Abstract. Peritoneovenous shunt is normally used for the treatment of refractory ascites. However, its efficacy in treating tolvaptan-resistant refractory ascites has not been reported thus far. In addition, the impact of peritoneovenous shunt on the prognosis of cirrhotic patients remains controversial. In the present report, a case of tolvaptan-resistant refractory ascites associated with liver cirrhosis and portal vein thrombosis is described. The male patient was diagnosed with hepatitis C virus-related liver cirrhosis at the age of 51 years. At the age of 56 years, the patient developed portal vein thrombosis, resulting in the development of refractory ascites. Since the ascites was resistant to treatment with a low-sodium diet and diuretics such as tolvaptan, a peritoneovenous shunt was implanted upon obtaining consent. The shunt immediately increased the urine volume, and the ascites was markedly decreased. The patient's body weight decreased from 62.7 to 57.1 kg in 2 days, and his ascites symptom inventory-7 score decreased from 23 to 0 points in 31 days. Although the patient succumbed to sepsis on day 486 following the shunt implant, his activities of daily living were preserved until 8 days prior to mortality. Thus, the present case supports the efficacy of peritoneovenous shunt for the treatment of tolvaptan-resistant refractory ascites associated with liver cirrhosis and portal vein thrombosis. Furthermore, the present case suggests that peritoneovenous shunt may prolong the survival of cirrhotic patents with refractory ascites.
IntroductionAscites that does not resolve with standard medical treatment such a low-sodium diet and diuretics is known as refractory ascites, and is frequently associated with the development of hepatorenal syndrome, spontaneous bacterial peritonitis and dilutional hyponatremia (1). Refractory ascites also causes a loss of appetite and muscle wasting, and impairs the activities of daily living (ADL) (1). Thus, refractory ascites is a life-threatening complication that lowers the quality of life of cirrhotic patients, and is an independent predictor of short survival (1,2).One of the main reasons for cirrhosis-related water retention is a reduced ability of the kidneys to excrete electrolyte-free water, due to an increase in the levels of arginine vasopressin (3). Arginine vasopressin receptor antagonists, a novel class of diuretics, have been recently approved for the treatment of cirrhosis-related fluid retention in Japan (3,4). These diuretics antagonize vasopressin V2 receptors, resulting in the inhibition of electrolyte-free water reabsorption and an increase in electrolyte-free water excretion (5). Tolvaptan, a vasopressin V2 receptor antagonist, improves hepatic edema and reduces ascites in cirrhotic patients (6,7). However, tolvaptan may not always be effective for treating refractory ascites, since there are various mechanisms involved in the development of this condition (1,8).Peritoneovenous shunt was designed to transport ascites from the peritoneal cavity back in...
