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Table of Contents
Vol. 23, No. 1, 2005
Issue release date: 2005
Section title: Review Article
Dig Dis 2005;23:30–38
(DOI:10.1159/000084723)

Refractory Ascites

Cárdenas A. · Arroyo V.
Liver Unit, Institute of Digestive Diseases, Hospital Clinic, University of Barcelona, Barcelona, Spain
email Corresponding Author

Abstract

Patients with cirrhosis have significant abnormalities in their fluid and electrolyte balance; this is manifested mainly by the development of ascites and edema. Ascites is the most common complication of patients with cirrhosis and its development constitutes the first and most important manifestation of the disease. With disease progression, patients with advanced cirrhosis and severe urinary sodium retention develop refractory ascites, a condition in which patients do not respond to diuretics or develop severe side effects to these that preclude their use. This condition occurs in 5–10% of cases admitted to the hospital for treatment of ascites. Approximately half of these patients will die within 1 year if not transplanted; therefore, the best therapy is liver transplantation in suitable candidates. During the last two decades, significant advances have been made in regard to pathogenesis and treatment of refractory ascites. The re-introduction of therapeutic paracentesis with plasma expansion in the 1980s was a milestone in the treatment of these patients. In addition, the introduction of transjugular intrahepatic portosystemic shunts as a therapy for refractory ascites has certainly provided a reasonable alternative for those patients with preserved liver function and unwilling to undergo several taps per month. This article will discuss the pathophysiology, clinical features and therapy of refractory ascites in cirrhosis.

© 2005 S. Karger AG, Basel


  

Key Words

  • Cirrhosis
  • Ascites
  • Transjugular intrahepatic portosystemic shunt
  • Paracentesis
  • Liver transplantation

