IMPACT OF REFRACTORY ASCITES ON THE SURVIVAL OF PATIENTS WITH CIRRHOSIS

Introduction and Objectives

Refractory ascites is an infrequent complication in patients with cirrhosis; it is considered in those who do not respond to diuretics or who have adverse effects with diuretics. Treatment is large-volume paracentesis, followed by plasma volume expansion to prevent paracentesis-induced circulatory dysfunction (PICD) to avoid deterioration in renal function and hyponatremia. Intermittent paracentesis could increase morbidity and mortality in these patients. Perhaps the classic prognostic scales, such as MELD, undervalue this factor that is not usually considered for prioritizing transplantation. The objective of this study is to assess the survival of patients with cirrhosis with refractory ascites.

Material and methods

Observational, retrospective, descriptive and analytical study. Patients with cirrhosis and refractory ascites were included, who were subjected to intermittent paracentesis on several occasions from February 2019 to June 2021. Descriptive statistics were performed with central tendency and dispersion measures, baseline and final MELD were calculated, and mortality was evaluated.

Results

Eleven patients were included, six men (54.5%) and five women (45.5%), aged 54 ± eight years. The patients had a range of paracentesis performed from 3 to 30 occasions (median five interventions), with a follow-up of 1 to 40 months (median of 8 months). The etiology of cirrhosis was alcoholic 63.6%, MALFD 9.1%, and 27.3% other causes. The total amount of fluid drained per patient was 37 to 439 L, 90% of the patients classified as Child-Pugh grade C, and 10% B. The median of the initial MELD was 15 (range = 13), and the median of the final MELD was 22 (range=17). There was no significant difference according to the Wilcoxon test p = 0.317. The renal function between the first and the last paracentesis decreased mildly by 24% and from 36% to 45% severely. Overall mortality was six patients (54.5%). The causes of death were spontaneous bacterial peritonitis (SBP) 9%, ACLF (Acute on Cronic Liver Failure) 27%, infarction 9%, and sepsis 9%. Median survival was 18 months (range 13-23)

Discussion

Patients with refractory ascites have very high mortality (59%); Despite the amount of fluid drained, up to 439L in one patient (for example), it did not seriously affect kidney function overall. We found no statistically significant difference between the initial and final MELD values (Figure 1). However, the MELD score does not make them candidates for liver transplantation; therefore, refractory ascites should be considered with an additional score to enter them on the transplant list.

Conclusions

Refractory ascites is uncommon, but it has high mortality; the MELD scale may not accurately predict the possibility of death, so they should be entered with an additional score to consider them candidates for liver transplantation.

The authors declare that there is no conflict of interest