Peritoneovenous shunting for refractory ascites results in worsening of nephrotic syndrome

Prediction factors of tolvaptan effectiveness in patients with refractory ascites complicated with hepatocellular carcinoma

OBJECTIVE

Tolvaptan (TVP) is an effective treatment for patients with cirrhotic ascites; however, studies have indicated that a sufficient effect is difficult to obtain in patients with hepatocellular carcinoma (HCC). This study evaluates the efficacy of TVP in patients with HCC with refractory ascites.

METHODS

We retrospectively enrolled 32 patients with liver cirrhosis and refractory ascites [mean age: 74 years (range, 47-86 years), men: 78.1% (25/32)]. All patients had HCC and were treated with TVP at our hospital. A TVP responder was defined as a patient who experienced decrease in body weight by ≥1.5 kg within 1 week of treatment. Univariate and multivariate analyses were performed to evaluate clinical and laboratory predictive factors of TVP response.

RESULTS

The TVP response rate was 46.9% (15/32 patients) after 1 week of treatment. HCC treatment (transcatheter arterial chemoembolization and/or radiofrequency ablation) was administered to 11/15 (73.3%) responders. In the multivariate analysis, the reduction of urine osmolality was higher in responders than nonresponders (202 mOsm/l vs. 65 mOsm/l, P = 0.040), and the tumor stage (P = 0.043) was worse in nonresponders. Multivariate Cox proportional hazards regression analysis indicated a significantly better prognosis among responders than among nonresponders (P < 0.01).

CONCLUSION

The HCC tumor stage and the reduction in urine osmolality can predict the efficacy of TVP in patients with refractory ascites complicated with HCC. TVP may allow therapeutic intervention for HCC and improve prognosis, even in patients with Child-Pugh class C.

Association between the Serum Sodium Levels and the Response to Tolvaptan in Liver Cirrhosis Patients with Ascites and Hyponatremia

Objective Hyponatremia is closely associated with the pathophysiology of cirrhosis. However, the association between the serum sodium level and the response to tolvaptan is unclear. This study evaluated the factors related to the tolvaptan response and the prognosis in cirrhosis patients with ascites and hyponatremia. Methods We retrospectively reviewed the clinical records of cirrhosis patients hospitalized for treatment with tolvaptan. The associations of patient baseline characteristics with the tolvaptan response after one week and of the characteristics after one-month tolvaptan treatment with the prognosis were analyzed. Results We analyzed 83 cirrhosis patients with ascites, including 34 patients with hyponatremia. The response rates to tolvaptan in patients with serum sodium <130 mEq/L, 130-135 mEq/L, and >135 mEq/L were 20%, 66%, and 58%, respectively (p=0.22). The serum sodium level was associated with the response to tolvaptan [odds ratio=1.18; 95% confidence interval (CI) =1.02-1.37; p=0.029]. In patients with hyponatremia, the serum sodium level after 1-month tolvaptan treatment was increased compared to baseline (132 mEq/L vs. 136 mEq/L, p=0.006), and an increasing serum sodium level was associated with a lower risk of mortality (hazard ratio=0.85; 95% CI=0.75-0.97; p=0.016). The survival rate was higher in patients with an increase in the serum sodium level after 1 month than in patients with a decreased serum sodium level (p=0.023). Conclusion Tolvaptan treatment was effective in cirrhosis patients with ascites and hyponatremia, but a low serum sodium level was associated with non-responsiveness to tolvaptan. An increased serum sodium level after one-month tolvaptan treatment may positively influence the mortality risk in cirrhosis patients with hyponatremia.