Ostojic A, Petrovic I, Silovski H, Kosuta I, Sremac M, Mrzljak A. Approach to persistent ascites after liver transplantation. World J Hepatol 2022; 14(9): 1739-1746 [PMID: 36185723 DOI: 10.4254/wjh.v14.i9.1739]
Corresponding Author of This Article
Anna Mrzljak, FEBG, PhD, Associate Professor, Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Kišpatićeva ulica 12, Zagreb 10000, Croatia. anna.mrzljak@gmail.com
Research Domain of This Article
Transplantation
Article-Type of This Article
Minireviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Hepatol. Sep 27, 2022; 14(9): 1739-1746 Published online Sep 27, 2022. doi: 10.4254/wjh.v14.i9.1739
Approach to persistent ascites after liver transplantation
Ana Ostojic, Igor Petrovic, Hrvoje Silovski, Iva Kosuta, Maja Sremac, Anna Mrzljak
Ana Ostojic, Maja Sremac, Anna Mrzljak, Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Zagreb 10000, Croatia
Igor Petrovic, Hrvoje Silovski, Department of Hepatobiliary Surgery and Transplantation, University Hospital Center Zagreb, Zagreb 10000, Croatia
Iva Kosuta, Department of Intensive Care Medicine, University Hospital Center Zagreb, Zagreb 10000, Croatia
Author contributions: Ostojic A contributed to the literature review, analysis, and interpretation of the data, drafting of the initial manuscript, and final approval of the manuscript; Petrovic I, Silovski H, Kosuta I, and Sremac M contributed to the analysis and interpretation of the data, and final approval of the manuscript; Mrzljak A contributed to the conception and design of the manuscript, critical revised the initial manuscript, and approved the final manuscript.
Supported bythe Croatian Science Foundation, Emerging and Neglected Hepatotropic Viruses after Solid Organ and Hematopoietic Stem Cell Transplantation (to Mrzljak A), No. IP-2020-02-7407.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Anna Mrzljak, FEBG, PhD, Associate Professor, Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Kišpatićeva ulica 12, Zagreb 10000, Croatia. anna.mrzljak@gmail.com
Received: July 6, 2022 Peer-review started: July 6, 2022 First decision: July 28, 2022 Revised: August 8, 2022 Accepted: September 2, 2022 Article in press: September 2, 2022 Published online: September 27, 2022
Abstract
Persistent ascites (PA) after liver transplantation (LT), commonly defined as ascites lasting more than 4 wk after LT, can be expected in up to 7% of patients. Despite being relatively rare, it is associated with worse clinical outcomes, including higher 1-year mortality. The cause of PA can be divided into vascular, hepatic, or extrahepatic. Vascular causes of PA include hepatic outflow and inflow obstructions, which are usually successfully treated. Regarding modifiable hepatic causes, recurrent hepatitis C and acute cellular rejection are the leading ones. Considering predictors for PA, the presence of ascites, refractory ascites, hepato-renal syndrome type 1, spontaneous bacterial peritonitis, hepatic encephalopathy, and prolonged ischemic time significantly influence the development of PA after LT. The initial approach to patients with PA should be to diagnose the treatable cause of PA. The stepwise approach in evaluating PA includes diagnostic paracentesis, ultrasound with Doppler, and an echocardiogram when a cardiac cause is suspected. Finally, a percutaneous or transjugular liver biopsy should be performed in cases where the diagnosis is unclear. PA of unknown cause should be treated with diuretics and paracentesis, while transjugular intrahepatic portosystemic shunt and splenic artery embolization are treatment methods in patients with refractory ascites after LT.
Core Tip: Despite being relatively rare, persistent ascites after liver transplantation is associated with worse clinical outcomes. Therefore, it is of primary concern to promptly diagnose and treat modifiable causes of ascites. Early evaluation should include ultrasound with Doppler and diagnostic paracentesis. Common treatable causes include hepatic inflow and outflow obstruction, recurrent hepatitis C infection, and acute cellular rejection. Ascites of unknown cause should be treated with diuretics and paracentesis, while transjugular intrahepatic portosystemic shunt and splenic artery embolization can be used in patients with refractory ascites. The latter option represents a novel treatment modality with promising results.
