Outcomes after TIPS in patients with cirrhosis and sarcopenia: A systematic review and meta-analysis.

Abstract Background Patients with cirrhosis and refractory ascites often require frequent large-volume paracentesis (LVP) to prevent symptomatic fluid accumulation and avoid emergency department (ED) visits or hospitalizations. At our tertiary care center, the outpatient paracentesis clinic offers six procedure slots weekly; however, baseline data showed underutilization, with 20–30% of slots remaining unfilled. Aims To optimize outpatient paracentesis clinic utilization through targeted workflow interventions and to assess whether improved access correlated with reduced ED visits for paracentesis. Methods This single-center pre-and post-intervention quality improvement (QI) at a tertiary-care liver program with a weekly outpatient paracentesis clinic (six slots per week). The baseline period (January–May 2024) established utilization patterns, followed by an intervention period (January–September 2025) Change Idea #1: Tracking and development of individualized “dry weights” and standardized patient education to identify when paracentesis was not required. Nursing staff performed pre-appointment assessments 48–72 hours prior to scheduled procedures to confirm. Change Idea #2: Implementation of an urgent-waitlist system to fill same-day cancellations resulting from patients at dry weight or without a safe paracentesis pocket. Monthly clinic utilization and ED visit data were analyzed descriptively to assess trends before and after intervention. Results During the baseline period (January–May 2024), 212 outpatient paracenteses were performed (mean 17.7 per month), with 20–30% of slots unfilled. Following the January 2025 intervention, throughput improved progressively. Between January and April 2025, 67 procedures were completed (mean 8.4 per month), and from May to September 2025, 109 were performed (mean 21.8 per month), a 23% increase from baseline. In the latest three months (July–September 2025), 69 procedures were completed (mean 23.0 per month), and unfilled slots declined to 11.9%, indicating sustained improvement and consistent scheduling. ED visit review (January–September 2025) showed higher use during periods of lower clinic throughput and fewer visits during months of optimal performance, demonstrating an inverse relationship between outpatient capacity and acute care demand. Conclusions Implementation of structured QI measures—pre-confirmation, rapid slot substitution, and individualized dry-weight protocols—significantly improved outpatient paracentesis utilization and reduced unfilled capacity. Enhanced clinic efficiency correlated with a reduction in ED visits, supporting the role of proactive outpatient optimization in improving access, resource use, and patient outcomes in advanced liver disease. Funding Agencies None

Background and AimTransjugular intrahepatic portosystemic shunt (TIPS) is pivotal for refractory ascites in cirrhosis, yet many patients experience poor outcomes. Sarcopenia, a common muscle-wasting syndrome in cirrhosis, is tied to portal hypertension, but its role in TIPS efficacy remains unclear. This study aimed to assess sarcopenia’s impact on post-TIPS ascites resolution, complications, and mechanisms.Materials and MethodsThis retrospective multicenter study included 294 cirrhotic patients undergoing TIPS (2016–2021). Sarcopenia was defined by CT-based L3-SMI. Outcomes included ascites resolution (International Club of Ascites criteria), HE, and stent dysfunction. Analyses were adjusted for ΔPPG (PPG reduction), MELD-Na, and NLR as the inflammatory marker.ResultsSarcopenic patients had reduced odds of ascites resolution (OR 0.42, 95% CI 0.28–0.63) and a higher HE risk (HR 2.48, 95% CI 1.72–3.57) versus non-sarcopenic patients.ConclusionIn this study, sarcopenia independently predicted poor TIPS outcomes, including reduced ascites resolution and increased risk of hepatic encephalopathy, through potential hemodynamic and metabolic pathways, supporting its value in personalized management. Screening for sarcopenia may help optimize TIPS candidacy and inform therapies targeting inflammation and ammonia.

