Published online Sep 27, 2024. doi: 10.4254/wjh.v16.i9.1245
Revised: July 20, 2024
Accepted: July 29, 2024
Published online: September 27, 2024
Processing time: 82 Days and 7.7 Hours
For cirrhotic refractory ascites, diuretics combined with albumin and vasoactive drugs are the first-line choice for ascites management. However, their therapeutic effects are limited, and most refractory ascites do not respond to medication treat
Core Tip: For cirrhotic refractory ascites, peritoneovenous shunt is rarely used due to its high complication rate. Initial treatment for most refractory ascites prioritizes large-volume paracentesis combined with albumin infusion and peritoneal catheter drainage. If these treatments are ineffective or result in severe complications, transjugular intrahepatic portosystemic shunt or automated low-flow ascites pump may be considered. Cell-free and concentrated ascites reinfusion therapy requires further validation for suitability.
- Citation: Yang JX, Peng YM, Zeng HT, Lin XM, Xu ZL. Drainage of ascites in cirrhosis. World J Hepatol 2024; 16(9): 1245-1257
- URL: https://www.wjgnet.com/1948-5182/full/v16/i9/1245.htm
- DOI: https://dx.doi.org/10.4254/wjh.v16.i9.1245
Ascites denotes the accumulation of excess free fluid in the abdominal cavity, with cirrhosis being the predominant cause, responsible for over 60% of cases. The onset of ascites is a critical marker in the progression of cirrhosis, often signaling a transition from a stable to a more severe clinical phase. This condition frequently accompanies acute decompensation events, such as acute-on-chronic liver failure, bacterial infections, and recurrent hospitalizations, significantly impacting overall treatment outcome[1]. Ascites is associated with multiple interrelated pathogenic mechanisms involving visceral and systemic hemodynamics, as well as dysfunctions in both liver and extrahepatic organs, primarily the kidneys and heart[2]. Portal hypertension is the primary and initiating factor of ascites formation in cirrhosis[3], causing reduced tissue fluid reabsorption and leakage into the abdominal cavity. Additionally, decreased serum albumin levels lead to reduced plasma colloid osmotic pressure, causing fluid to seep into the abdominal cavity or interstitial spaces. Systemic inflammatory response syndrome also significantly contributes to ascites formation. The primary mechanism involves interactions between bacterial products or pathogen-associated molecular patterns and their respective receptors, promoting the formation and release of inflammatory cytokines. This inflammation stimulates the production of endogenous vasodilators, such as endotoxins, vasoactive intestinal peptides, and nitric oxide, leading to vasodilation[4]. This vasodilation results in effective circulating volume (ECV) deficiency, reduced renal blood flow, and activation of the renin-angiotensin system, exacerbating sodium and water retention, thereby promoting ascites formation. Furthermore, the impaired hepatic processing function in cirrhotic patients weakens the inactivation of aldosterone and antidiuretic hormone, further promoting sodium and water retention. Increased pressure within the hepatic sinusoids in cirrhotic patients leads to increased lymph formation. When the volume of returning lymph exceeds the drainage capacity of the thoracic duct, it can seep from the liver surface into the abdominal cavity, forming ascites[5].
