Refractory Ascites
Refractory Ascites is a medical condition characterized by the persistent accumulation of fluid in the abdomen, despite standard treatment efforts. This fluid buildup is often a complication of advanced liver disease, and it poses challenges in management due to its resistance to conventional therapies. Common treatments for ascites include diuretics and paracentesis, but in refractory cases, more advanced interventions such as the Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure might be considered. The presence of refractory ascites often indicates a severe stage of the underlying liver condition and requires close medical monitoring and interventions.
Ascites in patients with cirrhosis compared with other diseases:
| Causes of Ascites | Cirrhosis | Congestive Cardiac Failure | Malignancy | Tuberculosis | SBP | Pancreatitis |
|---|---|---|---|---|---|---|
| Gross Appearance | Clear Straw or Milky | Clear to Pale Yellow | Milky or Bloody | Milky or None | Cloudy or Turbid | Milky, Cloudy, or Turbid |
| Total Protein (TP) | < 25 g/L | < 25 g/L | ≥ 25 g/L | ≥ 25 g/L | ≥ 25 g/L | ≥ 25 g/L |
| Serum-Ascites Albumin Gradient (SAAG) | ≥ 1.1 g/dL | ≥ 1.1 g/dL | < 1.1 g/dL | < 1.1 g/dL | < 1.1 g/dL | < 1.1 g/dL |
| LDH (Lactate Dehydrogenase) | ↓ (Decreased) | ↓ or Normal | ↑ (Increased) | ↑ or Normal | ↑ or Normal | ↑ or Normal |
| Glucose | Normal (N) | Normal (N) | ↓ (Decreased) | ↓ (Decreased) | ↓ (Decreased) | ↓ (Decreased) |
| Amylase | Normal (N) or ↑ (Increased) | - | ↓ (Decreased) or Normal (N) | - | ↑ (Increased) | - |
| ADA (Adenosine Deaminase) | ↓ (Decreased) or Normal (N) | - | ↓ (Decreased) or Normal (N) | ↑ (Increased) or - | - | - |
| Cell Counts | ≥ 250/μL or Normal (N) | - | ≥ 250/μL or Normal (N) | ≥ 250/μL or Normal (N) | - | ≥ 250/μL or Normal (N) |
| Bacterial Culture | + (Positive) or - (Negative) | - | + (Positive) or - (Negative) | + (Positive) | - | + (Positive) |
| Viscosity | < 1.03 cP | < 1.03 cP | ≥ 1.03 cP | ≥ 1.03 cP | ≥ 1.03 cP | ≥ 1.03 cP |
| 1H NMR (Nuclear Magnetic Resonance) | ↑ (Increased) or ↓ (Decreased) | ↑ (Increased) or ↓ (Decreased) | - | - | - | - |
| VEGF (Vascular Endothelial Growth Factor) | ↓ (Decreased) | - | ↑ (Increased) | ↓ (Decreased) | ↓ (Decreased) | ↓ (Decreased) |
| Tumor Markers | ↑ (Increased) or Normal (N) | Normal (N) | ↑ (Increased) | ↑ (Increased) or Normal (N) | - | ↑ (Increased) or Normal (N) |
Criteria for Refractory Ascites:
| Criteria | Description |
|---|---|
| Diuretic Resistance | Lack of response to maximal doses of diuretic for at least 1 week - Spironolactone 400 mg - Furosemide 160 mg |
| Diuretic-induced complications | - Hepatic Encephalopathy (HE): This arises without other causes, solely from diuretic use. - Renal Impairment: Marked by a significant increase in serum creatinine (over 100%) leading to levels greater than 2 mg/dL in patients with ascites under treatment. - Hyponatremia: A drop in serum sodium by more than 10 mmol/L, resulting in levels below 125 mmol/L. - Potassium Imbalance: Either a decrease (hypo-) or increase (hyper-) in serum potassium levels, leading to values below 3 mmol/L or above 6 mmol/L, even with preventive measures. |
| Early Recurrence | Recurrence of ascites within 4 weeks of fluid mobilization |
| Weight Loss | Mean weight loss <0.8 kg over 4 days |
| Sodium Restriction | Persistent ascites despite sodium restriction (50–90 mmol/d) |
| Sodium Excretion | Urinary sodium excretion less than sodium intake (<50 mmol/d) |
| Fractional excretion of sodium (FeNa) | > 0.2% may predict the development of refractory ascites in patients receiving diuretic therapy |
| Aspect | Description |
|---|---|
| Definition | Ascites that does not recede or recurs shortly after therapeutic paracentesis, despite sodium restriction and diuretic treatment. |
| Serum Ascites Albumin Gradient (SAAG) | SAAG is a tool used to classify ascites. A high SAAG (≥ 1.1 g/dL) indicates portal hypertension (PH), while a low SAAG (< 1.1 g/L) suggests causes unrelated to PH. |
| Management | 1. Large-volume paracentesis (LVP) with intravenous albumin supplementation (6-8 g/L). 2. Transjugular intrahepatic portosystemic shunt (TIPSS). 3. Automatic, low-flow pump for ascitic evacuation (ALFApump System)- the fluid volume that is removed daily ranges from 500 mL to 2.5 L. The ALFApump drains small volumes of ascitic fluid in cycles every 5–10 min, making the administration of albumin not obligatory 4. Cell-free and concentrated ascites reinfusion therapy (CART)- the filtration and concentration of ascitic fluid are followed by collected protein intravenous reinfusion 5. Liver transplantation. 6. Vasopressors to improve sensitivity to diuretics (e.g. Midodrine, Terlipressin, Clonidine, Tolvaptan) |
| Prognosis | Poor; 50% survival rate at 1 year |
| Complications | 1. Spontaneous Bacteria Peritonitis, 2. Hepatic hydrothorax, 3. SBEM, 4. Umbilical hernia |
| Curative Treatment | Liver transplantation |
- Kasztelan-Szczerbinska, Beata, and Halina Cichoz-Lach. “Refractory ascites-the contemporary view on pathogenesis and therapy.” PeerJ vol. 7 e7855. 15 Oct. 2019, doi:10.7717/peerj.7855
- Siqueira, Fabiolla et al. “Refractory Ascites: Pathogenesis, Clinical Impact, and Management.” Gastroenterology & Hepatology vol. 5,9 (2009): 647–656.