Cytomegalovirus (CMV) remains one of the most important opportunistic infections following solid organ transplantation, with variable incidence and clinical outcomes depending on organ type, immunosuppressive regimen, and donor-recipient serostatus. We conducted a large-scale retrospective analysis using data from the Korean Organ Transplantation Registry (KOTRY), a prospective multicenter cohort including kidney, liver, heart, and lung transplant recipients. A total of 9,777 adult patients who underwent transplantation between 2014 (lung added in 2015) and December 2022 were analyzed. CMV infection and disease were identified based on clinical diagnosis. Independent risk factors were determined using multivariable Cox regression. The overall incidence of CMV infection was highest among kidney transplant recipients (36.5%), followed by lung (21.3%), liver (12.9%), and heart (6.8%) recipients. Most CMV infections occurred within the first year after transplantation, with lung recipients exhibiting the longest median time to infection (112 days). Risk factors varied by organ: in kidney recipients, antithymocyte globulin (ATG) use and D+/R- serostatus were the strongest predictors; in liver recipients, higher Model for End-Stage Liver Disease scores, refractory ascites, and deceased donor status increased the risk; in heart recipients, ATG administration, desensitization, and CMV immunoglobulin G seronegativity were significant risk factors; and in lung recipients, diabetes and prolonged operation time were associated with higher infection rates. CMV infection significantly worsened patient survival among kidney, liver, and lung recipients. The incidence and risk factors of CMV infection differ substantially across organ types, yet its impact on outcomes remains considerable. These findings highlight the need for organ-specific prevention, monitoring, and novel therapeutic strategies to enable personalized management of transplant recipients.

Transjugular Intrahepatic Portosystemic Shunt Related Hepatic Encephalopathy in Cirrhotics With Refractory Ascites: Incidence and Correlation With TIPS Stent Diameter and Pre-TIPS Sarcopenia.

Long-term albumin treatment for decompensated cirrhosis in Italy: A propensity score-matched, retrospective, real-world chart analysis.

TIPS is commonly used to treat complications of portal hypertension. Hernia incarceration is a complication of the TIPS procedure that is poorly understood and not well documented. We examine this complication in a large, single-center cohort of TIPS patients and compared it to a cohort of patients with refractory ascites managed with serial large-volume paracentesis alone to determine whether TIPS itself increases incarceration risk. We identified 259 adults who underwent TIPS and 644 adults with refractory ascites managed with serial large-volume paracentesis at the University of California, San Francisco (UCSF) between 2015 and 2024. We extracted structured variables and unstructured documentation from the UCSF Clinical Data Warehouse. We used OpenAI's GPT-4o, a large language model, and manual chart review to identify post-TIPS hernia incarceration and clinical information from unstructured notes. We calculated time to events and used LASSO-Cox regression to identify risk factors associated with incarceration. Of 259 patients, 12.7% (33) developed post-TIPS incarceration with a median time to event of 31 days (IQR: 10-109). In comparison, only 0.9% (6/644) of large-volume paracentesis patients developed hernia incarceration. Within the TIPS cohort, patients with hernia incarcerations were more likely to have existing umbilical hernias (87.9% vs. 29.2%, p <0.01) and higher serum albumin (3.2 vs. 2.8g/dL, p <0.01) compared to those without incarceration. Multivariate Least Absolute Shrinkage and Selection Operator-Cox regression showed the presence of an umbilical hernia pre-TIPS (HR=3.1, 95% CI: 1.8-5.4, p <0.01), serum creatinine at TIPS (HR=1.3, 95% CI: 1.0_1.6, p =0.04), serum albumin at TIPS (HR=1.7, 95% CI: 1.0-2.8, p =0.04) were predictors of post-TIPS incarcerated hernia development. In the incarcerated hernia group, 36.4% underwent hernia repair at a median of 0.5 days (IQR: 0-259), 18.2% received liver transplant at 55 days (IQR: 6-152), and 24.2% died at 422 days (IQR: 261-747), all measured from the time of incarceration diagnosis. Of the patients who did not develop incarcerated hernias, 6.2% underwent hernia repair (for non-incarcerated hernias), 23.0% received a transplant, and 16.4% died after TIPS. Kaplan-Meier analysis showed no significant difference in mortality between the incarceration and no-incarceration group (2-y probability of 13.7% vs. 12.8%, log rank p =0.32). In sensitivity analyses including abdominal binder use, post-TIPS abdominal binder (HR=3.1, 95% CI: 1.7-5.6, p <0.01) and pre-TIPS umbilical hernia (HR=2.8, 95% CI: 1.6-4.9, p <0.01) remained significant predictors, while serum creatinine dropped out as a significant variable, suggesting binder use may be a marker of ascites or hernia severity. TIPS substantially increases hernia incarceration risk compared to serial paracentesis alone, with 12.7% of patients in this single-center cohort developing incarceration at a median of 1 month after TIPS. The presence of a known umbilical hernia prior to TIPS had the strongest association with this complication. Serum creatinine and albumin association also suggests ascites severity as a contributor. Identifying pre-TIPS risk factors could facilitate the development of targeted strategies to mitigate post-TIPS complications.

