Need For Paracentesis Research Articles

Midodrine plus propranolol versus propranolol alone in preventing first bleed in patients with cirrhosis and severe ascites: a randomized controlled trial.

Propranolol, a non-selective beta-blocker, commonly used to prevent variceal bleed, but might precipitate circulatory dysfunction in severe ascites. Midodrine, an alpha-1 adrenergic agonist improves renal perfusion and systemic hemodynamics. Addition of midodrine might facilitate higher maximum tolerated dose (MTD) of propranolol, thereby less risk of variceal bleed in cirrhosis patients with severe ascites. 140 patients with cirrhosis and severe/refractory ascites were randomized- propranolol and midodrine (Gr.A,n = 70) or propranolol alone (Gr.B,n = 70). Primary outcome was incidence of bleed at 1year. Secondary outcomes included ascites control, achievement of target heart rate (THR), HVPG response and adverse effects. Baseline characteristics were comparable between two groups. Cumulative incidence of bleed at 1year was lower in Gr.A than B (8.5%vs.27.1%,p-0.043). The MTD of propranolol was higher in Gr.A (96.67 ± 36.6mg vs. 76.52 ± 24.4mg; p-0.01) and more patients achieved THR (84.2%vs.55.7%,p-0.034). Significantly higher proportion of patients in Gr.A had complete resolution of ascites [17.1%vs.11.4%,p-0.014), diuretic tolerance (80%vs.60%,p-0.047) at higher doses(p-0.02) and lesser need for paracentesis. Patients in Gr.A also had greater reduction in variceal grade (75.7%vs.55.7%;p-0.01), plasma renin activity (54.4% from baseline) (p = 0.02). Mean HVPG reduction was greater in Gr.A than B [4.38 ± 2.81mmHg(23.5%) vs. 2.61 ± 2.87mmHg(14.5%),p-0.045]. Complications like post-paracentesis circulatory dysfunction and spontaneous bacterial peritonitis on follow-up were higher in Gr.B than A (22.8%vs.51.4%,p = 0.013 and 10%vs.15.7%, p = 0.03, respectively). Addition of midodrine facilitates effective use of propranolol in higher doses and greater HVPG reduction, thereby preventing first variceal bleed, reduced paracentesis requirements with fewer ascites- related complications in patients with cirrhosis with severe/refractory ascites.

D67. Functional Outcomes following Microsurgical Thoracic Duct Lymphovenous Bypass

PURPOSE: Thoracic duct (TD) lymphovenous bypass is a novel treatment for patients with symptomatic TD occlusion. Treatment response following surgery has yet to be fully characterized. METHODS: A retrospective review of all nonsyndromic patients undergoing TD bypass between 2019-2022 at our institution was performed. All cases were performed with intraoperative lymphangiography by interventional radiology. Postoperative functional outcome was assessed at one month and was compared to baseline presentation at the time of initial evaluation. RESULTS: TD bypass was attempted in 15 patients and completed in 14. Eight were female with a mean age of 44.8±13.9 yr. Eight patients (57.1%) had isolated TD occlusion at the level of the TD-central venous junction. Presenting pathologies included: chylous ascites (N=9), protein-losing enteropathy (N=6), lower-extremity lymphedema (N=5), and chylothorax/plastic bronchitis (N=5). Lymphovenous anastomosis was performed between the TD and the external jugular vein in ten patients with one undergoing vein grafting. Eight patients (57.1%) saw symptomatic improvement. Four patients saw improvement in lymphedema, three patients had reduced need for paracentesis in the setting of chylous ascites, and one patient had resolution of bronchial lymphatic casts. Six patients did not see any functional change in their condition. Five patients experienced complications (two infections of abdominal source, 2 TD leaks, 1 seroma). Seven of eight patients with positive treatment response had isolated distal TD occlusion without other lymphatic disease or malformation. CONCLUSION: TD lymphovenous bypass is a promising treatment for patients with isolated distal TD occlusion and was associated with improvements in lymphedema and chylous ascites.

A Clinical Audit of Diuretic Use in a Cohort of Patients with Decompensated Chronic Liver Disease in South India

