Critical commentary on the study comparing TIPS, tunneled peritoneal catheter, and ascites pump in refractory ascites

To the editor, The study by Schütte et al1 compared clinical outcomes among patients with refractory ascites treated with TIPS, tunneled peritoneal catheter (PeCa), or an ascites pump. While clinically relevant, this retrospective study has limitations, including selection bias, small sample sizes, and insufficient consideration of long-term functional and quality-of-life outcomes. A major limitation is the study’s retrospective design, which introduces inherent biases. Patients with contraindications for TIPS were placed in the PeCa and ascites pump groups, likely affecting comparability due to worse liver function and higher morbidity in these patients. Although propensity score matching was used, residual bias remains a concern. A prospective randomized controlled trial would provide more reliable results. Treatment allocation based on clinical judgment rather than a standardized protocol may have led to confounding by indication. For example, patients unfit for TIPS may have had underlying comorbidities influencing their outcomes independently of the treatment. The sample size, though large overall (918 patients), had small subgroups, particularly in the ascites pump group (31 vs. 62 for PeCa, and 35 vs. 70 for TIPS). This reduced statistical power and increased the risk of both type I and type II errors. The HRs for key outcomes, like acute kidney injury and peritonitis, had wide CIs, limiting precision. A larger sample would have provided more reliable estimates. The study also lacked sensitivity analyses and did not report handling of missing data, which could introduce bias. A critical omission is the lack of data on HE, a known complication of TIPS. While TIPS reduces ascites by lowering portal pressure, it increases the risk of HE due to portosystemic shunting. Up to 50% of TIPS patients develop HE, significantly impacting quality of life and long-term prognosis.2 Excluding this outcome limits the clinical applicability of the findings. The study reports a higher incidence of peritonitis in PeCa patients compared to the ascites pump group but lacks details on catheter care, patient adherence, or healthcare access, all factors influencing infection rates. Although microbial culture data are provided, antimicrobial resistance patterns or treatment outcomes were not discussed, a missed opportunity given the concern of multidrug-resistant organisms in cirrhotic patients.3 The study focuses on 1-year mortality and complications but omits long-term survival, functional status, and patient-reported outcomes, which are crucial for determining the best management approach, particularly for patients ineligible for liver transplantation. Previous research suggests that quality of life and nutritional status improve after TIPS compared to repeated paracentesis,4 but this was not addressed. In conclusion, Schütte et al1 provide valuable insights into refractory ascites management, but their study’s limitations, including its retrospective design, selection bias, small sample sizes, and omission of key outcomes like HE and quality of life, should be considered. Future research should focus on prospective randomized controlled trials with larger cohorts and comprehensive outcome assessments. Until then, clinicians should interpret these findings with caution when selecting refractory ascites treatment strategies.