Type-2 hepatorenal syndrome and refractory ascites: role of transjugular intrahepatic portosystemic stent-shunt in eighteen patients with advanced cirrhosis awaiting orthotopic liver transplantation.

Background/aims: TIPS (transjugular intrahepatic portosystemic stent-shunt) has been used increasingly in the management of refractory variceal bleeding. Its role in the management of refractory ascites and hepatorenal syndrome still awaits further prospective studies. Type-2 hepatorenal syndrome is a moderate steady renal impairment. It arises spontaneously and it is the main mechanism of refractory ascites. Precipitating factors may lead to type-1 hepatorenal syndrome. Hepatorenal syndrome is a common complication of advanced cirrhosis with a 3-month mortality of more than 90% unless treated by orthotopic liver transplantation. However, because of the short survival of patients with hepatorenal syndrome and the limited availability of organs, only a small percentage of patients with hepatorenal syndrome can actually reach orthotopic liver transplantation. That is why awaiting orthotopic liver transplantation we have submitted some suitable patients to a TIPS setting.

Methodology: We have considered eighteen consecutive patients affected by advanced cirrhosis (Child-Pugh 10-12) awaiting orthotopic liver transplantation and suitable for TIPS treatment for the presence of type-2 hepatorenal syndrome (10 males, average age 44.5). The criteria for the diagnosis of hepatorenal syndrome and refractory ascites have been effected according to a consensus recommendation. Organic kidney disease was excluded. After mild intravenous sedation and analgesia a puncture needle was advanced transjugular in a catheter through the inferior cava into one of the three hepatic veins. Subsequently, an intrahepatic branch of the portal vein was punctured and the shunt was established by the implantation of Wallstent (diameter 10 mm; Boston, Scientific, Natick, MA). In all patients, we compared serum creatinine, creatinine-clearance, sodium excretion and urine volume before the intervention and 12 weeks after TIPS. The differences among groups were analyzed using paired Student's t-test.

Results: The stent shunt was successfully established in all eighteen patients. Complications occurred in 4 patients (temperature above 38 degrees C or vomiting). No patients have developed hepatic encephalopathy resistant to medical treatment. As for the ascites a complete response with total remission of ascites was obtained in eight patients, while a partial response with the presence of sonographically detectable ascites--without the need of paracentesis--was obtained in ten patients. As regards renal functional parameters we have evidenced a significant improvement after TIPS.

Conclusions: We can notice how the setting of TIPS, at least in the presented case, has allowed the treatment of ascites and, furthermore, has lead to improvement of the renal functional parameters. It all implies the enormous advantage of a better management of the patient waiting for orthotopic liver transplantation and, most of all, the advantage of preparing the patient for the surgical intervention with normal renal functional parameters: in fact, it is well known that the increase of serum creatinine influences the pre- and post-orthotopic liver transplantation course, and in particular can modify the mortality rate of the patient list. The lack of effective alternative treatment modalities and the almost universally fatal outcome of hepatorenal syndrome make TIPS an attractive option in the treatment of hepatorenal syndrome as a bridge to orthotopic liver transplantation.