Outcomes in Cirrhotic Patients Receiving Transjugular Intrahepatic Portosystemic Shunt (TIPS) Versus Repeat Paracentesis for Recurrent Ascites

Author(s): Kenneth J. Fearn, MD, Maximilian G. Mayr, BS, Carissa Walter, MPH, Suzanne L. Hunt, MS, MA, Jianghua He, PhD, Yu Wang, MS, MA, Jacqueline Hill, PhD, MPH, Charles B. Davis, MD, Travis Everett, MD, Trevor Everett, MD, Steve Lemons, MD, Aaron Rohr, MD, MS, Adam Alli, MD

Purpose:

Many cirrhotic patients who cannot undergo liver transplantation are symptomatically treated for recurrent ascites with paracenteses and/or transjugular intrahepatic portosystemic shunts (TIPS). This study aimed to determine if there were reduced time between paracenteses, reduced hospital admissions from bacterial peritonitis, variceal bleeds, and hepatic encephalopathy for cirrhotic patients who did receive TIPS compared to those who did not receive TIPS.

Materials and Methods:

A retrospective analysis was performed on cirrhotic patients with refractory ascites between January 1, 2008 and December 31, 2016 at a single institution. Demographics, history, labs, paracenteses, TIPS, and hospitalization information were documented. Shared frailty and chi-square tests were used to determine time between paracenteses and hospitalization rates after the placement of TIPS.

Results:

344 patients with refractory ascites were included. Median age 57 years, male (62%) and white (85%). Cirrhotic etiology included alcohol (45%) and hepatitis C (37%). Ninety-two (27%) received TIPS. Patients averaged 26.2 days between paracentesis pre-TIPS and 51.5 days post-TIPS. The data suggest an association between TIPS and the risk of paracentesis for ascites (Chi-sqr=80.1 p<0.01). A sixty percent reduction in the risk of a paracentesis post-TIPS was observed in our particular sample (estimated Hazard Ratio=0.40 estimated 95% CI (0.33, 0.49)). Rates of hospitalizations for adverse events were not different between patients with and without TIPS: bacterial peritonitis (p=0.13 X2=2.25 df=1), variceal bleeding (p=0.23 X2=1.46 df=1), or hepatic encephalopathy (p=0.46 X2=0.53 df=1).

Conclusion:

TIPS placement increased the time between paracentesis without increasing hospital admission rates for bacterial peritonitis, variceal bleeding, or hepatic encephalopathy. This suggests that TIPS placement should be considered earlier in the cirrhotic disease process to improve symptomatic control which decreases the need for frequent paracentesis. Secondarily, associated hospital costs and risks of frequent paracenteses could be reduced.