References

  1. Ginès P, Quintero E, Arroyo V, et al: Compensated cirrhosis: Natural history and prognostic factors. Hepatology 1987;7:122–128.
  2. Ginès P, Fernández-Esparrach G: Prognosis of ascites; in Arroyo V, Ginès P, Rodés J, Schrier RW (eds): Ascites and Renal Dysfunction in Liver Disease. Malden, Blackwell Science, 1999, pp 431–441.
  3. Arroyo V, Ginès P, Gerbes A, et al: Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology 1996;23:164–176.
  4. Harris NR, Granger DN: Alterations of hepatic and splanchnic microvascular exchange in cirrhosis: Local factors in the formation of ascites; in Arroyo V, Ginès P, Rodés J, Schrier RW (eds): Ascites and Renal Dysfunction in Liver Disease. Malden, Blackwell Science, 1999, pp 351–362.
  5. Cárdenas A, Arroyo V: Mechanisms of sodium and water retention in liver cirrhosis. Best Pract Res Clin Endocrinol Metab 2003;17:607–622.
  6. Martin PY, Ginès P, Schrier RW: Nitric oxide as a mediator of hemodynamic abnormalities and sodium and water retention in cirrhosis. N Engl J Med 1998;339:533–541.
  7. Levy M, Allotey JB: Temporal relationships between urinary salt retention and altered systemic hemodynamics in dogs with experimental cirrhosis. J Lab Clin Med 1978;92:560–569.
  8. Rees CJ, Rose JD, Record CO, et al: Transjugular intrahepatic portosystemic shunt: A limited role in refractory ascites. Eur J Gastroenterol Hepatol 1997;9:969–973.
  9. Ming Z, Smyth DD, Lautt WW: Decreases in portal flow trigger a hepatorenal reflex to inhibit renal sodium and water excretion in rats: Role of adenosine. Hepatology 2002;35:167–175.
  10. Cárdenas A, Bataller R, Arroyo V: Mechanisms of ascites formation. Clin Liver Dis 2000;4:447–465.
  11. Moore KP, Wong F, Ginès P, et al: The management of ascites in cirrhosis: Report on the consensus conference of the International Ascites Club. Hepatology 2003;38:258–266.
  12. Salerno F, Borroni G, Moser P, et al: Survival and prognostic factors of cirrhotic patients with ascites: A study of 134 outpatients. Am J Gastroenterol 1993;88:514–519.
  13. Moreau R, Delegue P, Pessione F, Hillaire S, Durand F, Lebrec D, Valla DC: Clinical characteristics and outcome of patients with cirrhosis and refractory ascites. Liver Int 2004;24:457–464.
  14. Allard JP, Chau J, Sandokji K, Blendis LM, Wong F: Effects of ascites resolution after successful TIPS on nutrition in cirrhotic patients with refractory ascites. Am J Gastroenterol 2001;96:2442–2447.
  15. Gines P, Arroyo V, Vargas V, et al: Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. N Engl J Med 1991;325:829–835.
  16. Gines P, Arroyo V, Quintero E, Planas R, Bory F, Cabrera J, Rimola A, Viver J, Camps J, Jimenez W, et al: Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology 1987;93:234–241.
  17. Ruiz-del-Arbol L, Monescillo A, Jiménez W, Garcia-Plaza A, Arroyo V, Rodés J: Paracentesis-induced circulatory dysfunction: Mechanism and effect on hepatic hemodynamics in cirrhosis. Gastroenterology 1997;113:579–586.
  18. Ginès P, Cardenas, A, Arroyo V, Rodés J: Management of cirrhosis and ascites. N Engl J Med 2004;350:1646–1654.
  19. Gines A, Fernandez-Esparrach G, Monescillo A, et al: Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis. Gastroenterology 1996;111:1002–1010.
  20. Sola-Vera J, Minana J, Ricart E, et al: Randomized trial comparing albumin and saline in the prevention of paracentesis-induced circulatory dysfunction in cirrhotic patients with ascites. Hepatology 2003;37:1147–1153.
  21. Boyer TD, Haskal Z: The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005;41:386–400.
  22. Bureau C, Garcia-Pagan JC, Otal P, et al: Improved clinical outcome using polytetrafluoroethylene coated stents for TIPS: Results of a randomized study. Gastroenterology 2004;126:469–475.
  23. Williams DB, Waugh R, Selby W: Transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of refractory ascites. Aust New Zealand J Med 1998;28:620–626.
  24. Ochs A, Rossle M, Haag K, et al: The trans-jugular intrahepatic portosystemic stent-shunt procedure for refractory ascites. N Engl J Med 1995;332:1192–1197.
  25. LeMoine O, Nevens F, Deviere J, et al: TIPS for refractory ascites. A Belgian two-center experience (abstract). Hepatology 1996;24(suppl):445A.
  26. Benner KG, Sahagun G, Saxon R, et al: What predicts survival and resolution of refractory ascites after TIPS? (abstract). Hepatology 1996;24(suppl):449A.
  27. Hills C, Miller LS, Ter H, et al: Increased colloid pressure correlates with resolution of refractory ascites after transjugular intrahepatic portal-systemic shunt (TIPS) (abstract). Hepatology 1995;22(suppl):165A.
  28. Peron JM, Rousseau H, Vinel JP, et al: TIPS in the treatment of refractory ascites: Results in 31 consecutive patients with cirrhosis (abstract). Gastroenterology 1995;108(suppl):1145A.