Background and Aim: Diuretic doses for the optimal management of ascites may be influenced by the patient profile and conditions. We undertook this study to map the usage of common diuretics, alone or in combination, for the management of patients with decompensated cirrhosis and to determine the prevalence of adverse effects with the administered regimens and factors that predict the need for paracentesis while on diuretics. Methods: This prospective study was done in an outpatient clinic among patients with known liver cirrhosis, irrespective of etiology, belonging to Child-Pugh Class B or C, with mild to moderate ascites and no dyselectrolemia on diuretics. The primary outcome of the study was the need for paracentesis. The type and dose of diuretic at this instance were noted. Results: A total of 200 patients (168 male), predominantly from southern Indian states, formed the study group. The median model for endstage liver disease score was 18 and 70% of cases required paracentesis within 3 months. The single diuretic agent was used in 18% of cases while combination of two diuretics was used in 82%. Spironolactone was the most common single agent used (26, 72.2%). The combination of furosemide and spironolactone was the most common diuretic combination used (89.6%, 147 cases). One hundred and thirty patients (65%) reported the adverse effects to diuretics. Renal dysfunction and electrolyte disturbances were the most common adverse effects. Adverse effects to diuretic use and frequency of large volume paracentesis were significantly more common in patients taking furosemide 40 mg and spironolactone 100 mg per day. Conclusions: Indian patients with decompensated chronic liver disease do not appear to tolerate the high doses of diuretics and 65% of them develop diuretic-related adverse effects. There is a need to formulate the guidelines for the optimal management of ascites in decompensated chronic liver disease in the Indian setting.

Risk Factors for Hepatic Hydrothorax in Cirrhosis Patients with Ascites – A Clinical Cohort Study

The risk factors for hepatic hydrothorax are unknown. We used data from three randomized trials of satavaptan treatment in patients with cirrhosis and ascites followed for up to 1year. We excluded patients with previous hepatic hydrothorax or other causes for pleural effusion. The candidate risk factors were age, sex, heart rate, mean arterial pressure, diuretic-resistant ascites, a recurrent need for paracentesis, diabetes, hepatic encephalopathy, International Normalized Ratio, creatinine, bilirubin, albumin, sodium, platelet count, use of non-selective beta-blockers (NSBBs), spironolactone, furosemide, proton pump inhibitors, and insulin. We identified risk factors using a Fine and Gray regression model and backward selection. We reported subdistribution hazard ratios (sHR) for hepatic hydrothorax. Death without hepatic hydrothorax was a competing risk. Our study included 942 patients, of whom 41 developed hepatic hydrothorax and 65 died without having developed it. A recurrent need for paracentesis (sHR: 2.55, 95% CI: 1.28-5.08), bilirubin (sHR: 1.18 per 10µmol/l increase, 95% CI: 1.09-1.28), diabetes (sHR: 2.49, 95% CI: 1.30-4.77) and non-use of non-selective beta-blockers (sHR: 2.27, 95% CI: 1.13-4.53) were risk factors for hepatic hydrothorax. Development of hepatic hydrothorax was associated with a high mortality-hazard ratio of 4.35 (95% CI: 2.76-6.97). In patients with cirrhosis and ascites, risk factors for hepatic hydrothorax were a recurrent need for paracentesis, a high bilirubin, diabetes and non-use of NSBBs. Among these patients with cirrhosis and ascites, development of hepatic hydrothorax increased mortality fourfold.

Transjugular Intrahepatic Portosystemic Shunt Placement for Portal Hypertension: Meta-Analysis of Safety and Efficacy of 8 mm vs. 10 mm Stents.

Introduction Hepatic encephalopathy (HE) following transjugular intrahepatic portosystemic shunt (TIPS) placement remains a leading adverse event. Controversy remains regarding the optimal stent diameter given that smaller stents may decrease the amount of shunted blood and decrease the risk of HE, but stent patency and/or clinical adequacy of portal decompression may also be affected. We aim to provide meta-analysis-based evidence regarding the safety and efficacy of 8 mm vs. 10 mm stents during TIPS placement. Methods PubMed, Embase, Cochrane Library, and Web of Science were searched for studies comparing 8 mm and 10 mm stents during TIPS placement for portal hypertension decompression in cirrhotic patients. Randomized controlled trials and cohort studies were prioritized for inclusion. Overall evaluation of quality and bias for each study was performed. The outcomes assessed were the prevalence of HE, rebleeding or failure to control refractory ascites, and overall survival. Subgroup analysis based on TIPS indication was conducted. Results Five studies with a total number of 489 cirrhotic patients were identified. The pooled hazard ratio (HR) of post-TIPS HE was significantly lower in patients in the 8 mm stent group than in the 10 mm stent group (HR: 0.68, 95% CI: 0.51~0.92, p value < 0.0001). The combined HR of post-TIPS rebleeding/the need for paracentesis was significantly higher in patients in the 8 mm stent group than in the 10 mm stent group (HR: 1.76, 95% CI: 1.22~2.55, p value < 0.0001). There was no statistically significant difference in the overall survival between the 8 mm and 10 mm stent groups. The combined risk of HE in the variceal bleeding subgroup was statistically lower (HR: 0.52, CI: 0.34-0.80) with an 8 mm stent compared with a 10 mm stent. The combined risk of both rebleeding/paracentesis and survival was not statistically significant between 8 mm and 10 mm stent use in subgroup analysis. Conclusion 8 mm stents during TIPS placement are associated with a significant lower risk of HE compared to 10 mm stents (32% decreased risk), as well as a 76% increased risk of rebleeding/paracentesis. Meta-analysis results suggest that there is not one superior stent choice for all clinical scenarios and that the TIPS indication of variceal bleeding or refractory ascites might have different appropriate selection of the shunt diameter.

