A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites

Background: In patients with cirrhosis and ascites, creation of a transjugu lar intrahepatic portosystemic shunt may reduce the ascites and improve ren al function. However, the benefit of this procedure as compared with that o f large-volume paracentesis is uncertain. Methods: We randomly assigned 60 patients with cirrhosis and refractory or recurrent ascites (Child-Pugh class B in 42 patients and class C in 18 pati ents) to treatment with a transjugular shunt (29 patients) or large-volume paracentesis (31 patients). The mean (+/-SD) duration of follow-up was 45+/ -16 months among those assigned to shunting and 44+/-18 months among those assigned to paracentesis. The primary outcome was survival without liver tr ansplantation. Results: Among the patients in the shunt group, 15 died and 1 underwent liv er transplantation during the study period, as compared with 23 patients an d 2 patients, respectively, in the paracentesis group. The probability of s urvival without liver transplantation was 69 percent at one year and 58 per cent at two years in the shunt group, as compared with 52 percent and 32 pe rcent in the paracentesis group (P=0.11 for the overall comparison, by the log-rank test). In a multivariate analysis, treatment with transjugular shu nting was independently associated with survival without the need for trans plantation (P=0.02). At three months, 61 percent of the patients in the shu nt group and 18 percent of those in the paracentesis group had no ascites ( P=0.006). The frequency of hepatic encephalopathy was similar in the two gr oups. Of the patients assigned to paracentesis in whom this procedure was u nsuccessful, 10 received a transjugular shunt a mean of 5.5+/-4 months afte r randomization; 4 had a response to this rescue treatment. Conclusions: In comparison with large-volume paracentesis, the creation of a transjugular intrahepatic portosystemic shunt can improve the chance of s urvival without liver transplantation in patients with refractory or recurr ent ascites. (N Engl J Med 2000;342:1701-7.) (C) 2000, Massachusetts Medica l Society.