Refractory Ascites and the Alfapump

Ascites is often the first decompensation in patients with cirrhosis and is associated with reduced survival. The formation of ascites is complex and thought to be due to an increase in hydrostatic pressure, a decrease in oncotic pressure, and increased lymph production. Standard of care for ascites includes dietary sodium restriction, use of loop diuretics and aldosterone antagonists, large-volume paracentesis (LVP), and at times transjugular intrahepatic portosystemic shunt (TIPS). Alfapump was designed in response to the need for alternative treatments for patients with refractory ascites, particularly in those who are ineligible for TIPS. The initial PIONEER trial conducted in Europe demonstrated the benefit of Alfapump with reduced need for LVP and ultimately led to the commercial launch of the pump in Europe in 2012. The MOSAIC and POSEIDON trials not only proved the efficacy of the Alfapump but also provided an alternative to surgery by performing pump implantation with interventional radiology. While the benefit with reduced need for LVP has been shown in multiple studies, the risk of renal impairment and infections such as peritonitis have also been observed. The renal injury mostly responds to albumin, which should be considered in certain cases. The infection risk is mitigated with antibiotic prophylaxis and early treatment of confirmed infections. Consensus recommendations from Europe have also helped with best practices in patients with the pump. Premarket approval was granted by the Food and Drug Administration for the use of Alfapump in patients with cirrhosis and refractory or recurrent ascites in December 2024. In the United States, Alfapump may be a good alternative for cirrhotic patients with refractory ascites who are ineligible for TIPS and potentially as a bridge to liver transplantation.