Medical Therapy, Not TIPS, Should be Standard Therapy for Ascites

Laurie Barclay, MD

March 13, 2003

March 13, 2003 — Transjugular intrahepatic portosystemic shunts (TIPS) plus medical therapy is better than medical therapy alone in controlling ascites, but not in improving survival, hospitalization rates, or quality of life, according to the results of a multicenter, prospective trial reported in the March issue of Gastroenterology. The investigators suggest that medical therapy should be the principal therapy, with TIPS being offered selectively as a bridge to transplant or for patients with bleeding varices.

"TIPS have recently been used for the treatment of patients with refractory ascites. TIPS decompress the portal vein and correct portal hypertension without the need for general anesthesia or major surgery," write Arun J. Sanyal, MD, from the Medical College of Virginia in Richmond, and colleagues from the North American Study for the Treatment of Refractory Ascites Group. "The clinical utility of TIPS vis-a-vis total paracentesis in the management of refractory ascites is unclear."

Of 109 subjects with refractory ascites, 57 were randomized to medical therapy alone, consisting of sodium restriction, diuretics, and total paracentesis, and 52 were randomized to medical therapy plus TIPS. Shunting was technically adequate in 49 of 52 subjects.

Although TIPS plus medical therapy was superior to medical therapy alone in preventing recurrence of ascites ( P < .001), overall and transplant-free survival were similar in both groups, with 21 deaths in each group. Moderate to severe encephalopathy showed a trend toward being more common in the TIPS group (20 of 52 vs. 12 of 57; P = .058).

The two groups were similar in rates of liver failure (7 vs. 3), variceal hemorrhage (5 vs. 8), and acute renal failure (3 vs. 2). The frequency of emergency department visits, medically indicated hospitalizations, and quality of life also did not differ significantly between groups, nor did TIPS obviate the need for sodium restriction.

No baseline parameters identified a subset of patients who did better or worse after TIPS placement. In those patients treated with TIPS, the authors recommend initial placement of a 10-mm diameter TIPS, not pursuing a hepatic venous pressure gradient target of 8 mm Hg or less, and follow-up sonography or angiography to monitor for stent stenosis.

"TIPS may be more reasonable in an individual with variceal hemorrhage and relatively preserved liver function, whereas medical therapy may be a better option for those with advanced liver failure. It is also important to note that liver transplantation is the only definitive treatment of cirrhosis with refractory ascites," the authors write. "Based on these considerations, we believe the use of TIPS should be reserved in most instances as second-line therapy or a bridge to liver transplantation, particularly for those with relatively preserved liver function."

Gastroenterology. 2003; 124:634-641

Reviewed by Gary D. Vogin, MD