Currently, managing and controlling refractory ascites and its related complications remains a significant clinical challenge. Pharmacotherapy, commonly using diuretics (furosemide or spironolactone) combined with albumin and vasoactive drugs, is the first-line choice for ascites management[6]. However, its therapeutic effects are often limited, and most refractory ascites do not respond to drug treatment, necessitating consideration of drainage or surgical inter
Ascites drainage methods | Characteristics |
LVP | In the majority of patients suffering from refractory ascites, the preferred treatment approach involves the prioritization of LVP in conjunction with HSA administration. An advisable frequency for this therapeutic regimen is approximately once every two weeks, ensuring that the maximum volume of fluid removed during a single paracentesis does not surpass 5 L. It is imperative to note that repetitive LVP procedures heighten the potential for the development of complications. |
TIPS | For patients who require frequent paracentesis procedures, frequent hospitalizations, or are awaiting liver transplantation, TIPS can act as a vital bridge therapy, facilitating the transition to definitive liver transplantation. However, due to its associated complications and contraindications, TIPS is typically reserved as a second-line therapeutic option, employed subsequent to the failure of LVP treatment. This approach ensures that the most appropriate and safe treatment pathway is pursued for each individual patient’s unique circumstances. |
PVS | When addressing refractory ascites, PVS has not demonstrated superiority over repeated LVP in terms of treatment outcomes. Furthermore, the risk of severe complications associated with PVS has rendered this approach virtually obsolete, as it has led to its near-complete abandonment in clinical practice. |
Alfapump | The alfapump system holds significant potential in drastically reducing the reliance on LVP for patients. Nonetheless, it is important to acknowledge that the complication rate associated with this treatment modality remains relatively high. For those individuals diagnosed with non-malignant refractory ascites who are deemed ineligible for alternative therapies, such as TIPS or liver transplantation, the implantation of an alfapump represents an efficacious and viable treatment option. |
CART | CART exhibits remarkable efficacy in swiftly alleviating abdominal distension, mitigating the burden of ascites, and enhancing nutritional intake for patients. Nevertheless, this innovative therapy is not without its challenges, including substantial equipment costs, intricate procedural requirements, and potential allergic reactions. Presently, CART is predominantly utilized in Japan, and its universal applica |
Peritoneal catheter drainage | The adoption of peritoneal catheter drainage as a management strategy for cirrhotic ascites boasts a high rate of symptom alleviation, coupled with low financial costs and a minimal incidence of associated complications. This approach significantly diminishes the necessity for repeated LVP procedures, positioning it as a potential cornerstone in the evolving landscape of cirrhotic ascites management. Nevertheless, meticulous attention must be paid to minimizing the duration of catheter retention, as this is paramount in preventing the emergence of complications. |
LVP combined with human serum albumin (HSA) supplementation remains the cornerstone of current ascites management (Figure 1)[8]. Defined as the removal of more than 5 L ascites in a single session, LVP can significantly alleviate patient discomfort, such as abdominal distension, by draining 4-6 L per day. Studies indicate that patients undergoing paracentesis exhibit lower in-hospital mortality rates compared to those who do not[9]. Compared with diuretics, LVP rapidly controls large volumes of ascites and shortens hospital stays[10], with fewer complications, such as electrolyte abnormalities, renal dysfunction, and hemodynamic instability[11]. However, LVP requires repeated punctures and has limitations, as it does not address the underlying pathophysiology of ascites formation, leading to rapid recurrence. The reduction in intra-abdominal pressure after LVP often increases the pressure gradient between the liver and abdominal cavity, causing rapid ascites refilling. Thus, repeated LVP is typically necessary, with most patients needing another paracentesis within two weeks. Martin et al[12] found that repeated LVP increases the risk of complica
TIPS involves inserting a stent to bridge the portal vein branch and hepatic vein, effectively creating a portosystemic shunt to treat cirrhotic ascites (Figure 2). Unlike paracentesis, this procedure targets the elimination of portal hypertension and its complications rather than merely alleviating symptoms[25]. Successful TIPS insertion lowers portal vein pressure, enhances circulatory function in ascites patients[26], increases visceral blood flow to systemic circulation, mitigates effective arterial blood volume deficiency, and improves heart and kidney functions[27]. Two types of stents are used in TIPS: bare metal stents and covered stents. Approximately 70% of patients with bare metal TIPS stents develop stenosis due to excessive endothelial growth within the stent, narrowing the lumen[28]. TIPS stenosis can be treated by balloon dilatation of the stent, and new stent insertion is required if this fails. Covered stents, coated with polytetrafluo
PVS (LeVeen or Denver), first employed in the 1970s for refractory ascites, has been shown to reduce hospitalization duration, the number of hospitalizations, and diuretic dosage. This method involves implanting a device in the abdominal cavity to collect and filter blood from the peritoneal cavity based on the pressure gradient between the peritoneal cavity and central veins, directing it to the heart for further processing. The primary mechanism aims to reduce ascites volume while expanding plasma volume[60]. Ginès et al[61] have demonstrated that PVS effectively controls ascites compared to LVP combined with albumin infusion. Additionally, PVS has been reported to improve the glomerular filtration rate (GFR) in cirrhotic patients with refractory ascites, particularly those with moderate to severe renal impairment[62]. However, other studies indicate that PVS does not surpass repeated LVP and albumin infusion in treating refractory ascites[63]. Despite its relatively simple operation, PVS can cause serious, even fatal, complications, including infections[64], device blockage, shunt dysfunction, thrombosis, volume overload, disseminated intravascular coagulation, heart failure[65], air embolism, and complications related to surgical insertion[66]. These complications significantly increase patient mortality. Moreover, PVS placement can hinder TIPS procedures and cause peritoneal adhesions, complicating liver transplantation surgery. Although PVS can be used for refractory ascites patients ineligible for TIPS or liver transplantation, its high risk of adverse outcomes has led to its near-total abandonment[67].
