TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: a critical update

Refractory ascites is a frequent complication of advanced cirrhosis
and is associated with hepatorenal syndrome and hepatic
hydrothorax. Large volume paracentesis and pleurodesis are regarded
as first-line treatments in patients who do not respond adequately
to diuretics. These treatments, however, do not prevent recurrence
and carry the risk of worsening of the circulatory dysfunction
leading to hepatorenal syndrome. The transjugular intrahepatic
portosystemic shunt ( TIPS) has been proposed as an alternative to
paracentesis. TIPS reduces the rate of ascites recurrence mainly
due to the reduction in the filtration pressure. In addition, TIPS
results in a positive effect on renal function, including
hepatorenal syndrome, demonstrated by a rapid increase in urinary
sodium excretion, urinary volume, and improvement in plasma
creatinine concentration. Furthermore, plasma renin activity,
aldosterone, and noradrenalin concentrations improve gradually
after TIPS insertion suggesting a positive effect on systemic
underfilling, the factor of hepatorenal syndrome. As demonstrated
recently in two meta-analyses including five randomised studies,
TIPS also improves survival when compared with paracentesis.
However, the evidence is based on relatively few studies with only
305 patients included. The positive effects of the TIPS are opposed
by an increased frequency and severity of episodes of hepatic
encephalopathy which may be reduced by both patient selection and
reduced shunt diameter. Based on the present knowledge the
recommended hierarchy of treatments for refractory ascites may be
reconsidered upgrading TIPS in suitable candidates.