Determinants of burnout among transplant surgeons: a national survey in the United States.

Burnout is a response to chronic strain within the workplace characterized by feelings of inefficacy (reduced personal accomplishment), cynicism (depersonalization) and emotional exhaustion. The purpose of this study was to report prevalence and explore organizational and interpersonal contributors of burnout in transplant surgeons. We performed a national cross-sectional survey of 218 transplant surgeons on sociodemographics, professional characteristics, frequency of difficult patient interactions and comfort in dealing with difficult patient interactions, decisional authority, psychological job demands, supervisor and coworker support, with burnout as the outcome. 40.1% reported high levels of emotional exhaustion, 17.1% reported high levels of depersonalization and 46.5% reported low personal accomplishment. Greater emotional exhaustion was predicted by lower decisional authority, higher psychological work demands, and lower coworker support. Greater discomfort with difficult patient interactions and lower coworker support predicted depersonalization. Lastly, lower decisional authority, lower coworker support, less frequent difficult patient interactions but greater discomfort with difficult patient interactions predicted lower personal accomplishment. The findings of this study show that unsupportive environments with little decisional control and high work-related demands contribute to the development of burnout in transplant surgeons. Implications for interventions aimed at prevention of burnout in transplant surgeons are discussed.

Compensating the transplant professional: time for a model change.

Compensation models for physicians are currently based primarily on the work relative value unit (wRVU) that rewards productivity by work volume. The value-based payment structure soon to be ushered in by the Centers for Medicare and Medicaid Services rewards clinical quality and outcomes. This has prompted changes in wRVU value for certain services that will result in reduced payment for specialty procedures such as transplantation. To maintain a stable and competent workforce and achieve alignment between clinical activity, growth imperatives, and cost effectiveness, compensation of transplant physicians must evolve toward a matrix of measures beyond the procedure-based activity. This personal viewpoint proposes a redesign of transplant physician compensation plans to include the "virtual RVU" to recognize and reward meaningful clinical integration defined as hospital-physician commitment to specified and measurable metrics for current non-RVU-producing activities. Transplantation has been a leader in public outcomes reporting and is well suited to meet the challenges ahead that can only be overcome with a tight collaboration and alignment between surgeons, other physicians, support staff, and their respective institution and leadership.

Clostridium difficile infection in liver transplant recipients: a retrospective study of rates, risk factors and outcomes.

Clostridium difficile infection (CDI) occurs in 3-7% of liver transplant recipients (LTR). However, few data exist on the recent epidemiology, predictors and outcomes of CDI in LTR. A cohort study was performed including LTR from 2000 to 2010 at a tertiary care hospital in Detroit. CDI was defined as diarrhea with a stool C. difficile positive test. Data analyzed included demographics, comorbidities, length of stay (LOS), severity of CDI, rates of recurrence (<12 weeks), relapse (<4 weeks) and overall mortality. Predictors of CDI were calculated using Cox proportional hazard model; 970 LTR were followed for years. Overall prevalence of CDI was 18.9%. Incidence of CDI within 1 year of transplant was 12.4%. Severe CDI occurred in 29.1%. CDI recurrence and relapse rates were 16.9% and 9.7%, respectively. Independent predictors of CDI were year of transplant (hazard ratio [HR] 1.137, 95% confidence interval [CI] 1.06-1.22; p < 0.001), white race (105/162 whites, HR 1.47, 95% CI 1.03-2.1; p = 0.035), Model for End-Stage Liver Disease score (HR 1.03, 95% CI 1.01-1.045, p = 0.003) and LOS (HR 1.01, 95% CI 1.005-1.02, p < 0.001). Significant mortality was observed among LTR with CDI compared to those without CDI (p = 0.003). We concluded that CDI is common among LTR and is associated with higher mortality.

Transplant organizational structures: viewpoints from established centers.

This personal viewpoint report summarizes the responses of a survey targeting established transplant programs with a structured framework, such as center, institute, or department, and stability of leadership to assure valuable experiential observations. The 18-item survey was sent to 20 US institutions that met inclusion criteria. The response rate was 100%. Seventeen institutions had a distinct transplant governance structure. A majority of respondents perceived that their type of transplant structure was associated with enhanced recognition within their institution (85%), improved regulatory compliance (85%), transplant volume growth (75%), improved quality outcomes (75%) and increased funding for transplant-related research (75%). The prevailing themes in respondents' remarks were the perceived need for autonomy of the transplant entity, alignment among services and finances and alignment of authority with responsibility. Many respondents suggested that a dialogue be opened about effective transplant infrastructure that overcomes the boundaries of traditional academic department silos.

Efficacy and safety of maribavir dosed at 100 mg orally twice daily for the prevention of cytomegalovirus disease in liver transplant recipients: a randomized, double-blind, multicenter controlled trial.

