| [Background & Objective]Refractory ascites(RA) is the advanced fatal complications in patients with cirrhosis, occurred in 5% ~ 10% of the patients with ascites, the 1 year survival rate of less than 50%, 2 year survival rate is only 30%.Today, according to the American association of liver disease and liver disease Europe association updated clinical practice guidelines recommend treatment of refractory ascites, the standard treatment of refractory cirrhosis ascites is large volume paracentesis(LVP) after intravenous input albumin(each take 1L ascites and albumin intravenous input 6-8 g), transjugular intrahepatic portosystemic shunt(TIPS) should be as second-line treatment for control of ascites. Large-volume paracentesis(LVP) provides symptomatic relief, it does not correct the underlying pathophysiology of ascites formation and therefore, recurrence of tense ascites is inevitable, and easy cause symptoms of low blood volume and renal impairment, not good measures of long-term control of ascites, and does not apply to those who can’t liver transplantation and to puncture pumping ascites treatment for all life. Liver transplantation is the definitive treatment for refractory ascites, but the current system of organ allocation using the model for end-stage liver disease(MELD) score disadvantages patients, whose major problem is refractory ascites, as MELD score correlates poorly with severity of ascites and underestimates mortality in these patients.In recent years,TIPS become effective treatment for refractory ascites, The refractory ascites clinical response rate was 50%-90% for TIPS. Compared with the first-line treatment of 5 randomized clinical trials show that e refractory ascites clinical response rate was up to 43% for LVP. TIPS can significantly improve the response rate of ascites. In the 4 randomized clinical trials show that the ascites recurrence rate was significantly lower. Meta-analysis was carried out on the 6 RCT studies showed that the incidence of hepatic encephalopathy in different level have significant difference between the TIPS and LVP, increased the incidence of hepatic encephalopathy for TIPS, postoperative survival rate was not or slightly improved.Throughout the past, however, prospective randomized trial and retrospective case series studies for TIPS have found that most of their research groups were alcoholic liver cirrhosis patients. The liver in histology, disease progression and treatment methods are quite different between alcoholic liver cirrhosis and hepatitis B cirrhosis. At present, in the hepatitis B cirrhosis patients with refractory ascites, TIPS for long-term clinical outcome is not clear. and Currently no easy preoperative index or model can be applied to judge the prognosis after TIPS for the management of refractory ascites with cirrhosis, especially in Hepatitis B cirrhosis patients with refractory ascites. This study retrospectively analyzed 94 cases of patients with refractory ascites(57 cases disease due to hepatitis B), to evaluate the long-term clinical curative effect and prognosis factor analysis for TIPS. [Methods]The retrospective study enrolled consecutive patients from January 2001 to June 2014 who had received successful TIPS in Patients with refractory ascites. It is very important to follow up refractory ascites clinical response, ascites recurrence, complications(HE, Shunt dysfunction), survival. Cumulative survival rate were assessed with Kaplan– Meier curves and compared using the log-rank test. The independent predictors for survival were calculated using the Cox regression model, ROC curve to determine the best bound value of prognostic factors. [Results]1. TIPS procedure was technically successful in all 94 patients. Media duration of follow-up was 22.4 months. The refractory ascites clinical response rate was 90.4% at 1year. The ascites recurrence rate was 26.5% at 1year. The HE recurrence rate was 54.4% at 1year. The shunt dysfunction rate was 19.6% at 1year. The survival rate was 54.0%, 41.3% at 1year and 2 year.2. Using multivariate analysis, only BUN was independently associated with 1-year the refractory ascites clinical response. Using multivariate analysis, only Child-Pugh score was independently associated with 1-year the incidence of encephalopathy. According to ROC analysis, we selected the cut of values of 9 scores for Child-Pugh score. Kaplan-Meier survival analysis demonstrated that the 1 year cumulative HE in patients with Child-Pugh score ≤9 scores was 45.1% as compared to 74.7% in patients with Child-Pugh score >9 scores(P=0.001). Using multivariate analysis, Age and Child-Pugh score were independently associated with 1-year survival. According to ROC analysis, we selected the cut of values of 8 scores for Child-Pugh score and 51-years-old for age. Kaplan-Meier survival analysis demonstrated that the 1 year cumulative survival in patients with Child-Pugh score ≤ 8 scores and age ≤ 51-years-old were 90.5%,Child-Pugh score >8 scores or age>51-years-old were 55.3%,Child-Pugh score >8 scores and age>51-years-old were 15.4%.(P=0.001). [Conclusion]The BUN is prognostic factors 1-year cumulative the refractory ascites clinical response. The Child-Pugh score ≤9 scores is prognostic factors 1 year cumulative HE in patients with cirrhosis and refactory ascites treated with TIPS.The Child-Pugh score ≤8 scores and age≤51-years-old are prognostic factors1 year cumulative survival in patients with cirrhosis and refactory ascites treated with TIPS.This simple score could be used at bedside to help choosing the best therapeutic options. The refractory ascites clinical response in patients with cirrhosis and refactory ascites treated with TIPS at 6 month and 12 month was significantly higher no response about 1 year survival rate. |
PDF Full Text Request