TIPS versus paracentesis for cirrhotic patients with refractory ascites

  • Review
  • Intervention

Authors


Abstract

Background

Refractory ascites (ie, ascites that cannot be mobilized despite sodium restriction and diuretic treatment) occurs in 10 per cent of patients with cirrhosis. It is associated with substantial morbidity and mortality with a one-year survival rate of less than 50 per cent. Few therapeutic options currently exist for the management of refractory ascites.

Objectives

To compare transjugular intrahepatic portosystemic stent-shunts (TIPS) versus paracentesis for the treatment of refractory ascites in patients with cirrhosis.

Search methods

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (January 2006), the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2005), MEDLINE (1950 to January 2006), EMBASE (1980 to January 2006), CINAHL (1982 to August 2004), and Science Citation Index Expanded (1945 to January 2006).

Selection criteria

We included randomised clinical trials comparing TIPS and paracentesis with or without volume expanders for cirrhotic patients with refractory ascites.

Data collection and analysis

We evaluated the methodological quality of the randomised clinical trials by the generation of the allocation section, allocation concealment, and follow-up. Two authors independently extracted data from each trial. We contacted trial authors for additional information. Dichotomous outcomes were reported as odds ratio (OR) with 95% confidence interval (CI).

Main results

Five randomised clinical trials, including 330 patients, met the inclusion criteria. The majority of trials had adequate allocation concealment, but only one employed blinded outcome assessment. Mortality at 30-days (OR 1.00, 95% CI 0.10 to 10.06, P = 1.0) and 24-months (OR 1.29, 95% CI 0.65 to 2.56, P = 0.5) did not differ significantly between TIPS and paracentesis. Transjugular intrahepatic portosystemic stent-shunts significantly reduced the re-accumulation of ascites at 3-months (OR 0.07, 95% CI 0.03 to 0.18, P < 0.01) and 12-months (OR 0.14, 95% CI 0.06 to 0.28, P < 0.01). Hepatic encephalopathy occurred significantly more often in the TIPS group (OR 2.24, 95% CI 1.39 to 3.6, P < 0.01), but gastrointestinal bleeding, infection, and acute renal failure did not differ significantly between the two groups.

Authors' conclusions

The meta-analysis supports that TIPS was more effective at removing ascites as compared with paracentesis without a significant difference in mortality, gastrointestinal bleeding, infection, and acute renal failure. However, TIPS patients develop hepatic encephalopathy significantly more often.

摘要

背景

TIPS對照腹水穿刺術用以治療肝硬化病人併發難治性腹水的比較

10%的肝硬化病人都會出現難治性腹水(例如,即使限制鈉和利尿劑治療,仍無法使腹水移出) 。一般和持續發病率和死亡相關,1年的存活率小於50%。目前還沒有控制難治性腹水的治療選擇仍很少。

目標

比較經頸內靜脈肝內門體靜脈分流術(TIPS)對照腹水穿刺術用以治療肝硬化病人併發難治性腹水的比較。

搜尋策略

我們搜尋The Cochrane HepatoBiliary Group Controlled Trials Register (2006年1月), Cochrane Library (2005年第4期)的Cochrane Central Register of Controlled Trials, MEDLINE (1950年 2006年1月)、EMBASE (1980年 2006年1月)、CINAHL (1982年 2004年8月)和Science Citation Index Expanded (1945年 2006年1月)。

選擇標準

我們收納比較TIPS及腹水穿刺術搭配或不搭配容量擴張劑,用以治療肝硬化病人併發難治性腹水的隨機臨床試驗。

資料收集與分析

我們從分配順序的生成,分配方案的隱藏和後續追蹤以評估隨機臨床試驗的研究方法品質。兩位作者單獨從每次試驗摘錄數據。我們聯繫作者,尋找更多的資訊。 二分法結果以勝算比 (odds ratio,OR),95% 信賴區間 (CI)呈現。

主要結論

共有5個隨機臨床試驗符合收錄標準,包括330 位病人。多數試驗的分配隱藏屬於恰當,但是只有一個試驗使用盲法結果評估。TIPS和穿刺術在第30天的死亡率(OR 1.00, 95% CI 0.10 10.06, P = 1.0)和第24個月的死亡率(OR 1.29, 95% CI 0.65 2.56, P = 0.5) 沒有顯著差異。TIPS使得腹水的再聚集率在3個月(OR 0.07, 95% CI 0.03 0.18, P < 0.01)和24個月(OR 0.14, 95% CI 0.06 −0.28, P < 0.01)明顯降低。TIPS組的肝性腦病變明顯較多 (OR 2.24, 95% CI 1.39 −3.6, P < 0.01), 但是兩組在胃腸出血、感染、急性腎衰竭上沒有顯著差異。

作者結論

和穿刺術相比,統合分析支持TIPS更能有效治療腹水,在死亡率、胃腸出血、感染和急性腎衰竭方面,兩者沒有顯著差異。 但是,TIPS病人明顯經常患有肝性腦病變。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

難治性腹水的病人會暫時從經頸內靜脈肝內門體靜脈分流術中受益。 難治性腹水造成肝硬化病人的發病率很高。隨機試驗比較經頸內靜脈肝內門體靜脈分流術和腹水穿刺術。兩組在死亡率, 胃腸出血,腎衰竭,感染等方面沒有顯著差異。經頸內靜脈肝內門體靜脈分流術有效降低腹水再聚集的風險,但是和肝性腦病變增加的風險有關。

Plain language summary

Patients with refractory ascites may temporarily benefit from transjugular intrahepatic portosystemic stent-shunts

Refractory ascites causes substantial morbidity in patients with cirrhosis. Randomised trials have compared transjugular intrahepatic portosystemic stent-shunts with paracentesis. Mortality, gastrointestinal bleeding, renal failure, or infection did not differ significantly between the two intervention groups. Transjugular intrahepatic portosystemic stent-shunts effectively decreased the risk of ascites fluid re-accumulation, but was associated with an increased risk of hepatic encephalopathy.

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