Topic- Refractory ascites evaluation and tt.pptx

refractory ascites, diuretic intractable , diuretic non responsive ascites

1. Topic- Refractory ascites Presented by Dr S ambit Kumar Patel

2. INTRODUCTION Compensated CLD 60% decompensate( ascites ) Over 10 years CLD with ascites - mortality is 50% within 2 years Ascites become refractory about 5-10% per year Once refractory survival is only 6 month

3. Refractory ascites defined as Ascites that cannot be mobilized or the early recurrence ( after therapeutic paracentesis) cannot be satisfactorily prevented by medical therapy. - Diuretic-resistant ascites : lack of response to sodium restriction and intensive diuretic treatment - Diuretic-intractable ascites : development of diuretic-induced complications that preclude the use of an effective diuretic dosage

4. Diagnostic criteria Treatment duration -Intensive diuretic therapy( furosemide 160 + spironolactone 400) for at least one week and salt restriction (< 80 mEq /day) 5.2 gm of salt /day Lack of response -Mean weight loss of <0.8 kg over four days and urinary sodium output less than the sodium intake Early ascites recurrence -Reappearance of grade 2 or 3 ascites within four weeks of initial mobilization Diuretic-induced complications : hepatic encephalopathy, renal impairment ( creatinine >100% to a value> 2 mg/ dL ), hyponatremia (< 125 mEq /L), hypo- or hyperkalemia (< 3 or > 6 mEq /L). Invalidating muscle cramps

5. Pathogenesis of ascites

6. Pathogenesis of refractory ascites renal perfusion and glomerular filtration rate progressively decline. sodium reabsorption at the proximal convoluted tubules and its delivery to distal segments of the nephron is markedly Nullify action of both anti- mineralocorticoid and loop diuretics.

7. Continued… In addition, there is reduced cardiovascular responsiveness to vasoconstrictor systems the relative underfilling of the EABV and thus hypovolumic effects of diuretics exaggerated. Leading to devlopment of diuretic-related side effects

8. “False” refractory ascites Iatrogenic factors (NSAIDs, ACE-I,ARB, aminoglycosides ) Disorders manifesting with fluid loss due to vomiting, diarrhea and bleeding Bacterial infections (SBP) Compliance to low-sodium diet: evaluation of NaU /24 h

9. TREATMENT DIURETICS - In the majority of patients with RA, diuretic therapy has no effect in preventing or delaying ascites recurrence after paracentesis . Diuretics should be completely discontinued if complications (i.e., HE, impaired renal function, electrolyte disturbances) occur . Remaining patients should continue the treatment only when the excretion of sodium in the urine is greater than 30 mmol /day

10. Currently, several methods of RA treatment can be implemented, but none are entirely acceptable Large-volume paracentesis (LVP) and intravenous albumin supplementation ; 2. Transjugular , intrahepatic portosystemic shunt (TIPS ); 3. Automatic, low-flow pump for ascitic evacuation ( ALFApump System ); 4. Cell-free and concentrated ascites reinfusion therapy (CART ); 5. Liver transplantation ; 6. Vasopressors , that improve patient sensitivity to diuretics

11. Large-volume paracentesis (LVP) and intravenous albumin supplementation More effective and safer than diuretic treatment Recommended administration of human albumin* (8 g/L of ascites removed) to prevent post- paracentesis -induced circulatory disfunction Possible in outpatient setting SAFE procedure (hematoma <1%,bleeding into peritoneal cavity <0.1%)

12. Caraceni P, Riggio O, Angeli P, Alessandria C et al. Long-term albumin administration in decompensated cirrhosis (ANSWER): an open-label randomised trial. Lancet 2018 Overall 18-month survival: 38% mortality reduction - Rate of paracentesis: 54% reduction - Incidence of refractory ascites: 57% reduction - Reduction of: SBP, infections, AKI, HE (30-68%) - Increase of QoL Cost-effective: reduction in hospital admissions, days In hospital, fewer paracentesis, fewer complications (SBP, renal impairment, HE…)

13. no absolute contraindications for paracentesis avoided in patients with disseminated intravascular coagulation syndrome. attention should be paid to patients with intra-abdominal adhesions and distended urinary bladders Usg guided

14. Transjugular , intrahepatic portosystemic shunt (TIPS); Better control of ascites than LVP Lower rate of portal hypertension-related bleeding Higher incidence of hepatic encephalopathy (HE) Contraindications to TIPS placement Impaired liver function ( bilirubin > 3 mg/ dL , CTP > 11 (EASL-2010), CTP-13(AASLD -2023), MELD > 18 ) Age > 70 y Recurrent encephalopathy Concomitant cardiopulmonary disease

15. Indication of TIPS TIPS should be considered in patients who require > two large-volume paracentesis per month or when ascites is loculated and cannot be easily removed with a paracentesis , or when the patient becomes intolerant of repeated taps

16. PRE TIPS EVALUATION

17. Scoring for prediction of post TIPS SURVIVAL 2-year transplant-free survival integrated MELD score( bilirubin / inr / cr /age/Na) of <32(71%), between 32 and 38(54%), and >38(26%), respectively. In another study from Germany, the Freiberg index of post-TIPS survival (FIPS) score ([1.43 × (log10 bilirubin , mg/dl)] - [1.71 ×(1/ creatinine , mg/dl)] + [0.02 × (age, years)] - [0.02 × (albumin, g/L)] + 0.81)43 was able to identify patients at high risk for mortalityafter TIPS, significantly better than the MELD / MELDsodium / CTP FIPS >0.92 HIGH risk group ,post TIPS survival is only 5 month

18. Complication of TIPS TIPS stenosis /dislocation HE Intravascular hemolysis (subside by 12-15 weeks,endothelisation of stent) Cardiac failure Renal failure (systemic arterial vasodilatation) Liver failure (hepatic ischemia)

19. Peritoneovenous shunt Fast ascites control Renal function improvement Shunt infection/thrombosis Peritonitis Unsatisfactory long-term results Close patient monitoring Currently not recommended

20. Alfapump Significant reduction of number and volume of paracentesis Fluid removed daily 500 ml to 2.5 l/day , small volume every 5-10 min,albumin infusion is not obligatory. Improved QoL Improved nutrition status Technical difficulties Renal impairment Unclear survival benefit INDICATION : patients with refractory ascites not amenable to TIPS, preferably in experienced centers

21. Cell-free and concentrated ascites reinfusion therapy ( CART) Safe procedure Reduction of albumin infusions Improved QoL Endotoxin infusion Fever Low BP

22. midodrine Midodrine that acts as a splanchnic vasoconstrictor improves renal perfusion and glomerular filtration. It is recommended by the AASLD for RA treatment midodrine improved response rates and reduced plasma renin activity, but did not improve survival rate.

23. Thank you