본문 바로가기
KERD
논문KCI 등재

Management of refractory ascites

Florence Wong
대한간학회 (The korean Association for the Study of the Liver)|2023.02|Clinical and Molecular Hepatology|제29권 제1호|pp. 16-32

2

조회

0

다운로드

2

인용

0

참고문헌

키워드

AscitesLiver transplantationAlbuminParacentesis

초록

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.

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.

참고문헌 (96)

  1. Fleming KM, "The rate of decompensation and clinical progression of disease in people with cirrhosis : a cohort study", Aliment Pharmacol Ther, 32, pp.1343~1350 (2010)
  2. Macdonald S, "Quality of life measures predict mortality in patients with cirrhosis and severe ascites", Aliment Pharmacol Ther, 49, pp.321~330 (2019)
  3. Moreau R, "Clinical characteristics and outcome of patients with cirrhosis and refractory ascites", Liver Int, 24, pp.457~464 (2004)
  4. Jepsen P, "MELD remains the best predictor of mortality in outpatients with cirrhosis and severe ascites", Aliment Pharmacol Ther, 52, pp.492~499 (2020)
  5. Salerno F, "Refractory ascites : pathogenesis, definition and therapy of a severe complication in patients with cirrhosis", Liver Int, 30, pp.937~947 (2010)
  6. Gracia-Sancho J, "Hepatic microcirculation and mechanisms of portal hypertension", Nat Rev Gastroenterol Hepatol, 16, pp.221~234 (2019)
  7. Iwakiri Y, "Portal hypertension in cirrhosis : pathophysiological mechanisms and therapy", JHEP Rep, 3, pp.100316~ (2021)
  8. Engelmann C, "Pathophysiology of decompensated cirrhosis: portal hypertension, circulatory dysfunction, inflammation, metabolism and mitochondrial dysfunction", J Hepatol, 75(Suppl 1), pp.S49~S66 (2021)
  9. Stadlbauer V, "Relationship between activation of the sympathetic nervous system and renal blood flow autoregulation in cirrhosis", Gastroenterology, 134, pp.111~119 (2008)
  10. Moore KP, "The management of ascites in cirrhosis : report on the consensus conference of the International Ascites Club", Hepatology, 38, pp.258~266 (2003)
  11. Biggins SW, "Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome : 2021practice guidance by the American Association for the Study of Liver Diseases", Hepatology, 74, pp.1014~1048 (2021)
  12. Adebayo D, "Refractory ascites in liver cirrhosis", Am J Gastroenterol, 114, pp.40~47 (2019)
  13. Caraceni P, "Long-term albumin administration in decompensated cirrhosis(ANSWER) : an open-label randomised trial", Lancet, 391, pp.2417~2429 (2018)
  14. Caraceni P, "On-treatment serum albumin level can guide longterm treatment in patients with cirrhosis and uncomplicated ascites", J Hepatol, 74, pp.340~349 (2021)
  15. Solà E, "Midodrine and albumin for prevention of complications in patients with cirrhosis awaiting liver transplantation. A randomized placebo-controlled trial", J Hepatol, 69, pp.1250~1259 (2018)
  16. Di Pascoli M, "Longterm administration of human albumin improves survival in patients with cirrhosis and refractory ascites", Liver Int, 39, pp.98~105 (2019)
  17. Villanueva C, "β blockers to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension(PREDESCI) : a randomised, double-blind, placebo-controlled, multicentre trial", Lancet, 393, pp.1597~1608 (2019)
  18. Sersté T, "Deleterious effects of beta-blockers on survival in patients with cirrhosis and refractory ascites", Hepatology, 52, pp.1017~1022 (2010)
  19. Sersté T, "Beta-blockers cause paracentesis-induced circulatory dysfunction in patients with cirrhosis and refractory ascites : a crossover study", J Hepatol, 55, pp.794~799 (2011)
  20. Kalambokis GN, "Propranolol use beyond 6 months increases mortality in patients with Child-Pugh C cirrhosis and ascites", Hepatology, 64, pp.1806~1808 (2016)
  21. Mandorfer M, "Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis", Gastroenterology, 146, pp.1680~1690 (2014)
  22. Scheiner B, "Non-selective beta-blocker treatment does not impact on kidney function in cirrhotic patients with varices", Scand J Gastroenterol, 52, pp.1008~1015 (2017)
  23. Leithead JA, "Non-selective β-blockers are associated with improved survival in patients with ascites listed for liver transplantation", Gut, 64, pp.1111~1119 (2015)
