Transjugular Hepatic Venous Pressure Assessment and Mortality Risk in Patients with End-Stage Renal Disease Presenting with Non-Cirrhotic Ascites

Patients with end-stage renal disease (ESRD) maintained on hemodialysis who develop ascites are presumed to have underlying cirrhosis with portal hypertension; however, in many cases they do not have chronic liver disease and are considered to have nephrogenic ascites. Nephrogenic ascites in patients on hemodialysis may in fact be cardiogenic as a consequence of high-flow arteriovenous fistulas, although reports and characterization of this clinical presentation are limited. Retrospective cohort study of patients with ESRD on hemodialysis who presented with new onset ascites from 2011 to 2018 in a large tertiary care hepatology practice affiliated with a liver transplant program. Patients were evaluated with echocardiography, transjugular liver biopsy with hepatic venous pressure gradient (HVPG), and analysis of peritoneal fluid. Patients with intra-abdominal malignancy or infection were excluded. In patients with ESRD presenting with non-cirrhotic ascites, right-sided heart failure with passive hepatic congestion may be a major cause of ascites and mortality. Further study of the cardiovascular effects of hemodialysis in this population, including attention to high-output heart failure and arteriovenous fistula hemodynamics, may be important in defining risk and management strategies.