A meta-analysis of transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites

Background/Aims Meta-analysis designed to provide evidence-based guidance on the effect of TIPS and paracentesis on mortality and encephalopathy in cirrhotic patients with refractory ascites. Methods Five randomized trials published between 1989 and 2005 were identified. Results The five trials involved 330 patients, and none included patients >76 years, with bilirubin >5–10 mg/dl or creatinine >3 mg/dl. Ascites recurrence was lower in the TIPS arm (RR 0.56; 95% CI 0.47–0.66). TIPS was associated with a greater risk of encephalopathy (RR 1.36; 95% CI 1.1–1.68) and severe encephalopathy (RR 1.72; 95% CI 1.14–2.58). TIPS did not affect mortality, as estimated by the RR (0.93; 95% CI 0.67–1.28, random effect model) and pooled hazard ratio (RR 1.09; 95% CI 0.84–1.88). Analysis of this outcome measure was limited by significant heterogeneity among trials. Liver-related mortality was homogenous and similar in both arms. Results were unaffected by excluding trials of lower quality or with a greater number of alcoholics. Meta-analysis of trials including patients with recidivant ascites revealed a lower mortality in the TIPS arm (RR 0.68; 95% CI 0.49–0.93). Conclusions In patients with refractory ascites, a better control of ascites by TIPS does not translate into improved survival and worsens encephalopathy.