How to manage refractory ascites after Transjugular Intrahepatic Portosystemic Shunt (TIPS)?

Management of Refractory Ascites After TIPS

For patients with refractory ascites that persists after TIPS placement, serial large-volume paracentesis (LVP) with albumin administration should be the primary management strategy, while considering liver transplantation as the definitive treatment. 1

Assessment of TIPS Function and Patient Status

1. Evaluate TIPS patency and function:

   • Doppler ultrasound to assess shunt patency
   • Consider venography if TIPS dysfunction is suspected
   • Measure portosystemic gradient (target <12 mmHg for ascites control)

2. Assess severity of liver disease:

   • MELD score (patients with score ≥18 have poorer outcomes) 1
   • Child-Pugh score (higher scores predict worse survival post-TIPS) 2
   • Serum sodium (hyponatremia indicates poor prognosis) 1

Management Algorithm

First-line Management:

• Serial large-volume paracentesis with albumin administration
  • Administer albumin at 8g per liter of ascites removed 1, 3
  • For paracentesis >5L, albumin administration is strongly recommended 1
  • For paracentesis <5L in patients with ACLF, consider albumin administration 1

Diuretic Therapy:

• Continue diuretics only if urinary sodium excretion >30 mmol/day 1
• TIPS usually converts diuretic-resistant patients into diuretic-sensitive patients 1
• Titrate diuretics to achieve natriuresis:
  • Spironolactone (100-400 mg/day)
  • Furosemide (20-160 mg/day)
• Monitor for complications:
  • Renal dysfunction (serum creatinine >2.0 mg/dL)
  • Electrolyte abnormalities (serum sodium <120 mmol/L, potassium >6.0 mmol/L)
  • Hepatic encephalopathy

Additional Pharmacological Options:

• Consider midodrine (7.5 mg three times daily) to improve ascites control 1
• Avoid NSBBs in patients with refractory ascites and hypotension or worsening renal function 1

Definitive Treatment:

• Expedite liver transplantation evaluation 1
  • Median survival of patients with refractory ascites is approximately 6 months 1
  • Liver transplantation offers definitive cure for cirrhosis and its complications 4

Special Considerations

TIPS Revision:

• Consider TIPS revision if:
  • Evidence of shunt stenosis or occlusion
  • Persistent portal hypertension (gradient >12 mmHg)
  • Initial good response followed by recurrence of ascites 5

Management of Complications:

1. Hepatic Encephalopathy (occurs in 30-50% of patients post-TIPS) 1:

   • Lactulose titrated to 2-3 soft bowel movements daily
   • Rifaximin 550 mg twice daily if encephalopathy persists
   • Consider shunt reduction in severe, refractory cases 5

2. Hyponatremia:

   • Fluid restriction (1-1.5 L/day) only for severe hyponatremia (serum sodium <125 mmol/L) 1
   • Avoid rapid correction of hyponatremia to prevent central pontine myelinolysis 3

3. Renal Dysfunction:

   • Monitor renal function closely
   • Avoid nephrotoxic medications
   • Consider hepatorenal syndrome treatment if appropriate

Prognosis and Monitoring

• Response to treatment is unpredictable and varies over time 2
• Mortality at 1 year after TIPS for refractory ascites ranges from 35-50% 1, 2
• Regular monitoring should include:
  • Liver function tests
  • Renal function
  • Electrolytes
  • Doppler ultrasound of TIPS (every 6 months or with clinical deterioration)

Caveats and Pitfalls

• Patients with very advanced liver disease (bilirubin >5 mg/dL, INR >2) have poor outcomes with TIPS 1
• Cardiac dysfunction (ejection fraction <60%) increases risk of post-TIPS heart failure 1
• TIPS patency issues are common with uncovered stents (up to 80% stenosis rate) 1
• The response to treatment and mortality are both difficult to predict based on pre-TIPS variables 2

Remember that while TIPS can improve ascites control in many patients, persistent ascites after TIPS indicates poor prognosis, and liver transplantation should be prioritized whenever possible.