2270 The Path to Encephalopathy: A Case of Spontaneous Portosystemic Shunt Embolization

INTRODUCTION: Hepatic encephalopathy (HE) is a debilitating complication of cirrhosis that can lead to alterations in consciousness, behavior, and overall functional decline. It has been suggested that up to 70% of patients with HE refractory to medical treatment have evidence of spontaneous portosystemic shunts (SPSS). While this is a relatively well-known sequela of longstanding cirrhosis, and current guidelines recommend at least consideration of closure of SPSS if found, the literature is limited regarding procedural occlusion of these potentially harmful vascular phenomena. CASE DESCRIPTION/METHODS: We present the case of a 70-year-old female with cirrhosis secondary to non-alcoholic steatohepatitis and progressive ascites requiring repeated therapeutic paracentesis. Over a short period, her need for paracentesis inexplicably declined and her HE simultaneously worsened, despite appropriately titrated lactulose. Imaging at this point revealed spontaneous splenosystemic and intrahepatic shunts. At the time of presentation, the patient’s Model for End-Stage Liver Disease (MELD) score was 14. Despite optimization of medical therapy and shunt embolization, the patient’s mental status did not improve. Upon further review of post-embolization imaging, there was evidence of shunt collateralization that still appeared to be patent. This patient’s lack of clinical improvement may have been due to several factors, but incomplete embolization of known shunts or presence of additional undiagnosed shunts seem most likely. DISCUSSION: As hepatic fibrosis progresses, portal hypertension rises steadily to the point where otherwise insignificant portosystemic microvasculature can engorge to sizes greater than 1 centimeter. This phenomenon can relieve portal hypertension at the expense of releasing higher levels of ammonia and other neurotoxins into systemic circulation, resulting in more pronounced HE. While the decision to pursue embolization should be individualized, the presence of SPSS should always be considered in the setting of refractory HE. A MELD score of 11 or less may be associated with more favorable outcomes following embolization of SPSS and a majority of patients show rapid clinical improvement of HE following successful shunt closure. Dedicated post-embolization imaging should be obtained, especially if a patient’s HE remains refractory after intervention.

Ascites control by TIPS is more successful in patients with a lower paracentesis frequency and is associated with improved survival.

Background & AimsRefractory ascites is the main reason for the implantation of a transjugular intrahepatic portosystemic shunt (TIPS) in liver cirrhosis, but ascites control by TIPS fails in a relevant proportion of cases. Here, we investigated whether routine parameters pre-TIPS can predict persistent ascites after TIPS implantation and whether persistent ascites predicts long-term clinical outcome.MethodsA detailed retrospective analysis of 128 patients receiving expanded polytetrafluoroethylene-covered stents for the treatment of refractory ascites was performed. Persistent ascites post-TIPS was defined as the prolonged need for paracentesis >3 months after TIPS. The influence of demographics, laboratory results, pre-TIPS heart and liver ultrasound results, and invasive hemodynamic parameters on persistent ascites was evaluated by univariable and multivariable logistic regression. Predictors of the composite endpoint liver transplantation/death were analyzed using a multivariable Cox regression.ResultsAscites control post-TIPS was achieved in 95/128 patients (74%), whereas ascites remained persistent in 33/128 cases (26%). On multivariable analysis, a lower paracentesis frequency pre-TIPS (odds ratio 1.672; 95% CI 1.253–2.355) and lower baseline creatinine levels (odds ratio 2.640; CI 1.201–6.607) were associated with ascites control. Patients with persistent ascites post-TIPS had and impaired transplant-free survival (median 10.0 vs. 25.8 months), for which persistent ascites was the only independent predictor (hazard ratio 5.654; CI 3.019–10.59).ConclusionTIPS-placement in patients with lower paracentesis frequency and creatinine levels is associated with superior ascites control. Thus, TIPS implantation should be considered in moderate decompensation and not as a last resort. Persistent ascites post-TIPS seems to be the only predictor of liver transplantation and death.Lay summaryThe insertion of a transjugular intrahepatic portosystemic shunt (TIPS) in patients with refractory ascites should be considered in patients with moderate decompensation and not as a last resort, as lower paracentesis frequency and creatinine levels pre-TIPS are associated with superior ascites control. In turn, failure to control ascites seems to be the only predictor of liver transplantation and death.