    External Resources

  29. Sezai S, Kamisaka K, Hirano M: Effectiveness of transjugular intrahepatic shunt (TIPS) for refractory ascites (abstract). Hepatology 1995;22(suppl):489A.
  30. Thuluvath PJ, Mitchell S, Prescott C, Osterman F: TIPSS for refractory ascites and advanced cirrhosis (abstract). Hepatology 1995;22(suppl):165A.
  31. Shrestha R, McKinley C, Showalter R, et al: Transjugular intrahepatic portosystemic shunt (TIPS) for ascites: The prognostic and predictive value of quantitative liver function tests (abstract). Hepatology 1996;24:449A.
  32. Wong F, Sniderman K, Liu P, et al: Transjugular intrahepatic portosystemic stent shunt: Effects on hemodynamics and sodium hemostasis in cirrhosis and refractory ascites. Ann Intern Med 1995;122:816–822.
  33. Ferral H, Bjarnason H, Wegryn SA, et al: Refractory ascites. Early experience in treatment with transjugular intrahepatic portosystemic shunt. Radiology 1993;189:795– 801.
  34. Nazarian GK, Bjarnason H, Dietz CA Jr, et al: Refractory ascites: Midterm results of treatment with a transjugular intrahepatic portosystemic shunt. Radiology 1997;205:173–180.
  35. Forrest EH, Stanley AJ, Redhead DN, et al: Clinical response after transjugular intrahepatic portosystemic stent shunt insertion for refractory ascites in cirrhosis. Aliment Pharmacol Ther 1996;10:801–806.
  36. Deschenes M, Dufresne MP, Bao B, et al: Predictors of clinical response to transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients with refractory ascites. Am J Gastroenterol 1999;94:1361–1365.
  37. Trotter JF, Suhocki PV, Rockey DC: Transjugular intrahepatic portosystemic shunt (TIPS) in patients with refractory ascites: Effect of body weight and Child-Pugh score. Am J Gastroenterol 1998;93:1891–1894.
  38. Somberg KA, Lake JR, Tomlanovich SJ, et al: Transjugular intrahepatic portosystemic shunts for refractory ascites: Assessment of clinical and hormonal response and renal function. Hepatology 1995;21:709–716.
  39. Crenshaw WB, Gordon FD, McEniff NJ, et al: Severe ascites. Efficacy of the transjugular intrahepatic portosystemic shunt in treatment. Radiology 1996;200:185–192.
  40. Martinet JP, Fenyves D, Legault L, et al: Treatment of refractory ascites using transjugular intrahepatic portosystemic shunt (TIPS). Dig Dis Sci 1997;42:161–166.
  41. Quiroga J, Sangro B, Nunez M, et al: Trans-jugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: Effect on clinical, renal, humoral, and hemodynamic parameters. Hepatology 1995;21:709–716.
  42. Peron JM, Barange K, Otal P: Transjugular intrahepatic portosystemic shunts in the treatment of refractory ascites: Results in 48 consecutive patients. J Vasc Interv Radiol 2000;11:1211–1216.
  43. Lebrec D, Giuily N, Hadengue A, et al: Trans-jugular intrahepatic portosystemic shunts: Comparison with paracentesis in patients with cirrhosis and refractory ascites: A randomized trial. J Hepatol 1996;25:135–144.
  44. Ginès P, Uriz J, Calahorra B, et al: Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 2002;123:1839–1847.
  45. Rossle M, Ochs A, Gulberg V, et al: A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med 2000;342:1701–1707.
  46. Sanyal A, Genning C, Reddy RK, et al: The North American Study for Treatment of Refractory Ascites. Gastroenterology 2003;124:634–641.
  47. Salerno F, Merli M, Riggio O: Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites. Hepatology 2004;40:629–635.
  48. Gülberg V, Liss I, Bilzer M, Waggershauser T, Reiser M, Gerbes AL: Improved quality of life in patients with refractory or recidivant ascites after insertion of transjugular intrahepatic portosystemic shunts. Digestion 2002;66:127–130.
  49. Chalasani N, Clark WS, Martin LG, Kamean J, Khan A, Patel N, Boyer TD: Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting. Gastroenterology 2000;118:138–144.
  50. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC: A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000;31:864–871.

  

Author Contacts

Andrés Cárdenas
Liver Unit, Institute of Digestive Diseases, Hospital Clinic
University of Barcelona, C. Villarroel 170
ES–08036 Barcelona (Spain)
Tel. +34 93 227 75 499, Fax +34 93 451 55 22, E-Mail acardena@bidmc.harvard.edu

  

Article Information

Number of Print Pages : 9
Number of Figures : 4, Number of Tables : 2, Number of References : 50

  

Publication Details

Digestive Diseases (State-of-the-Art Clinical Reviews)

Vol. 23, No. 1, Year 2005 (Cover Date: 2005)

