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2018 ; 10
(ä): 55-71
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Management of refractory cirrhotic ascites: challenges and solutions
#MMPMID30013405
Fukui H
; Kawaratani H
; Kaji K
; Takaya H
; Yoshiji H
Hepat Med
2018[]; 10
(ä): 55-71
PMID30013405
show ga
Among the various risky complications of liver cirrhosis, refractory ascites is
associated with poor survival of cirrhotics and persistently worsens their
quality of life (QOL). Major clinical guidelines worldwide define refractory
ascites as ascites that cannot be managed by medical therapy either because of a
lack of response to maximum doses of diuretics or because patients develop
complications related to diuretic therapy that preclude the use of an effective
dose of diuretics. Due to the difficulty in receiving a liver transplantation
(LT), the ultimate solution for refractory ascites, most cirrhotic patients have
selected the palliative therapy such as repeated serial paracentesis,
transjugular intrahepatic portosystemic shunt, or peritoneovenous shunt to
improve their QOL. During the past several decades, new interventions and
methodologies, such as indwelling peritoneal catheter, peritoneal-urinary
drainage, and cell-free and concentrated ascites reinfusion therapy, have been
introduced. In addition, new medical treatments with vasoconstrictors or
vasopressin V2 receptor antagonists have been proposed. Both the benefits and
risks of these old and new modalities have been extensively studied in relation
to the pathophysiological changes in ascites formation. Although the best
solution for refractory ascites is to eliminate hepatic failure either by LT or
by causal treatment, the selection of the best palliative therapy for individual
patients is of utmost importance, aiming at achieving the longest possible,
comfortable life. This review briefly summarizes the changing landscape of
variable treatment modalities for cirrhotic patients with refractory ascites,
aiming at clarifying their possibilities and limitations. Evolving issues with
regard to the impact of gut-derived systemic and local infection on the clinical
course of cirrhotic patients have paved the way for the development of a new gut
microbiome-based therapeutics. Thus, it should be further investigated whether
the early therapeutic approach to gut dysbiosis provides a better solution for
the management of cirrhotic ascites.
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