title: Ascites in patients with hepatocellular carcinoma: prevalence, associated factors, prognostic impact, and staging strategy.
abstract: OBJECTIVE
  Ascites may develop in patients with hepatocellular carcinoma (HCC) with coexisting liver cirrhosis. Few studies had specifically evaluated the role of ascites in HCC. This study investigated its prevalence, associated factors, prognostic impact, and staging strategy in a large HCC patient cohort.
  
  
  METHODS
  A total of 2,203 HCC patients were analyzed. The grading of ascites was according to the European Association for the Study of Liver. The prognostic ability of the Cancer of the liver Italian Program (CLIP), Barcelona Clinic Liver Cancer, Japan Integrated Scoring system, and Taipei Integrated Scoring system in HCC patients with ascites was compared using the Akaike information criterion (AIC).
  
  
  RESULTS
  Ascites was present in 498 (23%) patients at diagnosis. Grades 1, 2, and 3 ascites were found in 13, 5, and 5% of the patients, respectively. The severity of ascites significantly correlated with hyperbilirubinemia, hypoalbuminemia, hyponatremia, prothrombin time (PT) prolongation, and renal insufficiency (all p < 0.001). Large tumor burden and more frequent vascular invasion were often observed in patients with more severe ascites (both p < 0.001). In the Cox proportional hazard model, ascites was identified as an independent prognostic predictor with 80-94% increased risk of mortality (p < 0.001). Among HCC patients with ascites, the CLIP system had the lowest AIC value.
  
  
  CONCLUSIONS
  Ascites is often seen in HCC patients and is associated with both tumoral and cirrhosis factors and decreased long-term survival. The CLIP staging system is a more feasible prognostic model for HCC patients with ascites. The optimal treatment strategy for these patients remains to be investigated.
authors.affiliation: Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan.|Department of Medicine, National Yang-Ming University Hospital, Yilan, Taiwan.|National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Chia-Yang
authors.initials: CY
authors.lastname: Hsu
authors.affiliation: Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan.|National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Yun-Hsuan
authors.initials: YH
authors.lastname: Lee
authors.affiliation: Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan.|National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Yi-Hsiang
authors.initials: YH
authors.lastname: Huang
authors.affiliation: Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan.|Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.|National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Cheng-Yuan
authors.initials: CY
authors.lastname: Hsia
authors.affiliation: Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan.|National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Chien-Wei
authors.initials: CW
authors.lastname: Su
authors.affiliation: Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan.|National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Han-Chieh
authors.initials: HC
authors.lastname: Lin
authors.affiliation: Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.|National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Rheun-Chuan
authors.initials: RC
authors.lastname: Lee
authors.affiliation: Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.|National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Yi-You
authors.initials: YY
authors.lastname: Chiou
authors.affiliation: Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan.|National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Fa-Yauh
authors.initials: FY
authors.lastname: Lee
authors.affiliation: Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan. tihuo@vghtpe.gov.tw.|National Yang-Ming University School of Medicine, Taipei, Taiwan. tihuo@vghtpe.gov.tw.
authors.forename: Teh-Ia
authors.initials: TI
authors.lastname: Huo
authors.affiliation: Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan.|National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Shou-Dong
authors.initials: SD
authors.lastname: Lee
keywords: Ascites; Hepatocellular carcinoma; Liver cirrhosis; MELD