatology and Liver Intensive Care Unit, Hôpital Beaujon, INSERM. Clichy; France
| | | | - Marco Senzolo
- Gastroenterology, Multi-visceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Italy
| | - Rajeshwar P Mookerjee
- Institute for Liver and Digestive Health, University College London, UK; Department of Hepatology and Gastroenterology, Aarhus University, Denmark.
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18
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Tunnelled Peritoneal Catheter for Malignant Ascites-An Open-Label, Prospective, Observational Trial. Cancers (Basel) 2021; 13:cancers13122926. [PMID: 34208108 PMCID: PMC8230746 DOI: 10.3390/cancers13122926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/01/2021] [Accepted: 06/08/2021] [Indexed: 02/06/2023] Open
Abstract
Treatment of recurrent malignant ascites in cancer patients is a challenge. Evidence based guidelines regarding the best treatment strategy are lacking. The aim of this prospective study was to investigate the safety and efficacy of a tunnelled peritoneal catheter (PleurX) in cancer patients with symptomatic ascites. Patients with symptomatic, diuretics-refractory ascites and indication for the implantation of a tunnelled peritoneal PleurX catheter were prospectively enrolled between August 2018 and July 2020. The number of catheter days, complications, amount of drained ascites and ascites-associated symptoms and hospitalization rate pre- and post-PleurX insertion were analysed. 51 Patients (64.7% male) were prospectively enrolled. The mean age was 66.6 (±7.9) years. The most common cause of ascites was pancreatic adenocarcinoma (n = 10) followed by cholangiocellular carcinoma (n = 9) and hepatocellular carcinoma (n = 8). The technical success rate of PleurX implantation was 100%. The mean volume of weakly drained ascites was 5.44l (±4.08). Major complications included cellulitis (n = 2), peritonitis and drainage dislocation (each n = 1). The mean catheter days per patient was 59.8 (±107.4) (Min 4, Max 668). Abdominal discomfort, impaired mobility, dyspnoea, fatigue, nausea and vomiting were significantly reduced 30 days after PleurX insertion (p < 0.05). Moreover, hospitalization rate was significantly reduced (p < 0.001; 27.08% of days preimplantation vs. 11.27% postimplantation). We conclude that implantation of a tunnelled ascites catheter is a safe and effective method for the treatment of refractory ascites in cancer patients with advanced disease. Serious complications are rare. Burdensome ascites-associated symptoms and hospitalization rates can be significantly reduced over a longer period of time.
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19
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Larrue H, Vinel JP, Bureau C. Management of Severe and Refractory Ascites. Clin Liver Dis 2021; 25:431-440. [PMID: 33838859 DOI: 10.1016/j.cld.2021.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Considering the poor prognosis, severe and refractory ascites is a milestone in cirrhotic patients. Liver transplantation must be considered first. In the case of contraindication to liver transplantation or when the waiting period is estimated to be more than 6 months, transjugular intrahepatic portosystemic shunt should be discussed in eligible patients. Regardless of the type of treatment, a careful selection of patients is crucial to avoid further decompensation and specific complications of each treatment.
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Affiliation(s)
- Hélène Larrue
- Service d'Hépatologie Hôpital Rangueil 1, Avenue Jean Poulhès CHU Toulouse France and Université Toulouse III-Paul Sabatier, France 31400
| | - Jean Pierre Vinel
- Service d'Hépatologie Hôpital Rangueil 1, Avenue Jean Poulhès CHU Toulouse France and Université Toulouse III-Paul Sabatier, France 31400
| | - Christophe Bureau
- Service d'Hépatologie Hôpital Rangueil 1, Avenue Jean Poulhès CHU Toulouse France and Université Toulouse III-Paul Sabatier, France 31400.
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20
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Aithal GP, Palaniyappan N, China L, Härmälä S, Macken L, Ryan JM, Wilkes EA, Moore K, Leithead JA, Hayes PC, O'Brien AJ, Verma S. Guidelines on the management of ascites in cirrhosis. Gut 2021; 70:9-29. [PMID: 33067334 PMCID: PMC7788190 DOI: 10.1136/gutjnl-2020-321790] [Citation(s) in RCA: 156] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022]
Abstract
The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.
