Introduction
Scoping Review Methodology
Scoping Review Results
Study/country/publication year | Type of study and outcome | Sample size and RA definition | Demographics, baseline characteristics | Clinical outcomes | Data on palliative care | Other comments |
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Refractory hepatic hydrothorax (HHT) is an independent predictor of mortality when compared to refractory ascites (RA) Osman et al., 2022 [23] USA | • Retrospective • 1:1 matched patients with RA vs. HHT based on age/gender and MELD-Na • Primary outcome: comparison of mortality between the two groups | 47 ‘Ascites that is either resistant/intractable to diuretics/low sodium diet, early recurrence of ascites, or has diuretic-induced complications’ HCC not excluded | • Median age 59 (IQR 55–59) • 26 (55%) male • Median MELD-Na 18 (IQR 13–23.5) • 51.2% alcohol aetiology • 12 (25.3%) had previous SBP • Ascitic protein not commented on | • 1-year mortality—19.2% • Median survival over > 12 months • 2 (4.3%) patients received TIPS • Rates of transplant—unknown | No | • Selected cohort of patients to match those with HHT—might not be truly representative |
Outcomes and mortality of grade 1 ascites and recurrent ascites in patients with cirrhosis Tonon et al., 2021 [45] Italy | Post hoc analysis of prospective cohort taking part in an outpatient management programme for over 14 years | 56 International Ascites Club 1996 definition HCC excluded | • Mean age 59 (± 10) • 41 (73.2%) male • Median MELD-Na 16 (IQR 13–21) • 32 (57.1%) alcohol aetiology • No comment on rates of SBP or ascitic fluid protein | • 13 (23.2%) underwent liver transplant • 26 (46.4%) died • Median follow-up (for the entire cohort) was 29 months | No | • Median survival NA • RA vs. responsive ascites independent predictor of 36-month mortality, HR 3.60 (1.18–10.98) p = 0.024 |
Frailty in nonalcoholic fatty liver cirrhosis: a comparison with alcoholic cirrhosis, risk patterns, and impact on prognosis Skladany et al., 2021 [26] Slovakia | A cirrhosis registry investigating impact of frailty on clinical outcomes in NAFLD and ALD—a subset had RA | 112 Definition of RA NA HCC not excluded | • Mean age 58 ± 10 • 81 (72.3%) male • 100 (89.2%) alcohol contributing aetiology • Mean MELD-Na 19 ± 6.8 • SBP data or ascitic fluid protein NA | • Median follow-up 9 months (2–18) • 3 (2.7%) underwent transplant • Median survival 10.3 months (CI interval 4.0–21.1) • 1-year mortality 53.1% | No | • Unpublished data, analysis done on raw data kindly provided by the authors • Aetiology only including patients with ALD/NAFLD |
Quality of life measures predict mortality in patients with cirrhosis and severe ascites Macdonald et al., 2019 [24] Multinational randomised control trial | • Retrospective evaluation of HRQoL data from published RCT assessing efficacy of satavaptan in ascites | 241 Patients having 2 LVPs in the last 3 months on a sodium‐restricted diet and having dose‐limiting diuretic side effects HCC exceeding Milan criteria excluded | • Median age 58 (IQR 51–66) • 181 (75%) male • 40 (17%) had previous SBP • 165 (68%) alcohol aetiology • Median MELD 14 (IQR 11–18) | • 1-year mortality 29% (CI 23–35) • 1-year follow-up • 4 (1.7%) underwent a LT • 2 (1.0%) underwent a TIPS • 24 (12%) developed new onset SBP | No | • Trial terminated due to increased mortality in one of the Satavaptan treatment group |
Severe hyponatremia is a better predictor of mortality than MELDNa in patients with cirrhosis and refractory ascites (RA) Sersté et al., 2012 [25] France | • Single-centre, observational, prospective study cirrhosis-related RA to establish predictors of mortality | 174 Patients had to have at least 2 LVPs in 1 month. Minimum follow-up 3 months unless death. RA definition based on the IAC criteria HCC not excluded | • Mean age 60.3 ± 11.6; 139 (79.9%) male • Mean MELD-Na 22.8 ± 4.4 • 96 (55.2%) alcohol aetiology • Median ascitic fluid protein (11 g/L) • Data on SBP NA | • Median transplant free follow-up 8 months • 34 (19.2%) underwent liver transplant • 1-year mortality 55% (55–56) | No | • Hyponatraemia (< 125) as the cause of RA and frequency of LVPs were independent predictors of morality (HR 2.11 p 0.001 and 1.42 p < 0.0001) |