Transjugular Intrahepatic Portosystemic Shunt for the Treatment of Portal Hypertension-Induced Refractory Ascites Due to Metastatic Carcinomatous Liver Disease

Three patients with a medical history of breast carcinoma and metastatic carcinomatous liver disease associated with severe portal hypertension and refractory ascites are presented. Transjugular intrahepatic portosystemic shunt creation was considered as a palliative treatment option and a valuable alternative to regular paracenteses in these patients. In 2 of the 3 patients, the refractory ascites was controlled for several months without need for paracentesis, and subsequently transjugular intrahepatic portosystemic shunt may provide valuable palliation and ascites control in patients with refractory ascites due to breast cancer-induced pseudocirrhosis.

11. Rationalising diuretic use in Indian patients with decompensated liver cirrhosis: a stepping stone to set guidelines for Indian patients

Background and Aims: To determine the dose requirement of commonly used diuretics among Indian patients with decompensated liver cirrhosis presenting with ascites. Methods: This prospective study was done at Gleneagles Global Health City, Chennai. Consecutive patients with cirrhosis and ascites attending outpatient clinic for from January to March 2018 were included. Patient information included age, gender, etiology of cirrhosis, state of origin, CTP score, MELD score, drug details, complications, need for paracentesis, and response to diuretic use at a single point. The primary outcome of the study was the need for a paracentesis. Indications for paracentesis were non-response to diuretics or inability to increase the dose due to complications. Chi square test and risk ratio calculation were done. p value <0.05 was considered statistically significant. Results: A total of 73 cases with median age of 54.6 years (range 26–74 years) and predominant male sex (61,83.6%) formed the study cohort. NASH and alcohol were the most common cause for liver cirrhosis. 68.5% of cases had MELD score >15 and 57% belonged to CTP class B. Majority of the cases (54, 74%) were on a combination of drugs with furosemide and spironolactone (20/50 mg) being the commonest dose. Nineteen patients were on a single drug with spironolactone being the most commonly prescribed drug (12,63%). Side effects of diuretics were noted in 48% of cases: renal dysfunction and dyselectrolytemia being the commonest. 25 patients required paracentesis. Diuretic induced complications and poor urine output were significantly more common among those requiring paracentesis. Conclusions: Indian patients seldom require high doses of diuretics and 48% develop complications related to diuretic use even at lower doses. The occurence of diuretic induced complications and poor urine output may be used as marker of requirement of paracentesis in Indian patients. The authors have none to declare.

EPTFE‐TIPS vs repetitive LVP plus albumin for the treatment of refractory ascites in patients with cirrhosis

Reduction in portal pressure by self-expandable polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunts (TIPS) is a treatment option for refractory ascites. Data on clinical outcomes after ePTFE-TIPS vs repetitive large-volume paracentesis (LVP) plus albumin (A) administration for the treatment of patients with refractory ascites are limited. Retrospective comparison of ePTFE-TIPS vs LVP+A in terms of (i) control of ascites, (ii) occurrence of overt hepatic encephalopathy (HE) and (iii) transplant-free survival in cirrhotic patients with refractory ascites. Among n=221 patients with cirrhosis and refractory ascites, n=140 received ePTFE-TIPS and were compared to n=71 patients undergoing repetitive LVP+A. After ePTFE-TIPS, ascites was controlled without any further need for paracentesis in n=76 (54%; n=7 without and n=69 with diuretics). The need for frequent large-volume paracentesis was significantly higher in the LVP+A group than with ePTFE-TIPS (median 0.67 (IQR: 0.23-2.63) months vs 49.5 (IQR: 5.07-102.60) months until paracentesis, log-rank P<.001). De-novo incidence of HE was similar in ePTFE-TIPS and LVP+A patients (log-rank P=.361). Implantation of ePTFE-TIPS was associated with improved 1-year survival as compared to LVP+A (65.6% vs 48.4%, log-rank P=.033). Age (odds ratio (OR):1.05; 95% confidence interval (95% CI):1.03-1.07; P<.001), serum albumin (OR: 0.95; 95% CI: 0.92-0.99; P=.013) and hepatocellular carcinoma (OR: 1.66; 95% CI: 1.06-2.58; P=.026) emerged as independent predictors of survival. ePTFE-TIPS results in superior control of ascites without increasing the risk for overt HE as compared to LVP+A. Although ePTFE-TIPS improved 1-year survival in cirrhotic patients with refractory ascites, its use was not independently associated with transplant-free survival.