Intractable ascites (IA) also referred to as refractory ascites, is a severe complication of cirrhosis marked by resistance to standard diuretic therapy. Its occurrence reflects advanced portal hypertension and is associated with poor prognosis. This literature review summarizes current evidence and management strategies for IA in cirrhotic patients. Sodium restriction remains a core component of management, even in diuretic-resistant cases. Large-volume paracentesis (LVP) with albumin infusion is considered first-line therapy, though it carries the risk of post-paracentesis circulatory dysfunction. Long-term albumin administration shows potential benefits but requires further confirmation. In selected patients, transjugular intrahepatic portosystemic shunt (TIPS) offers sustained ascites control. For non-TIPS candidates, the alfapump system provides continuous ascites drainage, improving appetite, mobility, and quality of life, though long-term antibiotic prophylaxis is required to prevent device-related infection. Liver transplantation remains the only curative option, and combined liver–kidney transplantation should be considered in patients with concurrent chronic kidney disease. Management of IA in cirrhosis requires a multidisciplinary approach. While LVP and TIPS remain the therapeutic mainstays, emerging strategies such as long-term albumin therapy and alfapump devices are promising. Given its poor prognosis, timely evaluation for liver transplantation is crucial.

Ascites is often treated through paracentesis, which requires repeated application and poses risks. In this study, we developed a peritoneobladder shunt that allows natural ascites drainage from the peritoneal cavity to the bladder. We conducted an experiment to determine the functional effect of the peritoneobladder shunt in a swine model. Peritoneobladder shunts were developed and placed in 4 swine models to test their effectiveness in draining ascitic fluid from the peritoneal cavity to the bladder. The peritoneobladder shunts were inserted laparoscopically; some models received the shunts with one-way check valves to prevent fluid reflux, while one received peritoneobladder shunts without the valves. After a short (7 days) survival period, experiments were conducted to verify that the peritoneobladder shunts were properly fixed in the bladder. During the survival period, two peritoneobladder shunts could be placed in the bladder wall without rupture or tearing. When the peritoneal cavity was filled with an ascitic fluid substitute, the fluid naturally drained into the bladder; when the peritoneobladder shunts with one-way check valves were used, no reflux occurred from the bladder into the peritoneal cavity. In experiments using swine models, the peritoneobladder shunts effectively drained fluid, and one-way check valves successfully prevented reflux. These findings suggest that the peritoneobladder shunt could be an alternative option to alleviate the burden on patients who require paracentesis, allowing home-based treatment. Further studies are needed to assess the long-term stability and safety of this procedure in humans.

BACKGROUNDRefractory ascites severely impairs quality of life in patients with liver cirrhosis (LC) and cancer-related peritonitis. For individuals who are intolerant to medical therapy and require frequent large-volume paracentesis, a peritoneovenous shunt (PVS) offers a potential treatment option. However, PVS placement is associated with high complication rates, perioperative mortality, and lacks well-defined indications.AIMTo identify prognostic factors for PVS placement and develop a novel postoperative survival scoring model for LC with refractory ascites.METHODSA total of 100 patients who underwent PVS placement for refractory ascites due to LC in our department between 1998 and 2024 were analyzed. Patients were stratified into two groups: Those who survived more than 180 days after PVS placement (L-group) and those who survived for less than 180 days (S-group). Prognostic factors were compared between groups, and four variables (sex, age, Child-Pugh score, and liver volume) were selected for the creation of a new scoring system.RESULTSSignificant differences between the S- and L-groups were observed for age, sex, Child-Pugh score and preoperative liver volume. Based on these variables, we developed a scoring system as follows: 1 point each for age ≥ 60 years, Child-Pugh score ≥ 10, female sex, and preoperative liver volume < 1057 mL. Patients scoring 0-2 points were classified as PVS grade A, and those scoring 3-4 points as PVS grade B. Survival analysis showed that overall survival was significantly higher in PVS grade A compared with PVS grade B. Multivariate analysis confirmed PVS grade as an independent prognostic factor.CONCLUSIONThe proposed PVS scoring system may be a useful tool for predicting postoperative prognosis following PVS placement in patients with LC and refractory ascites.