Clinical characteristics and outcome of patients with cirrhosis and refractory ascites (RA) Moreau et al., 2004 [8] France | • One-year single-centre retrospective cohort study in patients with RA | 75 Based on modified IAC definition HCC not specified as an exclusion criteria | • Mean age 57 ± 9; 60 (80.5%) male • 9 (12%) had previous SBP • Mean ascitic fluid protein 15 (± 7) g/L • 35 (47%) Child–Pugh B disease • Mean serum bilirubin, albumin, creatinine and prothrombin 45 (± 24) μmol/L; 28 (± 5) g/L; 112 (± 57) μmol/L and 53 (± 16) seconds, respectively | • Mean follow-up 18 (± 13) months • 1-year mortality 48% (37–60) • 8 (11%) underwent liver transplant • Age > 60 years commonest reason for transplant ineligibility—18 (26.7%) | No | • Older age (50–60) compared to < 50, HR 4.4 (1.6–12), presence of HCC, HR 2.8 (1.0–4.8) and diabetes 2.2 (1.1 to 4.5) independent predictors of mortality, abstinence from alcohol protective, HR 0.34 (0.14 to 0.84) |
Survival and prognostic factors and cirrhotic patients with ascites: a study of 134 outpatients Salerno et al., 1993 [6] Italy | • Prospective cohort study of 134 patients, a subset of which had developed refractory ascites | 24 RA defined as progressively accumulating ascites (judged by body weight) and stable urinary sodium < 10 mmol/L despite diuretics at highest tolerated dose | • Mean age 62 ± 2 • Mean serum bilirubin, albumin and creatinine 2.7 ± 0.4 mg/dl, 3.1 ± 0.1 g/dl and 1.3 ± 0.1 mg/dl, respectively | • 3 (12.5%) underwent peritoneovenous shunt, 1 (4.2%) liver transplant and 2 (8.3%) on transplant wait list • 1-year mortality 43% (KM curve) | No | • Study > 30 years old prior to IAC definition of refractory ascites with small sample size |
Retrospective Cohort Study
Patients and Methods
Inclusion Criteria
Exclusion Criteria
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Non-cirrhosis cause of ascites and/or if aetiology of cirrhosis uncertain
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Incomplete medical records
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Ascites occurring after liver transplantation
Statistical Analysis
Ethical Approval
Results
Age | 59 ± 13 years |
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Gender (% Male) | 69.3% |
Aetiology of cirrhosis* | |
Alcohol | 71 (81%) |
Metabolic associated liver disease | 16 (18%) |
Viral | 8 (9%) |
Other | 7 (8%) |
Comorbidity | |
Cardiovascular | 29 (33.0%) |
Diabetes | 28 (31.8%) |
Mental health | 21 (23.9%) |
Respiratory | 15 (17.1%) |
Gastroenterological | 12 (13.6%) |
Non-HCC malignancy | 14 (15.9%) |
HCC | 3 (3.4%) |
Other | 27 (30.7%) |
On diuretics | 60 (68.2%) |
Previous SBP | 33 (37.5%) |
Prophylactic antibiotics | 7 (8.0%) |
Serum bilirubin (µmol/L) | 29 (IQR 30.5) |
Serum bilirubin > 51 µmol/L | 21 (23.9%) |
INR | 1.3 (IQR 0.2) |
INR > 1.2 | 47 (51%) |
Serum creatinine (µmol/L) | 71.5 (IQR 62.5) |
Serum creatinine > 106 µmol/L | 24 (27.3%) |
Serum sodium (mmol/L) | 131.8 (± 5.6) |
Serum sodium < 128 mmol/L | 18 (20.5%) |
Serum albumin (g/L) | 32.7 (± 5.2) |
Serum albumin < 30 g/L | 27 (30.7%) |
Child–Pugh score | 9 (IQR 8–10) |
MELD-Na score | 16.6 ± 6.9 |
UKELD score | 55.7 ± 5.2 |
Ascitic fluid protein (g/L) | 13 (IQR 9) |
Ascitic fluid protein < 15 g/L | 51 (58%) |
Referral for Liver Transplant and TIPS
Referred for liver transplant | 31 (35%) |
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Underwent liver transplant | 11 (13.6%) |
Reason why not referred | |
Comorbidity | 17 (19.3%) |
Alcohol/substance misuse/psychosocial issues | 19 (21.6%) |
Frailty | 8 (9.1%) |
Not specified | 8 (9.1%) |
Recompensated | 3 (3.4%) |
Unspecified MDT decision | 2 (2.3%) |
Referred for TIPS | 6 (7%) |
Underwent TIPS | 1 (1%) |
Reasons why not referred | |
Substance misuse/psychosocial issues | 11 (12.5%) |
Serious comorbidity | 12 (13.6%) |
Hepatic encephalopathy | 13 (14.8%) |
Frailty | 10 (11.4%) |
Unspecified MDT decision | 1 (1.1%) |
Not specified | 20 (22.7%) |
Recompensating/improvement of refractory ascites | 6 (6.8%) |
Referred for transplant/listed | 8 (9.1%) |
Advanced liver disease | 1 (1.1%) |
Median number of large-volume paracentesis | 5 (IQR 3–8) |
Palliative Care Input
Documented end of life discussion | 50 (56%) |
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Referred to palliative care | 29 (33%) |
Weeks between diagnosis and referral to palliative care | 15 (IQR 4–32) |
LTAD inserted | 11 |
Received prophylactic antibiotics after LTAD | 8 |