Alfapump® system vs. large volume paracentesis for refractory ascites: A multicenter randomized controlled study

Patients with refractory ascites (RA) require repeated large volume paracenteses (LVP), which involves frequent hospital visits and is associated with a poor quality-of-life. This study assessed safety and efficacy of an automated, low-flow pump (alfapump® [AP]) compared with LVP standard of care [SoC]. A randomized controlled trial, in seven centers, with six month patient observation was conducted. Primary outcome was time to first LVP. Secondary outcomes included paracentesis requirement, safety, health-related quality-of-life (HRQoL), and survival. Nutrition, hemodynamics, and renal injury biomarkers were assessed in a sub-study at three months. Sixty patients were randomized and 58 were analyzed (27 AP, 31 SoC, mean age 61.9years, mean MELD 11.7). Eighteen patients were included in the sub-study. Compared with SoC, median time to first LVP was not reached after six months in the AP group, meaning a significant reduction in LVP requirement for the AP patients (AP, median not reached; SoC, 15.0days (HR 0.13; 95%CI 13.0-22.0; p<0.001), and AP patients also showed significantly improved Chronic Liver Disease Questionnaire (CLDQ) scores compared with SoC patients (p<0.05 between treatment arms). Improvements in nutritional parameters were observed for hand-grip strength (p=0.044) and body mass index (p<0.001) in the sub-study. Compared with SoC, more AP patients reported adverse events (AEs; 96.3% vs. 77.4%, p=0.057) and serious AEs (85.2 vs. 45.2%, p=0.002). AEs consisted predominantly of acute kidney injury in the immediate post-operative period, and re-intervention for pump related issues, and were treatable in most cases. Survival was similar in AP and SoC. The AP system is effective for reducing the need for paracentesis and improving quality of life in cirrhotic patients with RA. Although the frequency of SAEs (and by inference hospitalizations) was significantly higher in the AP group, they were generally limited and did not impact survival. Lay summary: The alfapump® moves abdominal fluid into the bladder from where it is then removed by urination. Compared with standard treatment, the alfapump reduces the need for large volume paracentesis (manual fluid removal by needle) in patients with medically untreatable ascites. This can improve life quality for these patients. www.clinicaltrials.gov#NCT01528410.

Home-based drainage of refractory ascites by a permanent-tunneled peritoneal catheter can safely replace large-volume paracentesis.

Refractory ascites has a poor prognosis. Recurrent large-volume paracentesis is the current standard of care; however, it results in circulatory dysfunction and renal dysfunction, and hospitalization is commonly required. Transjugular intrahepatic portosystemic shunt placement is not an option in a substantial number of patients because of contraindications. The placement of a tunneled peritoneal drainage catheter has been shown to be effective in patients with malignant ascites. However, data in patients with nonmalignant refractory ascites are rare. We followed 24 consecutive patients in whom tunneled peritoneal drainage catheters were placed in the Endoscopy Unit at Hannover Medical School between June 2013 and December 2014. Catheters were placed in 24 patients with refractory ascites in end-stage liver disease and with a contraindication to transjugular intrahepatic portosystemic shunt placement. Placement was technically successful in all patients. The dosage of diuretics could be reduced significantly. The number of paracentesis decreased from 2.2±1 to 0 per week, although the volume of daily ascites removal remained stable (2 l). Despite frequent drainage of ascites, kidney function, serum sodium, and serum albumin remained stable. Seven adverse events occurred in six (25%) patients. Five patients listed for liver transplantation underwent successful transplantation without a negative impact. The tunneled peritoneal drainage catheter placement is a viable and effective treatment alternative in patients with refractory ascites because of end-stage liver disease, reducing diuretic intake and the need for paracentesis. The procedure avoids hyponatremia, worsening kidney function, and albumin infusions without an increased risk of spontaneous bacterial peritonitis.

Evaluation of the value of hypertonic saline as adjuvant treatment of severe ovarian hyperstimulation syndrome