Maribavir is an oral benzimidazole riboside with potent in vitro activity against cytomegalovirus (CMV), including some CMV strains resistant to ganciclovir. In a randomized, double-blind, multicenter trial, the efficacy and safety of prophylactic oral maribavir (100 mg twice daily) for prevention of CMV disease were compared with oral ganciclovir (1000 mg three times daily) in 303 CMV-seronegative liver transplant recipients with CMV-seropositive donors (147 maribavir; 156 ganciclovir). Patients received study drug for up to 14 weeks and were monitored for CMV infection by blood surveillance tests and also for the development of CMV disease. The primary endpoint was Endpoint Committee (EC)-confirmed CMV disease within 6 months of transplantation. In a modified intent-to-treat analysis, the noninferiority of maribavir compared to oral ganciclovir for prevention of CMV disease was not established (12% with maribavir vs. 8% with ganciclovir: event rate difference of 0.041; 95% CI: -0.038, 0.119). Furthermore, significantly fewer ganciclovir patients had EC-confirmed CMV disease or CMV infection by pp65 antigenemia or CMV DNA PCR compared to maribavir patients at both 100 days (20% vs. 60%; p < 0.0001) and at 6 months (53% vs. 72%; p = 0.0053) after transplantation. Graft rejection, patient survival, and non-CMV infections were similar for maribavir and ganciclovir patients. Maribavir was well-tolerated and associated with fewer hematological adverse events than oral ganciclovir. At a dose of 100 mg twice daily, maribavir is safe but not adequate for prevention of CMV disease in liver transplant recipients at high risk for CMV disease.

Left renal vein ligation: a technique to mitigate low portal flow from splenic vein siphon during liver transplantation.

Low portal vein flows in liver transplant have been associated with poor allograft survival. Identifying and ameliorating causes of inadequate portal flow is paramount. We describe successful reversal of significant splenic vein siphon from a spontaneous splenorenal shunt during liver transplant. The patient is a 43-year-old male with cirrhosis from hepatitis C and Budd-Chiari syndrome, who had a variceal hemorrhage necessitating an emergent splenorenal shunt with 8 mm PTFE graft. Imaging in 2006 revealed thrombosis of the splenorenal shunt and evidence of a new spontaneous splenorenal shunt. The patient developed hepatocellular carcinoma and underwent transplant in 2009. After reperfusion, portal flows were low (150-200 mL/min). A mesenteric varix was ligated without improvement. Due to adhesions, direct collateral ligation was not attempted. In order to redirect the splenic siphon, the left renal vein was stapled at its confluence with the inferior vena cava. Portal flows subsequently increased to 1.28 L/min. Postoperatively, the patient had stable renal and liver function. We conclude that spontaneous splenorenal shunts can cause low portal flows. A diligent search for shunts with understanding of flow patterns is critical; ligation or rerouting of splanchnic flow may be necessary to improve portal flows and allograft outcomes.

Incidental hepatocellular carcinoma after liver transplantation: population characteristics and outcomes.

We combined data from two liver transplant centers to determine the tumor characteristics and outcomes of 51 patients transplanted with incidental hepatocellular carcinoma (iHCC) compared with 143 patients transplanted for previously known HCC (pkHCC). There were no differences in age, gender, or frequency of hepatitis C infection. Patients with iHCC were more likely to be African-American (22% vs 10%; P = .016), more likely to be screened by ultrasound (38% vs 9%; P < .001), had a lower alpha-fetoprotein (83.9 +/- 258.1 vs 572.4 +/- 2376.4 ng/mL; P = .005), and had a higher model for end-stage liver disease (MELD) score (14.3 +/- 4.1 vs 11.8 +/- 4.7; P < .001). The liver explants of patients with iHCC had smaller total tumor burden than patients with pkHCC (3.1 +/- 3.5 vs 4.1 +/- 2.6 cm; P < .001), but a similar percentage of single lesions (66% vs 65%) and tumors that met Milan criteria (76% vs 65%). Patients with iHCC had 1-, 3-, and 5-year survivals of 78%, 67%, and 58%, and 1-, 3-, and 5-year recurrence-free survivals of 90%, 87%, and 87% compared with the 1-, 3-, and 5-year survivals of 90%, 82%, and 70%, and the 1-, 3-, and 5-year tumor-free survivals of 91%, 84%, and 78% in patients with pkHCC. We concluded that patients with iHCC were more likely to be African-American, to be screened by ultrasound, to have a lower alpha-fetoprotein, and a higher MELD score. Ultrasound is not a sensitive modality for screening patients for HCC. Patients with iHCC do not have an advantage in survival over those with pkHCC.

Impact of model for end-stage liver disease on patient survival and disease-free survival in patients receiving liver transplantation for hepatocellular carcinoma.

