A retrospective evaluation of the effectiveness and safety of palliative long-term abdominal drains for the management of refractory ascites in patients with end stage liver disease, in comparison with large volume paracentesis

Introduction

Patients with end-stage liver disease (ESLD) and refractory ascites (RA) have a median transplant-free survival of 6 months. Large volume paracentesis (LVP) is the first-line treatment recommended by the current guidelines, but it results in frequent hospital visits and poor quality of life. Long-term abdominal drains (LTAD) are a cost-effective measure to manage malignant ascites in the community, but their use as a palliative measure in ESLD and RA is currently not routine practice.

Aim

We aimed to retrospectively evaluate the effectiveness and safety of LTAD in palliative patients with ESLD and RA followed-up at our UK tertiary centre between 2018 and 2022 in comparison with a group of palliative patients with ESLD undergoing regular LVP with albumin infusion. The endpoints of this study were survival rate and the incidence of peritonitis, acute kidney injury (AKI), drain-related complications and relevant hospitalisations.

Methods

Data were collected retrospectively from patients’ electronic health records. Patients were censored at death or last encounter, in case they were lost to follow up. Fisher’s Exact test and Mann-Whitney U test were used to compare qualitative and quantitative variables, respectively. Significance was set at p < 0.05. Kaplan-Meier survival estimate curves were generated to stratify outcomes according to type of drainage.

Results

Thirty patients had LTAD (total of 35 drains, draining between 1 and 2 litres per week) and 19 patients underwent regular LVP with a median drain frequency 21 days. There were no perioperative complications after the insertion of LTAD. Drain displacement occurred in 4 cases (11%), catheter blockage in 2 cases (6%). Symptomatic relief of shortness of breath and abdominal pain was seen in 70% of cases and anorexia in 50% of patients following LTAD placement. Median follow-up (with LTAD in place or undergoing LVP), age, Child-Pugh score, liver disease aetiology, baseline renal function, ascitic protein, and the presence of hepatocellular carcinoma were not significantly different between the LTAD and LVP cohort. Prophylactic antibiotics were more frequently prescribed in the patients with LTAD (p=0.012), but the incidence of peritonitis did not differ between the two groups (p = 0.46). Despite a similar use of diuretics, the incidence of AKI was significantly higher in the LVP group (p=0.014). Furthermore, ascites/drain-related hospital admissions occurred more frequently in the LVP cohort (p=0.004). Overall survival was similar in the two groups (log-rank p = 0.71). Endpoint-free survival was significantly shorter in the LVP group (p=0.004, p<0.001, p=0.018 for first ascites/drain-related hospitalisation, AKI and drain-related complications, respectively (figure 1).

Conclusions

The use of LTAD for the management of RA in palliative patients with ESLD is effective and relatively safe compared to LVP, and may reduce hospital admissions and health resource utilisation. A randomised controlled trial comparing LVP and LTAD is currently recruiting in the UK, to confirm these retrospective findings.

References

European Association for the Study of the Liver. J Hepatol. 2018 Aug;69(2):406–60. Hudson B, et al. Lancet Gastroenterol Hepatol. 2018 Feb;3(2):95–103. Fleming ND, et al. J Pain Symptom Manage. 2009 Sep;38(3):341–9. Macken L, et al. Aliment Pharmacol Ther. 2020 Jul;52(1):107–22.