Refractory Ascites - Newer Concepts in the Management

Refractory ascites is a challenging condition where the accumulation of fluid in the abdominal cavity (ascites) does not respond to standard medical therapies. It is often associated with advanced liver cirrhosis and is a significant complication that can lead to poor quality of life and increased mortality.

Over the years, several newer concepts in the management of refractory ascites have been explored to improve patient outcomes. Transjugular intrahepatic portosystemic shunt (TIPS) prevents further decompensation and improves survival in patients with cirrhosis and portal hypertension. But some of the challenges associated with this method are: Patient selection; timing; risk of liver failure and HE; post-TIPS cardiac decompensation.

Another new concept is the alfapump system for patients with refractory ascites when TIPS is not feasible. This device is also used for patients with previously failed TIPs, portal thrombosis and associated cardiac dysfunction. This battery-operated device is subcutaneously implanted in the peritoneal cavity and drains ascitic fluid from the peritoneal cavity and into the urinary bladder. However, it has several limitations, such as cost, availability and risk of infection.

A liver transplant is the first treatment of choice for refractory ascites. Some of the other points that should be considered for managing refractory ascites are:

• Patients with low MELD scores should be considered.
• Patients with spontaneous bacterial peritonitis (SBP) or hepatorenal syndrome should be prioritized.
• All other measures should be considered as bridge to transplant in the presence of refractory ascites.
• Simultaneous liver-kidney transplant for patients with concomitant chronic kidney disease stage 3b.
• Lastly, remember, other than these interventions, nutritional, frailty and palliation form an integral part of refractory ascites management