Transjugular Intrahepatic Portosystemic Shunt (TIPS) as possible therapeutic strategy for refractory ascites with early-onset after liver transplantation

Background

Early-onset ascites after liver transplantation (LT) is an uncommon complication, affecting approximately 6% of LT recipients. It is primarily associated with vascular complications, acute cellular rejection, and, historically, with early hepatitis C recurrence. The incidence and natural history of post-LT ascites in the modern era remain poorly characterized, and current diagnostic and therapeutic approaches are not well defined. While transjugular intrahepatic portosystemic shunt (TIPS) is a standard therapy for refractory ascites in cirrhosis, its role in the post-LT setting is less well established.

Aim

To evaluate the clinical characteristics and outcomes of LT recipients treated with TIPS for early post-LT ascites.

Methods

We conducted a retrospective, descriptive study of adult LT recipients who developed early-onset ascites, defined as ascites requiring paracentesis and persisting beyond 6 months, and subsequently underwent TIPS placement at our center between January 2016 and May 2025. Data collected included pre-LT characteristics, surgical details, etiology of ascites based on histological and hemodynamic findings, and TIPS procedural information. Clinical outcomes included periprocedural complication, ascites resolution within 3 months post-TIPS placement and graft and patient survival.

Results

During the study period 1080 patients received LT and a total of 10 (0,9%) patients underwent TIPS placement for early-onset ascites post-LT (6, [60%] male with median age 60 [IQR 50-62]). Main indication to LT was hepatocellular carcinoma (6, 60%) with a median Model of End Stage Liver Disease (MELD)-Na of 10 (IQR 8-22). Only two (20%) patients had ascites pre-LT. They mostly received donation after brain death donors (6, 60%) and all underwent caval anastomosis through piggy-back technique. Hemodynamic study and transjugular liver biopsy were performed in all the patients. Mean hepatic venous pressure gradient was 11 (IQR 6-16) mmHg, whereas a pathological gradient between hepatic vein and right atrium was found in 8 (80%) cases. Consistently, liver biopsy revealed features of hepatic venous outflow obstruction in 6 patients (60%), and signs of acute rejection in 6 (60%) as well, with overlapping findings in some cases. Mean interval time between LT and TIPS was 72 (IQR 47-88) days with mean portal pressure gradient of 7 (IQR 5-8) mmHg. All the procedure were technically feasible. Three patients (30%) showed a transient elevation in bilirubin and transaminases, of whom only one patient showed radiological feature of ischemic hepatitis. Other minor complications included a case of acute kidney injury and indirect hyperbilirubinemia due to intra-shunt hemolysis. All the condition were self-limiting. Early clinical success in resolving ascites was achieved in 8 out of 10 patients (80%). After a median follow-up of 25 (IQR 5-53) months one patients died for extrahepatic cancer. All the patients resolved ascites; however, 4 (40%) patients experienced at least one episode of hepatic encephalopathy post TIPS.

Conclusions

TIPS appears feasible and potentially effective for managing early-onset ascites post-LT with early clinical success and with manageable complications. Long term outcomes can potentially be affected by the occurrence of hepatic encephalopathy. Further studies are needed to confirm these findings, refine selection criteria and optimize preventive strategy in long term follow-up, but the favorable outcomes observed in our cohort highlight its potential clinical benefit.