Journal Editor: Malfertheiner, P. (Magdeburg)
ISSN: 0257–2753 (print), 1421–9875 (Online)

For additional information: http://www.karger.com/ddi


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Patients with cirrhosis have significant abnormalities in their fluid and electrolyte balance; this is manifested mainly by the development of ascites and edema. Ascites is the most common complication of patients with cirrhosis and its development constitutes the first and most important manifestation of the disease. With disease progression, patients with advanced cirrhosis and severe urinary sodium retention develop refractory ascites, a condition in which patients do not respond to diuretics or develop severe side effects to these that preclude their use. This condition occurs in 5–10% of cases admitted to the hospital for treatment of ascites. Approximately half of these patients will die within 1 year if not transplanted; therefore, the best therapy is liver transplantation in suitable candidates. During the last two decades, significant advances have been made in regard to pathogenesis and treatment of refractory ascites. The re-introduction of therapeutic paracentesis with plasma expansion in the 1980s was a milestone in the treatment of these patients. In addition, the introduction of transjugular intrahepatic portosystemic shunts as a therapy for refractory ascites has certainly provided a reasonable alternative for those patients with preserved liver function and unwilling to undergo several taps per month. This article will discuss the pathophysiology, clinical features and therapy of refractory ascites in cirrhosis.

© 2005 S. Karger AG, Basel


  

Author Contacts

Andrés Cárdenas
Liver Unit, Institute of Digestive Diseases, Hospital Clinic
University of Barcelona, C. Villarroel 170
ES–08036 Barcelona (Spain)
Tel. +34 93 227 75 499, Fax +34 93 451 55 22, E-Mail acardena@bidmc.harvard.edu

  

Article Information

Number of Print Pages : 9
Number of Figures : 4, Number of Tables : 2, Number of References : 50

  

Publication Details

Digestive Diseases (State-of-the-Art Clinical Reviews)

Vol. 23, No. 1, Year 2005 (Cover Date: 2005)

Journal Editor: Malfertheiner, P. (Magdeburg)
ISSN: 0257–2753 (print), 1421–9875 (Online)

For additional information: http://www.karger.com/ddi


Article / Publication Details

First-Page Preview
Abstract of Review Article

Published online: 5/19/2005
Issue release date: 2005

Number of Print Pages: 9
Number of Figures: 4
Number of Tables: 2

ISSN: 0257-2753 (Print)
eISSN: 1421-9875 (Online)