Background At present, ovarian hyperstimulation syndrome (OHSS) is an uncommon and potentially life-threatening complication of ovarian stimulation. The ideal colloid solution for the treatment of patients with severe OHSS is still unknown. Human albumin, however, is considered the most ‘physiologic’ solution for this purpose and commonly used. However, severe life-threatening anaphylaxis has been reported with albumin infusion. The purpose of this study was to compare the efficacy and safety of hypertonic saline 3% for the treatment of severe OHSS rather than albumin. Patients and methods Over a period of 2 years, this randomized prospective study was conducted on 60 patients diagnosed with severe or critical OHSS admitted to Obstetric ICU of Ain-Shams University Hospitals. Patients were randomly allocated into two groups, each containing 30 patients. Group A (n=30) received 100 ml of albumin 20% over 4 h every 12 h plus conventional treatment according to the Ain Shams obstetric ICU protocol. Group N (n=30) received 500 ml of hypertonic saline 3% over 24 h (20 ml/h) plus conventional treatment. The efficacy of the study medications was compared in this study between the two groups in terms of daily urine output, serum creatinitine, percentage of occurrence established renal impairment, need of paracentesis, occurrence of established acute respiratory distress syndrome, and ICU length of stay. Results Significant difference was found regarding daily urine output among the study groups, with a significantly higher value (3350±142.6) in group N compared with group A (2150±133.4) associated with significant reduction in occurrence of established renal impairment in three cases in group A rather than 1 in group N. This is reflected by significant reduction in the length of ICU stay (3.1±1.1) in group N rather than group A (3.7±1.2). Conclusion The use of hypertonic saline 3% as a small-volume resuscitation is comparable to and effective and superior to albumin for the treatment of severe OHSS with regard to urine output, and may have a protective effect against occurrence of acute respiratory distress syndrome in such patients, but further studies are needed to prove that.

PTH-105 Introduction of Transjugular Intrahepatic Portosystemic Shunt (TIPSS) Service for Refractory Ascites in A Non-Transplant Liver Unit

<h3>Introduction</h3> TIPSS has been shown to be an effective treatment for patients with refractory ascites (RA).The majority of TIPSS procedures in the UK are performed in a transplant centre. In 2009, Derby Teaching Hospitals introduced TIPSS service. The aim of our study was to evaluate our experience and assess its impact on the care of this patient group. <h3>Methods</h3> 56 successful TIPSS procedures were performed between May 2009 and August 2015, 32 for RA were included in this analysis.Data on patient demographics, aetiology of liver disease, inpatient bed days (6 months before and after the procedure), Model for End-Stage Liver Disease (MELD) scores, Child-Pugh score, procedure details, clinical outcomes, mortality and complications were collected retrospectively from our centres clinical results database.Complete response was defined as no further need for paracentesis and partial if frequency reduced to &gt;50%. <h3>Results</h3> 25/32 (78%) patients were male with a median age of 58 years (range, 39–77 years). 30 patients were Child-Pugh class B, 2 Child-Pugh C, with a median MELD and MELD Na of 11 (range, 6-16) and 14 (range, 6–22) respectively. Alcoholic Liver Disease was most common aetiology of cirrhosis (86.5%) followed by non-alcoholic fatty liver disease (6.45%). Pre-TIPSS and post-TIPSS hepatic venous pressure gradients (HVPG) were 20 mmHg (range, 10–30) and 8 mmHg (range, 1–21) respectively. Cumulative mortality at 1, 3, and 12 months was 3%, 9%,and 18% (n = 28) respectively. One early death (within 30 days) was secondary to pneumonia. Ascites resolved completely after the first procedure in 66% and partially in 6% of patients.Cummulative response rate was 24, 62 and 90 percent at 30,60 and 90 days respectively. Five patients (16%) showed no improvement in RA, of whom 2 underwent liver transplantation. 9 patients (28%) developed hepatic encephalopathy (HE), 5 of whom (16%) developed refractory HE, with 3 patients requiring TIPSS reduction. The number of inpatient days reduced from 23 (range, 4-52) days in the 6 months pre-TIPSS to 8 (range 0–48) in the 6 months post TIPSS. The main reason for hospital admission was elective admission for ascites drainage. <h3>Conclusion</h3> A safe and effective TIPSS service for patients with refractory ascites can be successfully introduced into a comprehensive secondary care liver service by careful patient selection and technical proficiency. Excellent outcomes with acceptable complication rates can be achieved for patients with a significant reduction in resource utilisation (inpatient bed days and paracentesis). An established elective service is an important precursor for the provision of early and rescue TIPSS for variceal bleeding. <h3>Disclosure of Interest</h3> None Declared

Automated low flow pump system for the treatment of refractory ascites: a single-center experience.

Ascites is a common complication of liver cirrhosis and represents the main cause of hospitalization among patients with cirrhosis. First-line therapy for those patients is the use of diuretics and dietary sodium restriction. However, 10 % of patients per year become therapy refractory to diuretic treatment with the need of repeated high-volume paracentesis or transjugular intrahepatic portosystemic shunt (TIPS). For these patients, an automated pump system (Alfapump/Sequana Medical) was developed. Here, we describe our single-center experience of ten consecutively implanted pump systems. Between 08/13 and 11/14, ten Alfapump systems were implanted in patients with refractory ascites all suffering from liver cirrhosis. Those patients were treated as a bridge to transplant (4/10) or as an end-stage therapy (6/10). Median follow-up was 165 days (23-379 days). Postimplant, the need of paracentesis could be markedly reduced to a mean of 0.45 (0-4/month) per month. In eight patients, paracentesis was not needed after implantation of the pump system. The median daily output volume was 1000 ml/day (450-2000 ml/day). Prerenal insufficiency was a recurrent complication in the postoperative period. The Alfapump system is a useful system in the treatment of patients suffering from therapy refractory ascites. However, due to the high level of comorbidities, careful patient selection and postoperative monitoring are required.