Hypoalbuminemia is commonly seen in patients with heart failure and is associated with worse outcomes. Multiple pathophysiologic mechanisms can contribute to low albumin levels in heart failure patients, such as malnutrition, hepatic congestion, inflammation, and protein-losing enteropathy. Hypoalbuminemia can exacerbate heart failure symptoms and contributes to pulmonary edema by reducing plasma oncotic pressure, thereby favoring fluid movement into the interstitial and alveolar spaces. In this sense, albumin supplementation has been used in clinical practice to stimulate diuresis. However, evidence regarding its efficacy remains controversial. Routine albumin use does not appear to improve outcomes and should not be adopted broadly. Instead, it may be considered selectively in those with refractory edema or ascites despite maximal diuretic therapy and in whom hypoalbuminemia is profound. While proper oral nutrition has clearly shown better outcomes in malnourished heart failure patients, no clear guidelines about the use of intravenous albumin therapy are currently available to guide this practice. This article aims to review the pathophysiology of hypoalbuminemia in heart failure and the current available evidence on the therapeutic role of albumin infusion.

EE191 Cost-Consequence Analysis of Transjugular Intrahepatic Portosystemic Shunt (TIPS) Treatment vs. Large-Volume Paracentesis (LVP) in the Management of Refractory Ascites: Preliminary Results Overview From an Italian Healthcare Perspective

Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive and effective treatment for gastrointestinal variceal bleeding and refractory ascites associated with portal hypertension. However, TIPS dysfunction occurs for various reasons and can lead to recurrent complications. In such cases, repeated endovascular intervention can be performed for portal hypertension. This article presents one of the methods of endovascular correction (Y-stenting) for TIPS thrombosis.

Background: Refractory ascites in cirrhosis presents major management challenges and is associated with frequent hospital admissions, reduced quality of life, and poor survival. Long-term abdominal drains (LTADs) have emerged as a palliative alternative to repeated large-volume paracentesis (LVP), yet real-world outcome data remain limited.Methods: We performed a retrospective analysis of 44 patients with cirrhosis and refractory ascites who underwent LTAD insertion between 2019 and 2024 at a district general hospital. Clinical outcomes, including survival, complication rates, hospital admissions, and length of stay (LOS), were evaluated. Data were analysed using Kaplan-Meier survival curves and descriptive statistics for pre- and post-LTAD comparisons.Results: Median survival after LTAD was eight months; Kaplan-Meier estimated 12-month survival was 65%. LTAD insertion was associated with a 47% reduction in hospital admissions and a 55% reduction in cumulative LOS in the six months post-procedure compared to the six months pre-procedure. Specifically, admissions dropped from 102 to 54, and LOS from 1,150 to 520 days for the cohort. Spontaneous bacterial peritonitis (SBP) occurred in 18% of patients and catheter-related infections in 11%. Ascitic fluid leakage was observed in 20% and drain blockage in 14%. No procedure-related mortality was identified.Conclusion: LTADs represent a safe and effective palliative strategy for managing refractory ascites in cirrhosis. They significantly reduce healthcare utilisation while maintaining acceptable complication rates. Careful patient selection and multidisciplinary management are essential to optimise outcomes. LTADs are currently a case-by-case palliative option, but ongoing trials will further clarify their role. Prospective studies are warranted to validate these findings and to assess quality-of-life improvements.

Shunt magnitude is a key determinant of overt hepatic encephalopathy in patients undergoing TIPS

The decision to proceed with liver transplant (LT) must account for the risk of death without LT and the likelihood of survival after, a concept known as "survival benefit." A 2005 study suggested that deceased donor LT (DDLT) survival benefit is achieved at a MELD score of 15, a threshold that persists today. This study reassesses that threshold in the context of MELD 3.0. Data from all adults listed for primary single-organ LT in the UNOS/OPTN registry (January 1, 2021-March 31, 2023) were analyzed. Those undergoing living donor LT were excluded. Using sequential stratification, Cox regression models comparing mortality between LT recipients and waitlist candidates estimated hazard ratios across MELD 3.0 subgroups. Among 21,594 LT candidates (median MELD 3.0, 22, IQR 16-30), LT recipients had a 95% lower adjusted mortality risk than waitlisted candidates (HR 0.05, 95% CI 0.04-0.07, p<0.001). This survival benefit varied by MELD 3.0 score, with an advantage emerging at MELD 3.0 ≥12. At MELD 3.0 of 12-14, DDLT reduced mortality by 46% (HR 0.54, 95% CI 0.30-0.96, p=0.04), while no significant survival benefit was seen below MELD 3.0 of 12, largely due to high post-LT mortality. In this analysis of UNOS/OPTN data, DDLT conferred a survival benefit at MELD 3.0 scores ≥12, revising the historical threshold of 15. However, MELD 3.0 alone does not capture the full complexity of LT candidacy. Factors such as refractory ascites, hepatic encephalopathy, frailty, and poor quality of life should also be considered when considering LT for the individual patient.

