From the Guidelines
Refractory ascites is a severe form of ascites that does not respond adequately to standard medical treatment, defined as ascites that cannot be mobilized or recurs after large-volume paracentesis despite dietary sodium restriction and diuretic therapy, and is associated with poor survival of 50% at 6 months 1.
Definition and Classification
Refractory ascites is further divided into two subgroups:
- Diuretic-resistant ascites, which is ascites that is refractory to dietary sodium restriction and intensive diuretic treatment
- Diuretic-intractable ascites, which is ascites that cannot be mobilized or the early recurrence of which cannot be prevented because of the development of diuretic-induced complications that preclude the use of an effective diuretic dosage 1.
Management
Patients with refractory ascites often require alternative management strategies such as:
- Large-volume paracentesis (removal of 5-10 liters of fluid at once)
- Transjugular intrahepatic portosystemic shunt (TIPS) placement
- Consideration for liver transplantation in appropriate candidates 1. Albumin infusion (typically 6-8 g per liter of fluid removed) is recommended during large-volume paracentesis to prevent circulatory dysfunction 1.
Prognosis
Refractory ascites typically develops in advanced liver cirrhosis when portal hypertension becomes severe and is associated with poor prognosis, with mortality rates of approximately 50% within one year 1. The underlying mechanism involves severe portal hypertension, reduced effective arterial blood volume, and activation of sodium-retaining mechanisms that overwhelm the effectiveness of diuretics 1.
Evaluation for Liver Transplantation
Patients with refractory ascites should be evaluated for liver transplantation when appropriate, as this represents the definitive treatment for the underlying liver disease 1.
From the Research
Definition of Refractory Ascites
- Refractory ascites is defined as ascites that does not respond or recurs after high-dose diuresis and sodium restriction 2, 3.
- It is also characterized as fluid overload that is unresponsive to sodium-restricted diet and high-dose diuretic treatment (diuretic-resistant) or when there is an inability to reach maximal dose of diuretics because of adverse effects (diuretic-intractable) 3.
Causes and Mechanisms
- Refractory ascites occurs in patients with functional renal failure as a consequence of alteration in both pharmacokinetics and pharmacodynamics of diuretics 4.
- The complex hemodynamic alterations, including decrease in renal plasma flow and increased sodium reabsorption, lead to refractory ascites 2.
Treatment Options
- The available therapies for refractory ascites are repeated large volume paracentesis (LVP), transjugular intrahepatic portosystemic shunts (TIPS), peritoneovenous shunts, investigational medical therapies, and liver transplantation 2, 4, 5, 3, 6.
- LVP with concomitant volume expanders is the initial treatment of choice 2, 6.
- TIPS seems to be superior to LVP in reducing the need for repeated paracentesis and improves the quality of life 2.
- Liver transplantation remains the only definitive therapy for refractory ascites and should be considered and incorporated early in the treatment plan 2, 5, 3, 6.