Alfapump is currently an alternative therapy for patients with refractory ascites (Figure 3)[68]. This implanted, battery-powered pump includes two silicone catheters: One in the peritoneum to collect ascites and the other in the bladder to deliver the ascites. The alfapump has four pressure sensors that monitor abdominal and bladder pressure, providing information on flow rates and system behavior. Generally, the pumping cycle starts when bladder pressure is below a certain threshold and stops immediately when peritoneal cavity pressure decreases significantly. This control allows the alfapump to manage the volume of ascites drained as well as the timing and frequency of pump activity. The alfapump’s purpose is to transfer ascites from the abdominal cavity to the bladder, allowing elimination through urination[69], effectively performing continuous small-volume, low-rate paracentesis daily. Despite requiring daily battery charging for less than 20 min, the pump operates for about 16 hours, with an expected battery life of over three years[70]. In managing cirrhotic ascites, the alfapump can significantly reduce the need for LVP[71,72]. A meta-analysis revealed that 62% of patients no longer needed LVP after alfapump implantation, and the number of required LVPs was significantly reduced[73]. Compared to repeated LVP, alfapump is more acceptable to patients with refractory ascites and improves their quality of life[74-76]. Studies show that the alfapump system offers advantages over LVP by reducing or eliminating the need for paracentesis and enhancing quality of life and nutritional status[77]. Although the alfapump system’s implan
CART was first reported in 1977[89]. It is mainly used for treating patients with ascites due to decompensated cirrhosis (Figure 4). The purpose of CART is to maintain plasma colloid osmotic pressure by reinfusing proteins recovered from ascites[90]. The CART procedure includes several steps: First, paracentesis is performed to remove ascites into a drainage bag. Next, filtration is used to remove pathogens and small molecular harmful substances such as urea nitrogen, creatinine, and bilirubin. Then, excess water is removed through concentration. Finally, the liquid obtained from these steps, including useful proteins like albumin and globulin, is reinfused intravenously[91]. This method avoids the loss of proteins contained in the ascites, reduces the cost of using large amounts of albumin, and avoids the risk of infection from using blood products. The main indication for CART is ascites due to cirrhosis, but it has also been used to treat malig
Peritoneal catheter drainage serves as an effective method for managing cirrhotic ascites. Studies suggest that long-term abdominal drainage provides a safe and effective palliative intervention for end-stage liver disease (Figure 5)[107]. Various catheter placements have been recommended as an alternative to traditional treatments for refractory ascites[108]. This approach involves inserting a peritoneal puncture catheter kit into the abdominal cavity under local anesthesia guided by ultrasound. The drainage amount is adjusted based on the patient’s condition, along with basic treatments such as liver protection, diuretics, and albumin supplementation. The catheter is removed once ascites is no longer present or ultrasound indicates near-total absorption. Typically, daily drainage is limited to 5 hours, with volumes controlled between 800 and 1500 mL over 3 to 7 days. Research indicates that peritoneal indwelling central venous cathe
Different drainage methods for cirrhotic ascites have their advantages and disadvantages. PVS is rarely used currently due to its high complication rate. Initial treatment for most refractory ascites should prioritize LVP combined with albumin infusion and peritoneal catheter drainage. If these treatments are ineffective or cause severe complications, TIPS or alfapump may be considered. CART, primarily used in Japan, requires further validation for suitability in other populations. Clinicians must evaluate the patient’s specific condition and circumstances to determine the most appropriate treatment.
We would like to thank our colleagues for their valuable contributions to this review. We gratefully acknowledge Jinan University and Shenzhen People’s Hospital for providing the necessary support for this study.
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