Digestive Diseases and Sciences, Vol. 48, No. 3 (March 2003), pp. 542–550 ( C  2003) TIPS for Management of Refractory Ascites Response and Survival Are Both Unpredictable PAUL J. THULUVATH, MD,* JASDEEP S. BAL, MD,* SALLY MITCHELL, MD,† GUNNAR LUND, MD,† and ANTHONY VENBRUX, MD† Refractory ascites is a serious complication of advanced cirrhosis with a 1-year transplant-free survival of 20–50%. The aim of our study was to investigate the short- and long-term effects of transjugular intrahepatic portosystemic shunt (TIPS) in the management of refractory ascites. In all 65 patients (39 M, 26 F; Child B 55%, Child C 45%, mean MELD score 14.8 ± 6.6) with liver disease (alcoholic 40%, cryptogenic 20%, HCV 14%, others 26%) and refractory ascites were included in this study. Forty-eight (74%) patients had no signs of hepatic encephalopathy (HE), 16 (24%) had mild and 1 (2%) had moderate HE before TIPS; 28 (43%) had mild (>1.2 and <2.4 mg/dl) and 6 patients (9%) had moderate (>2.4 mg/dl) renal dysfunction. Mean follow-up was 55.5 ± 70.2 weeks. Treatment success, defined as complete response, partial response, and no response, and survival was determined at 3 weeks, and 3, 6, 12, 24, and 36 months after TIPS. TIPS was successful in all patients. Mean portal venous pressure gradient improved significantly after TIPS (24 ± 8 to 10 ± 4). During follow-up, 40 (58%) patients died and 17 (27%) patients had liver transplantation (OLT); 20 (31%) patients had 38 shunt revisions due to lack of initial response or recurrence of ascites. The response was assessed in patients who were alive, without OLT, at each time point. Complete response was seen in 10%, 23%, 17%, 11%, 22% and 33%; partial response was seen in 46%, 46%, 40%, 44%, 28%, and 8%; and no response was seen in 44%, 31%, 43%, 41%, 39%, and 50% at 3 weeks, and 3, 6, 12, 24, and 36 months respectively. There were no pre-TIPS variables that could predict the response at 3 weeks, 3 months, or 6 months. Mild HE was seen in 8 (12%) patients and severe HE was seen in 16 (25%) immediately after TIPS. The mortality at 3 weeks, and 3, 6, 12, 24, and 36 months was 26%, 38%, 46%, 51%, 57%, and 58%, respectively. Three-week ( P = 0.01) and 3-month ( P = 0.04) mortality was higher in Child C patients compared to Child B. However, there were no independent predictors of survival on multivariate analysis at 3 or 6 months. Child-Pugh score 3 weeks after TIPS was a strong predictor of mortality. In conclusion, in patients with refractory ascites, TIPS was associated with a high mortality and morbidity. The response and the mortality were both unpredictable on the basis of pretransplant variables. KEY WORDS: ascites; TIPS; cirrhosis; liver. Refractory or diuretic-resistant ascites occurs in approx- imately 10% of patients with cirrhosis. The development of refractory ascites is considered a sign of end-stage cir- rhosis. Refractory ascites is associated with many life- Manuscript received July 9, 2002; accepted December 2, 2002. From the Department of *Medicine and †Radiology, The Johns Hop- kins University School of Medicine, Baltimore, Maryland 21205, USA. Address for reprint requests: Dr. Paul J. Thuluvath, The Johns Hopkins Hospital, Room 429, 1830 East Monument Street, Baltimore, Maryland 21205, USA. threatening complications including spontaneous bacte- rial peritonitis, respiratory compromise, rupture of um- bilical hernia, and hepatorenal syndrome. The reported 1-year mortality in patients with refractory ascites ranges from 28% to 79% (1–11). The pathogenesis of ascites formation in patients with cirrhosis is multifactorial, but two major components are an altered neurohormonal system and hypertension in the hepatic sinusoids and splanchnic capillaries (12– 18). It is therefore reasonable to assume that transjugular 542 Digestive Diseases and Sciences, Vol. 48, No. 3 (March 2003) 0163-2116/03/0300-0542/0 C  2003 Plenum Publishing Corporation