According to the 2017 Centers for Disease Control (CDC) national vital statistics, cirrhosis is the 10th leading cause of death in the United States with greater than 40,000 deaths per year . Mortality due to chronic liver disease continues to be on the rise, especially in those patients with alcoholic cirrhosis [2, 3]. In the United States, there was a 65% increase in cirrhosis deaths from 1999 to 2016 from approximately 20,000 to 34,000 . Approximately .3% (.27) of the population are affected by cirrhosis, with a greater incidence in non-Hispanic African Americans, Mexican Americans, and Native Americans seeing the highest rates [3, 4]. Many patients may remain undiagnosed meaning the prevalence may be even higher in certain populations and communities [4, 5, 6].
Cirrhosis places a serious economic burden on patients [7, 8]. The main financial burden of cirrhosis specifically was $7.37 billion based off the National Inpatient Sample (NIS) database . Major etiologies include hepatitis B and C infections, alcohol abuse, and nonalcoholic steatohepatitis (NASH) . The presence of cirrhosis and its comorbidities has further driven the increase in financial hardships . Because of advances in pharmacotherapy and surgical intervention, the cost continues to rise . The main drivers for increased cost are due to three procedural complications: mechanical ventilation, non-red blood cell transfusions, and hemodialysis . Other complications associated with cirrhosis include acute kidney injury (AKI), infection, non-pulmonary hypertension, gastrointestinal (GI) bleed, ascites, hepatorenal syndrome, variceal bleeding, hepatocellular carcinoma, hepatic encephalopathy, hyponatremia, malnutrition, and spontaneous bacterial peritonitis . Complications frequently include portal hypertension, which in turn may result in ascites, varices, and hepatic hydrothorax [9, 11, 12, 13]. As longevity is increased with improving therapy, unfortunately so does the economic and financial burden [9, 14].
Ascites associated with cirrhosis is the abnormal accumulation of transudative fluid in the peritoneal cavity due to portal hypertension. It is one of the main complications of cirrhosis which causes increased portal hypertension resulting in decreased hepatic perfusion [11, 13]. Ascites is a poor prognostic indicator with a 15% mortality rate 1-year after first presentation and 44% mortality rate at 5-years after first presentation . Ascites is considered refractory upon recurrence after paracentesis or when no longer tolerant or responsive to sodium restriction or diuretic therapy [11, 16]. Treatment usually consists of routine paracentesis, pharmacotherapy, diet modulations, or TIPS [13, 16].
TIPS is an image-guided endovascular procedure which bypasses blood flow from the portal venous system to the hepatic venous system, thus creating a new passage for venous blood flow. This interventional therapy is used to decrease portal venous and mesenteric venous pressure. These increased pressures may consequentially lead to bleeding varices, ascites, and other gastroenterological complications . TIPS is used for control of ascites symptoms and has been shown to resolve ascites in 60–70% of patients, effectively reducing the need for serial paracentesis [11, 17, 18, 19]. TIPS offers superior control compared to large volume paracentesis (LVP) in the management of refractory ascites and may also improve survival [20, 21, 22]. Mean hospital stays were also decreased in those with TIPS with an average of 17 days compared to those with LVP at 35 days .
The purpose of our study was to investigate whether TIPS placement reduced the time between paracenteses, reduced the number of hospitalizations due to hepatic encephalopathy (HE), spontaneous bacterial peritonitis, and gastroesophageal variceal bleeding in patients with refractory ascites due to end-stage liver disease.