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Affiliation(s)
- Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Louise China
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Suvi Härmälä
- Institute of Health Informatics, University College London, London, UK
| | - Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Jennifer M Ryan
- Institute of Liver Disease and Digestive Health, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Emilie A Wilkes
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kevin Moore
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Joanna A Leithead
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter C Hayes
- Hepatology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair J O'Brien
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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21
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Ali B, Salim A, Alam A, Zuberi BF, Ali Z, Azam Z, Kamani L, Farooqi JI, Salih M, Nawaz AA, Chaudhry AA, Hashmi ZY, Siddique M. HEP-Net opinion on the management of ascites and its complications in the setting of decompensated cirrhosis in the resource constrained environment of Pakistan. Pak J Med Sci 2020; 36:1117-1132. [PMID: 32704299 PMCID: PMC7372671 DOI: 10.12669/pjms.36.5.2407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Approximately one half of patients develop ascites within 10 years of diagnosis of compensated cirrhosis. It is a poor prognostic indicator, with only 50% surviving beyond two years. Mortality worsens significantly to 20% to 50% at one year if the ascites becomes refractory to medical therapy. Pakistan has one of the highest prevalence of viral hepatitis in the world and patients with ascites secondary to liver cirrhosis make a major percentage of both inpatient and outpatient burden. Studies indicate that over 80% of patients admitted with ascites have liver cirrhosis as the cause. This expert opinion suggests proper assessment of patients with ascites in the presence of underlying cirrhosis. This expert opinion includes appropriate diagnosis and management of uncomplicated ascites, refractory ascites and complicated ascites (including spontaneous bacterial peritonitis (SBP) ascites, hepatorenal syndrome (HRS) and hyponatremia. The purpose behind this expert opinion is to help consultants, postgraduate trainees, medical officers and primary care physicians optimally manage their patients with cirrhosis and ascites in a resource constrained setting as is often encountered in a developing country like Pakistan.
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Affiliation(s)
- Bushra Ali
- Bushra Ali, Fatima Memorial Medical and Dental College, Lahore, Pakistan
| | - Adnan Salim
- Adnan Salim, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan
| | - Altaf Alam
- Altaf Alam, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan
| | - Bader Faiyaz Zuberi
- Bader Faiyaz Zuberi, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Zeeshan Ali
- Zeeshan Ali, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Zahid Azam
- Zahid Azam, NILGID, Dow University of Health Sciences, Karachi, Pakistan
| | - Lubna Kamani
- Lubna Kamani, Liaquat National Hospital, Karachi, Pakistan
| | | | - Muhammed Salih
- Muhammed Salih, Quaid e Azam International Hospital, Islamabad, Pakistan
| | - Arif Amir Nawaz
- Arif Amir Nawaz, Fatima Memorial Medical and Dental College, Lahore, Pakistan
| | | | | | - Masood Siddique
- Masood Siddique, Jinnah Memorial Hospital, Rawalpindi, Pakistan
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22
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Bendel EC, Sniderman K, Shaw C, Frederick RT, Wong F, Sanyal A, Asrani SK, Kamath PS, Capel J, Haskal ZJ. Feasibility and Procedural Safety of alfapump System Implantation by IR: Experience from the MOSAIC Study, a Multicenter, Open-Label Prospective Study in Cirrhotic Patients with Refractory Ascites. J Vasc Interv Radiol 2020; 31:1256-1262.e3. [PMID: 32654961 DOI: 10.1016/j.jvir.2020.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/02/2020] [Accepted: 02/01/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To evaluate feasibility, procedural outcomes, and safety aspects of implantation of the alfapump system for management of refractory ascites by interventional radiology (IR) methods. MATERIALS AND METHODS The multicenter open-label prospective MOSAIC study included 29 patients (mean age 60.0 y ± 9.9; range, 32-72 y, 17 [56.7%] male) with cirrhotic refractory ascites who received an alfapump system implanted by IR. The fully subcutaneous alfapump system consists of a pump and 2 silicone catheters, whose distal ends are inserted in the peritoneum and the bladder, respectively. The device moves ascites from the peritoneum to the bladder, reducing the requirement of paracentesis. Pumped volume and speed can be customized as required. The implant procedure was performed under general or local anesthesia. Both catheters were placed under ultrasound guidance. The pump was inserted in a subcutaneous pocket on the upper abdomen. Incidence and severity of procedure-related serious adverse events up to 3 months after implantation were recorded. RESULTS Technical success was achieved in 29 (100%) IR implant procedures. The pump was usually implanted on the right abdomen (76.7%). In 5 patients, deviation from the Instructions for Use was required. Adverse events (requirement of additional incisions, postoperative bleed) occurred in 3 patients. At 3 months after implantation, 3 possibly procedure-related serious adverse events (ascites leakage, bacterial peritonitis, postoperative bleeding) had occurred. Two explantations (2/29; 6.8%) (cellulitis, pump pocket infection) and 4 reinterventions (pump or catheter replacement) were required, corresponding to an adverse event incidence rate of 9/29 (31.0%). CONCLUSIONS Placement of the alfapump using IR methods is both feasible and technically successful.
