title: Transjugular intrahepatic portosystemic shunt for refractory ascites: an analysis of the literature on efficacy, morbidity, and mortality.
abstract: OBJECTIVE
  Transjugular intrahepatic portosystemic shunt (TIPS) is frequently used to treat patients with refractory ascites, but its role is controversial. We sought to determine from the literature the efficacy, morbidity, and mortality associated with TIPS for refractory ascites.
  
  
  METHODS
  We searched MEDLINE and identified studies published in English from January, 1985, to March, 2003, that evaluated the effect of TIPS in patients with refractory ascites. Outcomes that were analyzed included complete resolution of ascites, reduction in ascites, mortality, encephalopathy, stenosis, and renal function. Data were analyzed on an intention to treat basis.
  
  
  RESULTS
  Of 25 studies identified, 16 were included in the analysis. The pooled estimate for complete response at 6 months was 45% and for any response (complete and partial) was 63%. Pooled 6-month mortality after TIPS was 36%. Risk factors for mortality included renal insufficiency (serum creatinine >1.5 mg/dl), hyperbilirubinemia (total bilirubin >3 mg/dl), advanced age (>60 yr), and poor response to TIPS. The pooled rate of new or worsening encephalopathy after TIPS was 32%. In most cases, encephalopathy was managed medically or by reduction in shunt size; however, refractory cases were associated with 100% mortality in most studies. Studies reporting the effect of TIPS on kidney function showed improvement in creatinine clearance and urinary sodium excretion.
  
  
  CONCLUSIONS
  TIPS is effective in eliminating ascites or substantially reducing ascites in cases refractory to medical therapy. Renal insufficiency, refractory encephalopathy, and hyperbilirubinemia were consistently associated with mortality after TIPS. In individuals with risk factors for mortality, alternative strategies should be recommended.
authors.affiliation: Department of Medicine, University of North Carolina, Chapel Hill, North Carolina 27599-7080, USA.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Russo
authors.forename: Asheesh
authors.initials: A
authors.lastname: Sood
authors.forename: Ira M
authors.initials: IM
authors.lastname: Jacobson
authors.forename: Robert S
authors.initials: RS
authors.lastname: Brown
mesh_terms: D000328:Adult; D000368:Aged; D001201:Ascites / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D002423:Cause of Death; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000379:methods / Q000401:mortality*; D011379:Prognosis; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013223:Statistics as Topic; D016019:Survival Analysis; D016896:Treatment Outcome