For additional information: http://www.karger.com/DDI


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Ginès P, Quintero E, Arroyo V, et al: Compensated cirrhosis: Natural history and prognostic factors. Hepatology 1987;7:122–128.
  2. Ginès P, Fernández-Esparrach G: Prognosis of ascites; in Arroyo V, Ginès P, Rodés J, Schrier RW (eds): Ascites and Renal Dysfunction in Liver Disease. Malden, Blackwell Science, 1999, pp 431–441.
  3. Arroyo V, Ginès P, Gerbes A, et al: Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology 1996;23:164–176.
  4. Harris NR, Granger DN: Alterations of hepatic and splanchnic microvascular exchange in cirrhosis: Local factors in the formation of ascites; in Arroyo V, Ginès P, Rodés J, Schrier RW (eds): Ascites and Renal Dysfunction in Liver Disease. Malden, Blackwell Science, 1999, pp 351–362.
  5. Cárdenas A, Arroyo V: Mechanisms of sodium and water retention in liver cirrhosis. Best Pract Res Clin Endocrinol Metab 2003;17:607–622.
  6. Martin PY, Ginès P, Schrier RW: Nitric oxide as a mediator of hemodynamic abnormalities and sodium and water retention in cirrhosis. N Engl J Med 1998;339:533–541.
  7. Levy M, Allotey JB: Temporal relationships between urinary salt retention and altered systemic hemodynamics in dogs with experimental cirrhosis. J Lab Clin Med 1978;92:560–569.
  8. Rees CJ, Rose JD, Record CO, et al: Transjugular intrahepatic portosystemic shunt: A limited role in refractory ascites. Eur J Gastroenterol Hepatol 1997;9:969–973.
  9. Ming Z, Smyth DD, Lautt WW: Decreases in portal flow trigger a hepatorenal reflex to inhibit renal sodium and water excretion in rats: Role of adenosine. Hepatology 2002;35:167–175.
  10. Cárdenas A, Bataller R, Arroyo V: Mechanisms of ascites formation. Clin Liver Dis 2000;4:447–465.
  11. Moore KP, Wong F, Ginès P, et al: The management of ascites in cirrhosis: Report on the consensus conference of the International Ascites Club. Hepatology 2003;38:258–266.
  12. Salerno F, Borroni G, Moser P, et al: Survival and prognostic factors of cirrhotic patients with ascites: A study of 134 outpatients. Am J Gastroenterol 1993;88:514–519.
  13. Moreau R, Delegue P, Pessione F, Hillaire S, Durand F, Lebrec D, Valla DC: Clinical characteristics and outcome of patients with cirrhosis and refractory ascites. Liver Int 2004;24:457–464.
  14. Allard JP, Chau J, Sandokji K, Blendis LM, Wong F: Effects of ascites resolution after successful TIPS on nutrition in cirrhotic patients with refractory ascites. Am J Gastroenterol 2001;96:2442–2447.
  15. Gines P, Arroyo V, Vargas V, et al: Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. N Engl J Med 1991;325:829–835.
  16. Gines P, Arroyo V, Quintero E, Planas R, Bory F, Cabrera J, Rimola A, Viver J, Camps J, Jimenez W, et al: Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology 1987;93:234–241.
  17. Ruiz-del-Arbol L, Monescillo A, Jiménez W, Garcia-Plaza A, Arroyo V, Rodés J: Paracentesis-induced circulatory dysfunction: Mechanism and effect on hepatic hemodynamics in cirrhosis. Gastroenterology 1997;113:579–586.
  18. Ginès P, Cardenas, A, Arroyo V, Rodés J: Management of cirrhosis and ascites. N Engl J Med 2004;350:1646–1654.
  19. Gines A, Fernandez-Esparrach G, Monescillo A, et al: Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis. Gastroenterology 1996;111:1002–1010.
  20. Sola-Vera J, Minana J, Ricart E, et al: Randomized trial comparing albumin and saline in the prevention of paracentesis-induced circulatory dysfunction in cirrhotic patients with ascites. Hepatology 2003;37:1147–1153.
  21. Boyer TD, Haskal Z: The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005;41:386–400.
  22. Bureau C, Garcia-Pagan JC, Otal P, et al: Improved clinical outcome using polytetrafluoroethylene coated stents for TIPS: Results of a randomized study. Gastroenterology 2004;126:469–475.
  23. Williams DB, Waugh R, Selby W: Transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of refractory ascites. Aust New Zealand J Med 1998;28:620–626.
  24. Ochs A, Rossle M, Haag K, et al: The trans-jugular intrahepatic portosystemic stent-shunt procedure for refractory ascites. N Engl J Med 1995;332:1192–1197.
  25. LeMoine O, Nevens F, Deviere J, et al: TIPS for refractory ascites. A Belgian two-center experience (abstract). Hepatology 1996;24(suppl):445A.
  26. Benner KG, Sahagun G, Saxon R, et al: What predicts survival and resolution of refractory ascites after TIPS? (abstract). Hepatology 1996;24(suppl):449A.
  27. Hills C, Miller LS, Ter H, et al: Increased colloid pressure correlates with resolution of refractory ascites after transjugular intrahepatic portal-systemic shunt (TIPS) (abstract). Hepatology 1995;22(suppl):165A.
  28. Peron JM, Rousseau H, Vinel JP, et al: TIPS in the treatment of refractory ascites: Results in 31 consecutive patients with cirrhosis (abstract). Gastroenterology 1995;108(suppl):1145A.