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Affiliation(s)
- Emily C Bendel
- Department of Radiology, Mayo Clinic, 200 First Street SW, Mayo 2 West, Rochester, MN, 55901.
| | - Kenneth Sniderman
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Florence Wong
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Arun Sanyal
- Virginia Commonwealth University, Richmond, Virginia
| | | | - Patrick S Kamath
- Department of Radiology, Mayo Clinic, 200 First Street SW, Mayo 2 West, Rochester, MN, 55901
| | | | - Ziv J Haskal
- Division of Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia
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23
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Will V, Rodrigues SG, Stirnimann G, Gottardi AD, Bosch J, Berzigotti A. Transjugular intrahepatic portosystemic shunt and alfapump® system for refractory ascites in liver cirrhosis: Outcomes and complications. United European Gastroenterol J 2020; 8:961-969. [PMID: 32588789 DOI: 10.1177/2050640620938525] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Treatment of refractory ascites in liver cirrhosis is challenging. Transjugular intrahepatic portosystemic shunt and alfapump® have been proposed for the management, but few data comparing both exist. AIMS The aim of this study was to evaluate the characteristics and outcomes of patients treated with transjugular intrahepatic portosystemic shunt and alfapump® for refractory ascites at our centre. METHODS All consecutive patients were retrospectively reviewed for baseline characteristics, efficacy of treatment, complications and survival. RESULTS In total, 19 patients with transjugular intrahepatic portosystemic shunt and 40 patients with alfapump® were included. Patients with transjugular intrahepatic portosystemic shunt had better liver function and less hepatic encephalopathy at baseline. Fifty-eight per cent of patients developed hepatic encephalopathy in the first six months after transjugular intrahepatic portosystemic shunt. In patients with alfapump®, renal function decreased and 58% developed prerenal impairment and 43% hepatorenal syndrome in the first six months. Alfapump® patients with new catheters required less reinterventions (26% versus 57% with old catheters, p = 0.049). Transplant-free survival at 1 year was 25% in alfapump® and 65% in transjugular intrahepatic portosystemic shunt. Hepatic encephalopathy predicted transplant-free survival in patients with alfapump® (hazard ratio 2.00, 95% confidence interval 0.99-4.02, p = 0.05). In a sensitivity analysis comparing patients with similar liver function, the rate of hepatorenal syndrome and prerenal impairment was higher in patients with alfapump® and these patients were hospitalised more frequently, whereas the rate of hepatic encephalopathy was similar in both treatment groups. CONCLUSIONS Both transjugular intrahepatic portosystemic shunt and alfapump® were effective treatments for refractory ascites in cirrhosis. Patients treated with transjugular intrahepatic portosystemic shunt had a better one-year transplant-free survival but had less negative prognostic factors at baseline. Selecting patients without hepatic encephalopathy prior to implantation of an alfapump® might improve transplant-free survival.
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Affiliation(s)
- Valerie Will
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland
| | - Susana G Rodrigues
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland
| | - Guido Stirnimann
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland
| | - Andrea De Gottardi
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland
| | - Jaime Bosch
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland.,Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Annalisa Berzigotti
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland
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