  24. Sasso R, "Non-selective beta-blocker use in cirrhotic patients is associated with a reduced likelihood of hospitalisation for infection", Aliment Pharmacol Ther, 53, pp.418~425 (2021)
  25. Bossen L, "Nonselective β-blockers do not affect mortality in cirrhosis patients with ascites : post hoc analysis of three randomized controlled trials with 1198 patients", Hepatology, 63, pp.1968~1976 (2016)
  26. Mookerjee RP, "Treatment with non-selective beta blockers is associated with reduced severity of systemic inflammation and improved survival of patients with acute-on-chronic liver failure", J Hepatol, 64, pp.574~582 (2016)
  27. Téllez L, "Non-selective beta-blockers in patients with ascites : the complex interplay among the liver, kidney and heart", Liver Int, 42, pp.749~761 (2022)
  28. Téllez L, "Non-selective beta-blockers impair global circulatory homeostasis and renal function in cirrhotic patients with refractory ascites", J Hepatol, 73, pp.1404~1414 (2020)
  29. Reiberger T, "Beta adrenergic blockade and decompensated cirrhosis", J Hepatol, 66, pp.849~859 (2017)
  30. Ginés P, "Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study", Gastroenterology, 93, pp.234~241 (1987)
  31. Ruiz-del-Arbol L, "Paracentesis-induced circulatory dysfunction : mechanism and effect on hepatic hemodynamics in cirrhosis", Gastroenterology, 113, pp.579~586 (1997)
  32. Bernardi M, "Albumin infusion in patients undergoing large-volume paracentesis : a metaanalysis of randomized trials", Hepatology, 55, pp.1172~1181 (2012)
  33. Alessandria C, "Prevention of paracentesis-induced circulatory dysfunction in cirrhosis : standard vs half albumin doses. A prospective, randomized, unblinded pilot study", Dig Liver Dis, 43, pp.881~886 (2011)
  34. Tan HK, "Albumin may prevent the morbidity of paracentesis-induced circulatory dysfunction in cirrhosis and refractory ascites : a pilot study", Dig Dis Sci, 61, pp.3084~3092 (2016)
  35. Peltekian KM, "Cardiovascular, renal, and neurohumoral responses to single large-volume paracentesis in patients with cirrhosis and diuretic-resistant ascites", Am J Gastroenterol, 92, pp.394~399 (1997)
  36. Arora V, "Paracentesis-induced circulatory dysfunction with modest-volume paracentesis is partly ameliorated by albumin infusion in acute-on-chronic liver failure", Hepatology, 72, pp.1043~1055 (2020)
  37. De Gottardi A, "Risk of complications after abdominal paracentesis in cirrhotic patients : a prospective study", Clin Gastroenterol Hepatol, 7, pp.906~909 (2009)
  38. Wong F, "Transjugular intrahepatic portosystemic stent shunt : effects on hemodynamics and sodium homeostasis in cirrhosis and refractory ascites", Ann Intern Med, 122, pp.816~822 (1995)
  39. Rössle M, "TIPS : 25 years later", J Hepatol, 59, pp.1081~1093 (2013)
  40. Tan HK, "Long-term clinical outcome of patients with cirrhosis and refractory ascites treated with transjugular intrahepatic portosystemic shunt insertion", J Gastroenterol Hepatol, 30, pp.389~395 (2015)
  41. Russo MW, "Transjugular intrahepatic portosystemic shunt for refractory ascites : an analysis of the literature on efficacy, morbidity, and mortality", Am J Gastroenterol, 98, pp.2521~2527 (2003)
  42. Lebrec D, "Transjugular intrahepatic portosystemic shunts : comparison with paracentesis in patients with cirrhosis and refractory ascites : a randomized trial. French Group of Clinicians and a Group of Biologists", J Hepatol, 25, pp.135~144 (1996)
  43. Rössle M, "A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites", N Engl J Med, 342, pp.1701~1707 (2000)
  44. Ginès P, "Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis", Gastroenterology, 123, pp.1839~1847 (2002)
  45. Sanyal AJ, "The North American study for the treatment of refractory ascites", Gastroenterology, 124, pp.634~641 (2003)
  46. Salerno F, "Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites", Hepatology, 40, pp.629~635 (2004)
  47. Narahara Y, "Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function : a prospective randomized trial", J Gastroenterol, 46, pp.78~85 (2011)
  48. Bai M, "TIPS improves liver transplantation-free survival in cirrhotic patients with refractory ascites : an updated meta-analysis", World J Gastroenterol, 20, pp.2704~2714 (2014)