    External Resources

  29. Sezai S, Kamisaka K, Hirano M: Effectiveness of transjugular intrahepatic shunt (TIPS) for refractory ascites (abstract). Hepatology 1995;22(suppl):489A.
  30. Thuluvath PJ, Mitchell S, Prescott C, Osterman F: TIPSS for refractory ascites and advanced cirrhosis (abstract). Hepatology 1995;22(suppl):165A.
  31. Shrestha R, McKinley C, Showalter R, et al: Transjugular intrahepatic portosystemic shunt (TIPS) for ascites: The prognostic and predictive value of quantitative liver function tests (abstract). Hepatology 1996;24:449A.
  32. Wong F, Sniderman K, Liu P, et al: Transjugular intrahepatic portosystemic stent shunt: Effects on hemodynamics and sodium hemostasis in cirrhosis and refractory ascites. Ann Intern Med 1995;122:816–822.
  33. Ferral H, Bjarnason H, Wegryn SA, et al: Refractory ascites. Early experience in treatment with transjugular intrahepatic portosystemic shunt. Radiology 1993;189:795– 801.
  34. Nazarian GK, Bjarnason H, Dietz CA Jr, et al: Refractory ascites: Midterm results of treatment with a transjugular intrahepatic portosystemic shunt. Radiology 1997;205:173–180.
  35. Forrest EH, Stanley AJ, Redhead DN, et al: Clinical response after transjugular intrahepatic portosystemic stent shunt insertion for refractory ascites in cirrhosis. Aliment Pharmacol Ther 1996;10:801–806.
  36. Deschenes M, Dufresne MP, Bao B, et al: Predictors of clinical response to transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients with refractory ascites. Am J Gastroenterol 1999;94:1361–1365.
  37. Trotter JF, Suhocki PV, Rockey DC: Transjugular intrahepatic portosystemic shunt (TIPS) in patients with refractory ascites: Effect of body weight and Child-Pugh score. Am J Gastroenterol 1998;93:1891–1894.
  38. Somberg KA, Lake JR, Tomlanovich SJ, et al: Transjugular intrahepatic portosystemic shunts for refractory ascites: Assessment of clinical and hormonal response and renal function. Hepatology 1995;21:709–716.
  39. Crenshaw WB, Gordon FD, McEniff NJ, et al: Severe ascites. Efficacy of the transjugular intrahepatic portosystemic shunt in treatment. Radiology 1996;200:185–192.
  40. Martinet JP, Fenyves D, Legault L, et al: Treatment of refractory ascites using transjugular intrahepatic portosystemic shunt (TIPS). Dig Dis Sci 1997;42:161–166.
  41. Quiroga J, Sangro B, Nunez M, et al: Trans-jugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: Effect on clinical, renal, humoral, and hemodynamic parameters. Hepatology 1995;21:709–716.
  42. Peron JM, Barange K, Otal P: Transjugular intrahepatic portosystemic shunts in the treatment of refractory ascites: Results in 48 consecutive patients. J Vasc Interv Radiol 2000;11:1211–1216.
  43. Lebrec D, Giuily N, Hadengue A, et al: Trans-jugular intrahepatic portosystemic shunts: Comparison with paracentesis in patients with cirrhosis and refractory ascites: A randomized trial. J Hepatol 1996;25:135–144.
  44. Ginès P, Uriz J, Calahorra B, et al: Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 2002;123:1839–1847.
  45. Rossle M, Ochs A, Gulberg V, et al: A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med 2000;342:1701–1707.
  46. Sanyal A, Genning C, Reddy RK, et al: The North American Study for Treatment of Refractory Ascites. Gastroenterology 2003;124:634–641.
  47. Salerno F, Merli M, Riggio O: Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites. Hepatology 2004;40:629–635.
  48. Gülberg V, Liss I, Bilzer M, Waggershauser T, Reiser M, Gerbes AL: Improved quality of life in patients with refractory or recidivant ascites after insertion of transjugular intrahepatic portosystemic shunts. Digestion 2002;66:127–130.
  49. Chalasani N, Clark WS, Martin LG, Kamean J, Khan A, Patel N, Boyer TD: Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting. Gastroenterology 2000;118:138–144.
  50. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC: A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000;31:864–871.