PWE-141 Alfa pump for the treatment of refractory ascites: a “real world” experience from the uk

<h3>Introduction</h3> Up to 10% of cirrhotic patients with ascites become refractory to diuretic therapy requiring either large volume paracenteses (LVP), transcutaneous intrahepatic portosystemic shunt (TIPSS) or liver transplantation (LT). In patients where TIPSS or LT is contraindicated, repeated LVP is the only option. LVP is an uncomfortable procedure requiring hospital visits and has risk of complications. The ALFA pump is a surgically implanted automated low flow pump system that transports fluid from the peritoneal cavity to the bladder and is an alternative treatment option for patients with refractory ascites. Our aim was to evaluate the early “real world” experience of the ALFA pump for the treatment of refractory ascites from centres in the UK. <h3>Method</h3> Retrospective case note review of the outcomes of patients who had an ALFA pump implanted for refractory ascites outside trials at 4 NHS hospitals since Sept 2013. <h3>Results</h3> ALFA pumps were implanted in 9 patients (6 male, 3 female; median age 74, range 41–81) at four centres (4 NCL, 2 UCL, 2 CAM, 1 QEHB). 7 patients had ascites related to cirrhosis (4 Child-Pugh B, 3 Child-Pugh C), 1 due to congestive cardiac failure and 1 with portal hypertension due to arterio-venous malformation. Prior to insertion of the ALFA pump the median frequency of paracenteses was every 10 days (range 7 – 20) and the median volume of ascites drained was 9 litres (range 8 to 12). ALFA pumps were successfully implanted in all patients. Requirement for paracenteses was substantially reduced post ALFA pump implantation with 7 patients no longer requiring any paracenteses. In one patient the pump blocked after 3 weeks and required reimplantation with a second pump that also blocked and the patient has returned to LVP. In another patient the pump blocked after 8 months and a second ALFA pump was successfully implanted. All 9 patients had ALFA pump related complications including 4 post-operative seromas, 3 bladder catheter migrations/occlusions, 5 site related infections, 6 acute kidney injury/electrolyte disturbance and 1 urinary incontinence. 5 of the 9 patients were alive with a functioning pump 6 months after implantation. <h3>Conclusion</h3> The ALFA pump offers an alternative option for patients who have refractory ascites in whom TIPSS and LT are contraindicated. ALFA pump implantation substantially reduces the need for paracenteses in a cohort of patients who had previously required a significant number of LVP. ALFA pump related complications were frequent suggesting the need for careful patient selection in this high risk group. Outcomes of a randomised controlled trial are eagerly awaited. <h3>Disclosure of interest</h3> None Declared.

The Development of a Hepatology Care Coordination Program: An Effort to Achieve Reductions in Hospital Readmissions

Introduction: Due to the progressive nature of cirrhosis, patients are prone to frequent hospital admissions and readmissions. The period immediately after discharge is a ‘high risk’ one. Patients often carry new diagnoses, are on new medications, have received changes in the dosages of existing medications, and are deconditioned from their hospital stay. The aim of this endeavor was to create a sustainable care coordination program that would improve patient outcomes and achieve reductions in cirrhosis-related re-admissions at our institution. Methods: Our hospital is an inner-city quaternary care medical center with a dedicated hepatology inpatient service and an active liver transplant program that performed 53 orthotopic liver transplants in 2013. Based on an over 30% patient 30-day readmission rate to the inpatient hepatology service for cirrhosis-related complications, a care coordination program was created in February 2014. Patients at high risk for readmission (i.e. recurrent encephalopathy, refractory ascites with frequent need for paracentesis, failure to thrive, poor social support systems) are enrolled on an ongoing basis. Once these patients are recognized by the attending hepatologist, the inpatient liver transplant coordinator is notified. When appropriate patients are identified, monitoring equipment is installed in the patient’s home and education/medication reconciliation is provided to the patient and family before discharge. On arrival home and on a daily basis, the patient’s daily weight, heart rate, blood pressure, and pulse oximetry are monitored by a home monitoring company call center. The program also includes frequent phone follow-up post-discharge by the inpatient coordinator for continued assessment. Any identified clinical issues are discussed real-time with attending hepatologist enabling medication adjustments and/or rapid clinic follow-up. After regular office hours, clinical abnormalities and concerns are discussed with the on-call doctor by the call center. Additionally, all enrolled patients are seen in the outpatient hepatology office within 1 week of hospital discharge. As of May 8, 2014, 11 patients have been enrolled in the program. Conclusion: In an effort to respond to the frequent and costly readmissions for management of complications due to cirrhosis, we created an intensive care coordination program. Although still in its early implementation, it may be a tool to avoid hospital readmissions in select cases. This model of patient discharge care coordination can be replicated at other institutions.