  49. Salerno F, "Transjugular intrahepatic portosystemic shunt for refractory ascites : a meta-analysis of individual patient data", Gastroenterology, 133, pp.825~834 (2007)
  50. Trebicka J, "Does transjugular intrahepatic portosystemic shunt stent differentially improve survival in a subset of cirrhotic patients?", Semin Liver Dis, 38, pp.87~96 (2018)
  51. Bureau C, "Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites", Gastroenterology, 152, pp.157~163 (2017)
  52. Barrio J, "Comparison of transjugular intrahepatic portosystemic shunt dysfunction in PTFE-covered stent-grafts versus bare stents", Eur J Radiol, 55, pp.120~124 (2005)
  53. Casadaban LC, "Clearing the confusion over hepatic encephalopathy after TIPS creation : incidence, prognostic factors, and clinical outcomes", Dig Dis Sci, 60, pp.1059~1066 (2015)
  54. Fonio P, "Incidence of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt(TIPS)according to its severity and temporal grading classification", Radiol Med, 122, pp.713~721 (2017)
  55. Schindler P, "Shunt-induced hepatic encephalopathy in tips : current approaches and clinical challenges", J Clin Med, 9, pp.3784~ (2020)
  56. Schepis F, "Under-dilated TIPS associate with efficacy and reduced encephalopathy in a prospective, non-randomized study of patients with cirrhosis", Clin Gastroenterol Hepatol, 16, pp.1153~1162 (2018)
  57. Seifert LL, "Recurrence of hepatic encephalopathy after TIPS : effective prophylaxis with combination of lactulose and rifaximin", J Clin Med, 10, pp.4763~ (2021)
  58. Bureau C, "The use of rifaximin in the prevention of overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt : a randomized controlled trial", Ann Intern Med, 174, pp.633~640 (2021)
  59. García-Pagán JC, "Where does TIPS fit in the management of patients with cirrhosis?", JHEP Rep, 2, pp.100122~ (2020)
  60. Billey C, "A prospective study identifying predictive factors of cardiac decompensation after transjugular intrahepatic portosystemic shunt : the toulouse algorithm", Hepatology, 70, pp.1928~1941 (2019)
  61. Mizrahi M, "Endotipsitispersistent infection of transjugular intrahepatic portosystemic shunt : pathogenesis, clinical features and management", Liver Int, 30, pp.175~183 (2010)
  62. European Association for the Study of the Liver, "EASL clinical practice guidelines for the management of patients with decompensated cirrhosis", J Hepatol, 69, pp.406~460 (2018)
  63. Gülberg V, "Improved quality of life in patients with refractory or recidivant ascites after insertion of transjugular intrahepatic portosystemic shunts", Digestion, 66, pp.127~130 (2002)
  64. Allard JP, "Effects of ascites resolution after successful TIPS on nutrition in cirrhotic patients with refractory ascites", Am J Gastroenterol, 96, pp.2442~2447 (2001)
  65. Jahangiri Y, "Muscle gain after transjugular intrahepatic portosystemic shunt creation : time course and prognostic implications for survival in cirrhosis", J Vasc Interv Radiol, 30, pp.866~872 (2019)
  66. Will V, "Current treatment options of refractory ascites in liver cirrhosis-a systematic review and meta-analysis", Dig Liver Dis, 54, pp.1007~1014 (2022)
  67. Tsien C, "Reversal of sarcopenia predicts survival after a transjugular intrahepatic portosystemic stent", Eur J Gastroenterol Hepatol, 25, pp.85~93 (2013)
  68. Bettinger D, "Refining prediction of survival after TIPS with the novel Freiburg index of post-TIPS survival", J Hepatol, 74, pp.1362~1372 (2021)
  69. Trebicka J, "Smaller-diameter covered transjugular intrahepatic portosystemic shunt stents are associated with increased survival", Clin Gastroenterol Hepatol, 17, pp.2793~2799 (2019)
  70. Bureau C, "Alfapump® system vs. large volume paracentesis for refractory ascites : a multicenter randomized controlled study", J Hepatol, 67, pp.940~949 (2017)
  71. Bellot P, "Automated low flow pump system for the treatment of refractory ascites : a multi-center safety and efficacy study", J Hepatol, 58, pp.922~927 (2013)
  72. Thomas MN, "Automated low flow pump system for the treatment of refractory ascites : a single-center experience", Langenbecks Arch Surg, 400, pp.979~983 (2015)
