The clinical course of recurrent versus refractory ascites in outpatients with cirrhosis

Abstract

Refractory ascites (RA) has been defined by the International Club of Ascites (ICA) as an ascites that recurs within 4 weeks after large volume paracentesis (LVP) and cannot be prevented by medical therapy. Recurrent ascites was defined by the ICA as an ascites that recurs at least 3 times within 12-month. In contrast with RA, its impact on survival is still unknown. Aim of the study was to assess the mid term-survival in outpatients with refractory, recurrent or responsive ascites. 199 patients with ascites attending our outpatient clinic from March 2008 were included in the study and followed up until death, liver transplant or a maximum of 36 months. RA was defined according to the ICA criteria. Recurrent ascites was defined as the need of at least 3 LVPs within 12 months with a time interval between LVPs > 4 weeks. Patients without refractory or recurrent ascites where defined as patients with responsive ascites. RA, recurrent ascites and responsive ascites were found in 56 (28%), 28 (14%) and 115 (58%) patients, respectively. No difference was found in MELD score among the 3 groups. The 36-month cumulative incidence of mortality was significantly higher in RA than in recurrent or responsive ascites (76.7%, 38.1% and 22%, respectively; p < 0.001), while no significant difference was found between recurrent ascites and responsive ascites. In multivariate analysis, age (sHR = 1.07; p < 0.001), MELD score (sHR = 1.17; p < 0.001) and RA (sHR = 3.88; p < 0.001) were found to be independent predictors of 36-month mortality. Patients with RA have a significant worse prognosis than those with recurrent ascites, which in turns had similar outcomes than those with responsive ascites. These findings have relevant implications in clinical practice, for example when considering TIPS, or priority in the LT waiting list.