O23 DECREASED DEVELOPMENT OF DIABETES MELLITUS WITH IMPROVEMENT OF NONALCOHOLIC FATTY LIVER DISEASE: A 10-YEAR JAPANESE COHORT STUDY

in 10-mm group (43.3% vs. 5.4%; p < 0.01). After TIPS, the decrease in PPG was significantly higher in 10-mm group (10.4±4.2 vs. 8.7±3.5mmHg; p =0.004). The 3-months need of paracentesis was not statistically different (23% vs. 18%; p =0.36), however the longterm need of paracentesis was higher in 8-mm group (58% vs. 31%; p =0.003). Overall HE, severe HE (grade III-IV), new episodes or worsening of HE, acute HE, chronic HE, and cumulative probability of developing the first episode of HE were similar in both groups. Similarly, no significant differences were observed in new episodes of VB, SBP, TIPS dysfunction, Child–Pugh score, MELD, need of liver transplantation, overall survival and transplant-free survival. Conclusions: This study supports the use of 10-mm diameter ePTFE-covered stent in cirrhotic patients with refractory ascites.

Eradication of a chronic wound and driveline infection after redo-LVAD implantation

A 48 year old patient with dilated cardiomyopathy and chronic acne inversa underwent implantation of a LVAD system (Heartmate II, Thoratec, USA) March 2011. During 2011 and 2012 the patient was repeatedly readmitted for treatment of driveline infection with MRSA. Colonization was controlled with Linezolid and Rifampicin however reoccurred after discontinuation. In August 2012 the LVAD-system was exchanged due to pump dysfunction (HVAD, HeartWare Inc., USA). Postoperatively, the patient presented with ascites which secreted through the driveline exit. Consequently, the abdominal wall was surgically corrected to prevent exit of peritoneal fluid through the driveline, and the patient was discharged with sterile wound swabs. However 6 weeks after discharge the driveline exit wound started secreting pus showing abundant growth of multi resistant staphylococcus aureus (MRSA). With clinical signs of increasing liver failure with regular need for paracentesis, and clinical signs of local infection, a CT scan of the abdomen was performed revealing an enrichment of contrast medium along the driveline and an abscess-like formation on the abdominal wall. Patient was admitted receiving regular dose Daptomycin and Rifampicin. The latter was discontinued after ten days. The abscess, surrounding driveline exit and abdominal wall cavity was excised and vacuum treatment initiated. Total duration of Daptomycin therapy was 3 weeks. While first week skin and wound swabs were still positive for MRSA, all samples were sterile after the second week. Inflammation was monitored by leucocyte count and IL6. The secretion of pus along the driveline ceased, the wound cavity was closed subsequently. After discharge and stop of antibiotics skin and driveline swabs remained negative for MRSA (10 weeks).

A phase II study of cediranib as palliative treatment in patients with symptomatic malignant ascites or pleural effusion

Malignant ascites and pleural effusion are challenging clinical problems, with a major impact on quality of life. We conducted a randomized phase II trial to assess the palliative value of cediranib, an oral vascular endothelial growth factor tyrosine kinase inhibitor (VEGF TKI). After a baseline paracentesis or thoracentesis (on day 0), patients with symptomatic malignant ascites and/or pleural effusion were randomized between immediate treatment with cediranib (Immediate Cediranib) or delayed treatment with cediranib (Delayed Cediranib) on day 29, or after a new puncture was needed. The primary objective of the study was the puncture-free survival, defined as the time from study start (day 1) to the first need for paracentesis or thoracentesis, or time to death, whichever event occurred first. Twelve patients were enrolled. The median puncture-free survival was 45 days (range 10-368) in the Immediate Cediranib patients and 7 days (range 4-13) in the Delayed Cediranib patients (P = 0.011). The change in puncture-free interval (the puncture-free survival after study start minus the puncture-free interval before study start) increased with a median of 31 days in the Immediate Cediranib patients and shortened with a median of 3 days in the Delayed Cediranib patients (P = 0.015). The most common adverse events were fatigue and anorexia. In conclusion, cediranib increased the puncture-free survival and puncture-free interval with an acceptable toxicity profile. This is the first study in which an oral VEGFR TKI showed beneficial palliative effects in patients with malignant effusions.