  73. Stirnimann G, "Treatment of refractory ascites with an automated lowflow ascites pump in patients with cirrhosis", Aliment Pharmacol Ther, 46, pp.981~991 (2017)
  74. Solbach P, "Automated low-flow ascites pump in a real-world setting : complications and outcomes", Eur J Gastroenterol Hepatol, 30, pp.1082~1089 (2018)
  75. Wong F, "Improvement in quality of life and decrease in largevolume paracentesis requirements with the automated lowflow ascites pump", Liver Transpl, 26, pp.651~661 (2020)
  76. Will V, "Transjugular intrahepatic portosystemic shunt and alfapump® system for refractory ascites in liver cirrhosis : outcomes and complications", United European Gastroenterol J, 8, pp.961~969 (2020)
  77. Lepida A, "Systematic review with meta-analysis : automated low-flow ascites pump therapy for refractory ascites", Aliment Pharmacol Ther, 50, pp.978~987 (2019)
  78. Solà E, "Effects of alfapump™ system on kidney and circulatory function in patients with cirrhosis and refractory ascites", Liver Transpl, 23, pp.583~593 (2017)
  79. Aagaard NK, "Consensus care recommendations for alfapump ® in cirrhotic patients with refractory or recurrent ascites", BMC Gastroenterol, 22, pp.111~ (2022)
  80. Stepanova M, "Patients with refractory ascites treated with alfapump®system have better health-related quality of life as compared to those treated with large volume paracentesis : the results of a multicenter randomized controlled study", Qual Life Res, 27, pp.1513~1520 (2018)
  81. Mazumder NR, "Patients with persistently low MELD-Na scores continue to be at risk of liver-related death", Transplantation, 104, pp.1413~1418 (2020)
  82. Heuman DM, "Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death", Hepatology, 40, pp.802~810 (2004)
  83. Somsouk M, "Moderate ascites identifies patients with low model for endstage liver disease scores awaiting liver transplantation who have a high mortality risk", Liver Transpl, 17, pp.129~136 (2011)
  84. Prohic D, "Prognostic significance of ascites and serum sodium in patients with low meld scores", Med Arch, 70, pp.48~52 (2016)
  85. Hadengue A, "Persistence of systemic and splanchnic hyperkinetic circulation in liver transplant patients", Hepatology, 17, pp.175~178 (1993)
  86. Salerno F, "Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis", Gut, 56, pp.1310~1318 (2007)
  87. Kumar R, "Chronic renal dysfunction in cirrhosis : a new frontier in hepatology", World J Gastroenterol, 27, pp.990~1005 (2021)
  88. Bassegoda O, "Development of chronic kidney disease after acute kidney injury in patients with cirrhosis is common and impairs clinical outcomes", J Hepatol, 72, pp.1132~1139 (2020)
  89. Patil V, "Paracentesis-induced acute kidney injury in decompensated cirrhosis-prevalence and predictors", Clin Exp Hepatol, 5, pp.55~59 (2019)
  90. Ponzo P, "Transjugular intrahepatic porto-systemic shunt in cirrhotic patients with hepatorenal syndrome-chronic kidney disease : Impact on renal function", Dig Liver Dis, 54, pp.1101~1108 (2022)
  91. D’Amico G, "Clinical states of cirrhosis and competing risks", J Hepatol, 68, pp.563~576 (2018)
  92. Macken L, "Randomised clinical trial : palliative long-term abdominal drains vs large-volume paracentesis in refractory ascites due to cirrhosis", Aliment Pharmacol Ther, 52, pp.107~122 (2020)
  93. Corrigan M, "Tunnelled peritoneal drainage catheter placement for the palliative management of refractory ascites in patients with liver cirrhosis", Frontline Gastroenterol, 12, pp.108~112 (2020)
  94. Cooper M, "Palliative long-term abdominal drains versus large volume paracentesis in refractory ascites due to cirrhosis(REDUCe study) : qualitative outcomes", J Pain Symptom Manage, 62, pp.312~325 (2021)
  95. Roy A, "Letter : long-term abdominal drains in refractory ascites-evolving concept of palliative care in decompensated cirrhosis", Aliment Pharmacol Ther, 52, pp.1266~1267 (2020)
  96. Macken L, "Permanent indwelling peritoneal catheters for palliation of refractory ascites in endstage liver disease : a systematic review", Liver Int, 39, pp.1594~1607 (2019)