ObjectivesTo analyze revision rates after transjugular intrahepatic portosystemic shunt (TIPS) using expanded polytetrafluoroethylene-covered stentgrafts and to identify predictors of shunt revisions.Materials and methodsThis single-center retrospective study included 514 consecutive patients (mean age 56.9 ± 12.7 years; 194 females) with TIPS placement between 2003 and 2021. Follow-up included clinical assessment, laboratory testing, ultrasound, and computed tomography. Reinterventions were categorized by type and technique. Univariable and multivariable Cox regression analyses were performed to identify predictors of shunt dilation and reduction.ResultsA total of 149 patients (28.9%) required TIPS revision: 95 (18.5%) shunt dilation, 42 (8.2%) shunt reduction, and 12 (2.3%) others. Median time to first revision was 2.8 months (3.2 months for dilation, 1.9 months for reduction). Indications for first shunt dilation were persistent or recurrent refractory ascites (n = 61), recurrent variceal bleeding (n = 7), and asymptomatic stenosis or occlusion of the TIPS tract (n = 27). Indications for shunt reduction were hepatic encephalopathy refractory to conservative measures (n = 39) and acute liver failure following TIPS (n = 3). Forty-seven patients (9.1%) underwent two or more reinterventions. Multivariable Cox analysis identified immediate post-TIPS portosystemic pressure gradients > 8 mmHg, prior hepatic encephalopathy, and hepatorenal syndrome prior to TIPS as predictors of mandatory shunt dilation. In contrast, age ≥ 65 years, female gender, serum sodium levels, and a pre-TIPS hepatic hydrothorax were predictive of shunt reduction during revision.ConclusionAround one in three patients requires shunt revision. Predictive factors for revision varied by intervention type: shunt dilation was linked to disease severity and portal pressure, whereas reduction was more closely related to the patient’s age and gender.Critical relevance statementPatients who undergo TIPS require structured, long-term follow-up to identify clinical situations that may necessitate shunt adaptation or other secondary interventions.Key PointsShunt revision after TIPS occurs in one-third of patients, with prognostic significance.Several independent prognostic factors for both shunt dilation and reduction were identified.Structured long-term follow-up is crucial to identify patients needing shunt revision.Graphical

Outcomes following nurse-led day-case paracentesis

ZusammenfassungPortale Hypertonie ist mit erheblicher Morbidität und Mortalität verbunden. Die Leberzirrhose macht bis zu 90 % der Fälle von portaler Hypertonie aus, während etwa 10 % auf nicht-zirrhotische Faktoren, einschließlich vaskulärer Lebererkrankungen, zurückzuführen sind.Diese Erkrankung kann zu schweren Komplikationen führen, wie der Entwicklung von gastroösophagealen Varizen, die das Risiko von varikösen Blutungen erheblich erhöhen. Weitere häufige Komplikationen der portalen Hypertonie sind Aszites und hepatorenales Syndrom (HRS).Eine transjuguläre intrahepatische portosystemische Shunt (TIPS)-Implantation wird als die effektivste Behandlung zur Bewältigung der portalen Hypertonie angesehen. Studien zeigen, dass die TIPS-Implantation die Überlebensraten bei Patienten mit wiederkehrendem Aszites sowie bei ausgewählten Patienten mit refraktärem Aszites und varikösen Blutungen verbessern kann. Allerdings können periinterventionelle und postinterventionelle Komplikationen die Anwendung von TIPS einschränken. Neueste Entwicklungen bei Geräten, Techniken und prophylaktischen Medikamenten zielen darauf ab, das Risiko von Komplikationen nach dem Eingriff zu minimieren.Dieses interdisziplinäre Positionspapier fasst Empfehlungen und Anleitung zur Patientenwahl, zu Indikationen und Kontraindikationen, zu Techniken sowie zur Nachsorge von Patienten zusammen, die in Deutschland ein TIPS-Verfahren erhalten.

Letter to the Editor: Few-shot learning-A methodological bridge from pilot experiments to large-scale studies in refractory ascites research.