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Targeted decrease of portal hepatic pressure gradient improves ascites control after TIPS.

BACKGROUND
Ascites is a definitive sign of decompensated liver cirrhosis driven by portal hypertension. Although transjugular intrahepatic portosystemic shunt insertion (TIPS) is indicated for therapy of recurrent and refractory ascites, yet there is no evidence-based recommendation for a specific target of portal hepatic pressure gradient (PPG) decrease.


METHODS
In this single center, retrospective trial we investigated the decrease of PPG in 341 patients undergoing TIPS insertion for therapy of refractory or recurrent ascites until 2015. During each procedure, portal and inferior vena cava pressures were invasively measured and correlated with patients' outcome and ascites progression over time, according to the prespecified NEPTUN protocol (NCT03628807).


RESULTS
Patients without ascites at 6 weeks after TIPS had significantly greater PPG reduction immediately after TIPS, compared to the patients with refractory ascites (median reduction 65% vs. 55% of pre-TIPS PPG; P=0.001). Survival was significantly better if ascites was controlled, compared to patients with need for paracentesis six weeks after TIPS (median survival: 185 vs. 41 weeks; HR 2.0 [1.3 - 2.9]; P<0.001). Hereby, higher PPG reduction by TIPS (P=0.005) and lower PPG after TIPS (P=0.02) correlated with resolution of severe ascites 6 weeks after TIPS. Multivariable analyses demonstrated that higher Child-Pugh score before TIPS (OR 1.3 [1.0-1.7]; P=0.03) and lower serum sodium levels (OR 0.9 [0.9-1.0]; P=0.004) were independently associated with ascites persistence six weeks after TIPS, while PPG reduction (OR 0.98 [0.97-1.00]; P=0.02) was associated with resolution of ascites six weeks after TIPS.


CONCLUSION
Extend of PPG reduction and/or lowering of target PPG immediately after TIPS placement is associated with improved ascites control in the short term and with survival in the long term. A structured follow up visit for patients should assess persistence of ascites at 6 weeks after TIPS.