Current treatment options of refractory ascites in liver cirrhosis – A systematic review and meta-analysis

Background Refractory ascites is a severe complication of liver cirrhosis and treatment options consist in large volume paracentesis, transjugular intrahepatic portosystemic shunt, alfapump®, peritoneovenous shunt and permanent indwelling peritoneal catheter. Aim Our aim was to assess the efficacy, mortality and complications of each treatment. Methods We performed a systematic review using Pubmed and Embase. Frequencies were summarized with Comprehensive Meta-Analysis Software. Results Seventy-seven studies were included. In patients with transjugular intrahepatic portosystemic shunt, 1-year mortality was 33% (95% CI 0.29–0.39, I 2 =82.1; τ 2 = 0.37; p <0.001) with lower mortality in newer studies (26% vs. 44%). At 6 months, mortality in patients with alfapump® was 24% (95% CI 0.16–0.33, I 2 =0.00; τ 2 = 0.00; p = 0.83), 31% developed acute kidney injury (95% CI 0.18–0.48, I 2 =44.0; τ 2 = 0.22; p = 0.15). Mortality at 12 months was 44% (95% CI 32%-58%, I 2 =76.7, τ 2 = 0.44, p <0.001) in peritoneovenous shunts and 45% (95% CI 38%–53%, I 2 =61.4, τ 2 = 0.18, p = 0.003) in large volume paracentesis, respectively. Overall mortality in patients with permanent indwelling catheters was 66% (95% CI 33%-89%, I 2 =82.5, τ 2 = 1.57, p = 0.001). Discussion Mortality in patients with transjugular intrahepatic portosystemic shunt was lower in newer studies, probably due to a better patient selection. Acute kidney injury was frequent in patients with alfapump®. Permanent indwelling catheters seemed to be a good option in a palliative setting.