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. 2025 Jan 23;7(7):101335.
doi: 10.1016/j.jhepr.2025.101335. eCollection 2025 Jul.

Minimal residual ascites 3 months after TIPS implantation implicates worse clinical outcomes in patients with cirrhosis

Jim Benjamin Mauz  1 , Lukas Hartl  2   3 , Andrea Kornfehl  2 , Sarah Lisa Schütte  1 , Paul Hemetsberger  2 , Theresa Müllner-Bucsics  2   3 , Mathias Jachs  2   3 , Anja Tiede  1   4 , Hannah Rieland  1 , Michael Schwarz  2   3 , Nina Dominik  2   3 , Georg Kramer  2   3 , Bernhard Meyer  5 , Lukas Reider  6 , Michael Trauner  2 , Heiner Wedemeyer  1   4 , Mattias Mandorfer  2   3 , Benjamin Maasoumy  1   4 , Thomas Reiberger  2   3   7 , Tammo Lambert Tergast  1   2   3
Affiliations

Minimal residual ascites 3 months after TIPS implantation implicates worse clinical outcomes in patients with cirrhosis

Jim Benjamin Mauz et al. JHEP Rep. .

Abstract

Background & aims: Transjugular intrahepatic portosystemic shunt (TIPS) implantation is indicated for recurrent/refractory ascites in patients with cirrhosis. The prognostic impact of residual minimal ascites after TIPS implantation has not yet been investigated.

Methods: We included patients with cirrhosis undergoing covered TIPS implantation for refractory ascites in Vienna (2000-2022) and Hannover (2009-2021) with available abdominal ultrasound 3 months after TIPS insertion (3M). The patients were followed up for further decompensation and transplant-free mortality. Two distinct competing risk regression models (Adjusted model I and Adjusted model II) were performed to determine the prognostic impact of no vs. minimal ascites at 3M.

Results: Overall, 292 patients with male predominance (71.7%) and mostly alcohol-related liver disease (71.7%) were included. At 3M, n = 105 (36.0%) patients showed no ascites on abdominal ultrasound, whereas n = 82 (28.1%) exhibited minimal and n = 105 (36.0%) moderate/severe ascites. The portal pressure gradient after TIPS implantation was similar in the three groups (median 7 mmHg; p = 0.311). Patients with no or minimal ascites had comparable Model for End-Stage Liver Disease and Freiburg Index of Post-TIPS Survival scores at baseline and 3M. Competing risk regression models showed that minimal ascites (vs. no ascites) was an independent predictor of further decompensation (Adjusted model I: adjusted subdistribution hazard ratio [aSHR], 1.69; 95% CI, 1.03-2.77; p = 0.038; Adjusted model II: aSHR, 1.76; 95% CI, 1.07-2.88; p = 0.026) and transplant-free mortality (Adjusted model I: aSHR, 1.76; 95% CI, 1.08-2.88; p = 0.024; Adjusted model II: aSHR, 1.73; 95% CI, 1.05-2.82; p = 0.030).

Conclusions: Patients with residual minimal ascites at 3M remain at higher risk for further decompensation and transplant-free mortality compared with those with no residual ascites.

Impact and implications: This study evaluated the prognostic relevance of residual ascites grades in patients with advanced chronic liver disease after TIPS placement. Severe ascites was linked to the worst outcomes, underscoring the need for urgent liver transplantation evaluation. However, even minimal residual ascites significantly increased the risk of further decompensation and transplant-free mortality. These findings suggest that patients with minimal residual ascites will benefit from enhanced post-TIPS clinical monitoring. Further research is warranted to uncover the underlying mechanisms and investigate the potential of targeted interventions to improve outcomes in this vulnerable group.

Keywords: Ascites; Cirrhosis; Portal hypertension; Transjugular intrahepatic portosystemic shunt.

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Conflict of interest statement

Given their role as Associate Editor of this journal, MM had no involvement in the peer-review of this article and had no access to information regarding its peer-review. Full responsibility for the editorial process for this article was delegated to the Co-Editor of the journal, Virginia Hernández-Gea. BM reports lecture and/or consultant fees from AbbVie, Astella, BMS, Falk, Fujirebio, Gilead, Luvos, MSD, Norgine, Roche, and W.L. Gore & Associates. He also received research support from Altona, EWIMED, Fujirebio, and Roche. MS received travel support from MSD, Sandoz, BMS, AbbVie, and Gilead, and speaking honoraria from BMS and Gilead. MT received research grants, travel grants, speaker fees, and advised for Gilead Sciences; received consultancy fees from AbbVie, Albireo, Agomab, BiomX, Boehringer Ingelheim, Chemomab, Falk, Glaxo Smith Kline, Genfit, Hightide, Intercept, Ipsen, Jannsen, Mirum, MSD, Novartis, Pliant, Regulus, Siemens, and Shire; research funding from Albireo, Alnylam, Cymabay, Falk, Intercept, MSD, Takeda, and UltraGenyx; travel grants from AbbVie, Falk, Intercept, and Jannsen; speaker fees from Albireo, BMS, Falk, Intercept, Ipsen, MSD, and Madrigal; the Medical Universities of Graz and Vienna have filed patents on medical use of NorUDCA, on which MT is listed as a co-inventor. HW has received fees for lectures and/or consultations from AbbVie, Aligos, Altimmune, Biotest, BMS, BTG, Dicerna, Enanta, Gilead, Janssen, Merck/MSD, MYR GmbH, Roche, and Vir Biotechnology. TR served as a speaker and/or consultant and/or advisory board member for AbbVie, Bayer, Boehringer Ingelheim, Gilead, Intercept, MSD, Siemens, and W.L. Gore & Associates, and received grants/research support from AbbVie, Boehringer Ingelheim, Gilead, Intercept, MSD, Myr Pharmaceuticals, Pliant, Philips, Siemens, and W.L. Gore & Associates, as well as travel support from AbbVie, Boehringer Ingelheim, Gilead, and Roche. JM and LH declare no conflicts of interest. Please refer to the accompanying ICMJE disclosure forms for further details.

Figures

Image 1
Graphical abstract
Fig. 1
Fig. 1
Patient selection and exclusion criteria. 3M, 3 months after TIPS insertion; TIPS, transjugular intrahepatic portosystemic shunt.
Fig. 2
Fig. 2
Cumulative incidence of transplant-free mortality in patients with no ascites, minimal ascites, and moderate/severe ascites 3 months after TIPS implantation. Liver transplantation was considered as a competing event. Cumulative incidences were compared using Grey’s test. Levels of significance: p = 0.007. 3M, 3 months after TIPS insertion; TIPS, transjugular intrahepatic portosystemic shunt.
Fig. 3
Fig. 3
sHR of univariable competing risk analysis compared with no ascites at 3M. (A) Further decompensation (sHR): moderate/severe ascites–minimal ascites at 3M, sHR vs. no ascites at 3M. (B) Death/LTx (sHR): moderate/severe ascites–minimal ascites at 3M, sHR vs. no ascites at 3M. 3M, 3 months after TIPS insertion; LTx, liver transplantation; sHR, subdistribution hazard ratio; TIPS, transjugular intrahepatic portosystemic shunt.
See this image and copyright information in PMC

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