관련 논문AI추천

Albumin for End-Stage Liver Disease이준성대한내과학회 · The Korean Journal of Internal Medicine2012 · 제27권 제1호Pharmacological Interventions for Cirrhotic Ascites: From Challenges to Emerging Therapeutic HorizonsChen Yu, Duan Meili, Gao Yuan, Gao Yunyi, Hou Bing, Liu Xin거트앤리버 소화기연관학회협의회 · Gut and Liver2024 · 제18권 제6호Predictors of Refractory Ascites Development in Patients with Hepatitis B Virus-Related Cirrhosis Hospitalized to Control Ascitic Decompensation김도영, 김승업, 박준용, 서주희, 안상훈, 전재윤, 한광협연세대학교의과대학 · Yonsei Medical Journal2013 · 제54권 제1호The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: Advantages and pitfallsHae Lim Lee, Sung Won Lee대한간학회 · Clinical and Molecular Hepatology2022 · 제28권 제2호Various Treatment Modalities in Hepatic Hydrothorax: What Is Safe and Effective?김희준, 윤재현, 전충환, 정요천, 조성범, 최성규연세대학교의과대학 · Yonsei Medical Journal2019 · 제60권 제10호The impact of paracentesis flow rate in patients with liver cirrhosis on the development of paracentesis induced circulatory dysfunctionAyman Alsebaey, Eman Abdelsamee, Eman Rewisha, Maha Mohammad Elsabaawy, Manar Abdelaal Obada, Shimaa Rashad Abdelhamid, Tary Abdelhamid Salman대한간학회 · Clinical and Molecular Hepatology2015 · 제21권 제4호

이 간행물의 다른 논문 (46건)

Subclinical versus advanced forms of alcohol-related liver disease: Need for early detectionLuma Melo, David Martí-Aguado, Ramón Bataller, Concepción Gómez-Medinapp. 1-15PrefaceYoon Jun Kimpp. 2-2PrefaceSeung Up Kimpp. 3-3Non-alcoholic fatty liver disease: Definition and subtypesSeul Ki Han, 김문영, 백순구pp. 5-16Wnt signaling in liver regeneration, disease, and cancerJae-Il Park, Gengyi Zoupp. 33-50
원문 보기