How to manage large volume ascites after Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure?

Management of Large Volume Ascites After TIPS

For patients with persistent large volume ascites after TIPS placement, serial large-volume paracentesis with albumin administration (8g/L of ascites removed) is the first-line treatment approach. 1

Initial Assessment

1. Evaluate TIPS function:

   • Doppler ultrasound to assess shunt patency
   • Consider venography if TIPS dysfunction is suspected
   • Measure portosystemic gradient (target <12 mmHg for ascites control) 2

2. Assess liver disease severity:

   • MELD score calculation (scores ≥18 indicate poorer outcomes)
   • Serum sodium levels (hyponatremia suggests poor prognosis)
   • Cardiac function (ejection fraction <60% increases risk of heart failure) 2

Treatment Algorithm

First-Line Treatment

• Large-volume paracentesis (LVP) with albumin replacement:
  • Administer 8g albumin per liter of ascites removed 1
  • For paracentesis >5L, albumin administration is mandatory 1, 2
  • For paracentesis <5L, synthetic plasma expanders may be sufficient 1
  • Perform paracentesis in a single session with volume expansion given after completion 1

Diuretic Management

• Continue diuretics only if effective:
  • Maintain only if urinary sodium excretion >30 mmol/day 1, 2
  • TIPS typically converts diuretic-resistant patients to diuretic-sensitive 1
  • Start with spironolactone 100-200 mg/day and furosemide 20-40 mg/day 3
  • Maximum doses: spironolactone 400 mg/day and furosemide 160 mg/day 3
  • Target weight loss: 300-500g/day without peripheral edema 3

TIPS Revision Considerations

• Consider TIPS revision if:
  • Doppler ultrasound shows shunt stenosis/occlusion
  • Portosystemic gradient >12 mmHg
  • Recurrent ascites with previously functioning TIPS 4

Complications Management

1. Hepatic encephalopathy (occurs in 25-30% of patients post-TIPS):

   • Treat with lactulose and rifaximin
   • Consider shunt reduction in severe cases 1, 4

2. Renal dysfunction:

   • Monitor serum creatinine closely
   • Avoid nephrotoxic medications
   • Consider hepatorenal syndrome treatment if appropriate 2

3. Hyponatremia:

   • Fluid restriction (1-1.5 L/day) for severe cases (serum sodium <125 mmol/L) 2

4. Circulatory dysfunction:

   • Consider midodrine (7.5 mg three times daily) to improve ascites control 2
   • Avoid non-selective beta-blockers in patients with refractory ascites and hypotension 2

Long-Term Management

• Expedite liver transplantation evaluation:

  • Median survival of patients with refractory ascites is approximately 6 months 2
  • Liver transplantation offers definitive cure for cirrhosis and its complications 3, 5

• Regular monitoring:

  • TIPS patency via Doppler ultrasound every 3-6 months
  • Liver and renal function tests
  • Electrolyte levels
  • Signs of hepatic encephalopathy 2

Important Caveats

• Resolution of ascites after TIPS is slow; most patients require continued diuretics and salt restriction 1
• TIPS is contraindicated in patients with severe liver failure (bilirubin >5 mg/dl, INR >2, Child-Pugh score >11), current hepatic encephalopathy ≥grade 2, active infection, progressive renal failure, or severe cardiopulmonary diseases 1
• Mortality at 1 year after TIPS for refractory ascites ranges from 35-50% 2
• Peritoneovenous shunts have very limited role due to frequent complications and shunt dysfunction 1

The persistence of large volume ascites after TIPS suggests either TIPS dysfunction or advanced liver disease with poor hepatic reserve. In either case, the patient should be evaluated for liver transplantation as the definitive treatment while managing ascites with serial paracentesis and albumin replacement.