Reply: Targeted decrease of portal hepatic pressure gradient immediately after TIPS improves ascites control and prognosis

We appreciate the interest of Tantai and colleagues in our work and share their aim to highlight the lack of guidance for targeted PPG for refractory ascites, which we addressed in our recent study published in Hepatology.1 We fully agree that studies are warranted to validate different etiologies of liver cirrhosis. However, in Germany and most western countries, alcohol-associated liver disease is still the leading cause of liver cirrhosis.2,3 The colleagues raised concerns about censored patients within a 6-week follow-up and suggested stratification of patients by PPG with survival as a direct endpoint. Since our study had ascites response as the primary outcome, all patients without information on paracentesis (n=19) had to be censored and we performed landmark analyses, which revealed targeted PPG reduction as a predictor for the outcome. Indeed, the survival analyses in our cohort suggests a significant association of ascites response with survival showing the lowest survival in patients with a continued need for paracentesis after TIPS. The best survival was observed in patients with ascites resolution after TIPS. Therefore, our study has a completely different and clinically more relevant focus in providing practical guidance for post-TIPS PPG in daily practice. However, despite the different focus, our data strongly suggests a significant association between PPG reduction, ascites response and survival in patients with recurrent and refractory ascites. Nevertheless, this discussion stimulated us to perform competing risk analysis for ascites response with death and liver transplantation as competing events, since 35 and 4 patients were censored for death and liver transplantation, respectively even before the 6 weeks. Indeed, our competing risk analysis adjusted for white blood cell count, Child-Pugh score and serum sodium confirmed our previous results of targeted PPG reduction as independent predictor of post-TIPS ascites response (HR=0.782, p=0.0151). Therefore, we are confident that the targeted pressure reduction provides robust clinical guidance for sufficient post-TIPS ascites response.