We combined data from two transplant centers to determine the impact of the model for end-stage liver disease (MELD) allocation system on outcomes in patients undergoing liver transplantation for hepatocellular carcinoma (HCC). We compared 55 patients listed before MELD to 117 patients in the MELD era. Patients before MELD were less likely to receive a transplant (67% vs 91%) and waited a median of 127 days vs 20 days (P < .001). On an intention to treat (ITT) basis, the 1-, 3-, and 5-year survivals for patients before MELD were 79%, 60%, and 48%, and in the MELD era were 84%, 73%, and 73% (P = .055). On an ITT basis, the 1-, 3-, and 5-year tumor-free survivals before MELD were 58%, 58%, and 55% vs 83%, 74%, and 70% in the MELD era (P = .018). In patients who received a transplant, however, there were no differences in overall or tumor-free survival. In these patients, the 1-, 3-, and 5-year patient survivals were 92%, 84%, and 67% before MELD, and 90%, 81%, and 81% in the MELD era (P = .57). In transplanted patients, the 1-, 3-, and 5-year tumor-free survivals before MELD were 88%, 88%, and 83% vs 92%, 83%, and 78% in the MELD era (P = .403). On explant, patients listed before MELD had lower grade tumors (P = .046). We concluded that patients with HCC listed in the MELD era had higher and more rapid rates of transplantation with improvements in survival. However, the more efficacious rates of transplantation did not result in lower rates of tumor recurrence.

New application of the bipolar vapor plasma coagulation system for laparoscopic major liver resections.

BACKGROUND: In recent years, laparascopic techniques have become a more widely used and accepted means for performing various types of liver resections. In this report, the authors describe the use and initial applications of a new approach to laparoscopic liver resection using vapor pulse coagulation. METHODS: Liver resections using vapor plasma coagulation technology were performed for 11 patients at the authors' center. Candidates were initially selected because they had benign disease and lesions amenable to standard resections along anatomic planes. Four resections were performed with a hand-assist technique and seven without it. RESULTS: All the patients faired well. The length of the hospital stay was 3.4 +/- 0.7 days. There were no major surgical complications, bile leaks, or reoperations. None of the patients required blood transfusions. One patient was readmitted for fever and urinary tract infection, and one patient had 1 week of right leg swelling attributable to the use of stirrups. CONCLUSIONS: Vapor plasma coagulation using a laparoscopic approach for hepatic resection is a promising new technology that deserves further exploration.

Transplant Surgeon Burnout and Marital Distress in the Sandwich Generation: The Call for Organizational Support in Family Life.

Burnout (emotional exhaustion, depersonalization, and low personal accomplishment) is the enervation an individual experiences from a chronically taxing work environment. Little research has examined the demands of the sandwich generation (both children and older adults in the home) on burnout and marital satisfaction. METHODS: This is a cross-sectional survey of American and European transplant surgeons on the effects of sandwich generation-related demands on burnout and marital satisfaction, covarying for transplant surgeon age. RESULTS: A total of 286 married or partnered transplant surgeons were included. Presence (vs absence) of children in the home did not impact burnout, but those with children who reported difficulties with flexible childcare reported greater emotional exhaustion (P = .03) and depersonalization (P = .02) than those without difficulties. A total of 38.5% of married transplant surgeons reported marital distress. European transplant surgeons reported lower marital satisfaction than those from the United States (P < .01). Having an older adult in the home may also negatively impact transplant surgeons' marital satisfaction (P = .048). DISCUSSION: As health care organizations move forward with programs aimed at creating a sustainable workforce, providing professional environments supportive of important family-related demands is imperative.

Neuropsychological changes in a large sample of liver transplant candidates.

One-hundred forty-eight pre-liver transplant candidates completed a psychological interview and brief neuropsychological testing. Assessment measures included the Repeatable Battery of Neuropsychological Status, Shipley Institute of Living Scale, Trail Making Test Parts A and B (TMT-A and TMT-B), and the Folstein Mini Mental State Exam. Participants in our sample scored in the Below Average range of functioning (mean score = 100; SD = 10) on measures of memory (mean = 89.51, SD = 17.43), attention (mean = 87.62, SD = 17.23), and spatial perception (mean = 88.69, SD = 20.39). Scores reflected moderate to severe impairment in organization and processing speed (TMT-B completion time in seconds: mean = 137.22, SD = 88.64). Controlling for the effects of prior education, MELD scores were strongly correlated with poorer performance on immediate and delayed memory subtests (both P < .01), as well as with diminished attentional capacity (P = .03). MELD scores also were significantly related to slower completion times on the TMT-A and TMT-B (both P < .05). Furthermore, independent sample t tests indicated that patients with higher MELD scores (>10) experienced significantly greater difficulty with executive functioning (P < .05) and delayed memory (P < .05) than those with lower MELD scores. Thorough evaluations of cognitive functioning are needed pretransplant to identify and treat cases of subclinical hepatic encephalopathy before daily functioning becomes significantly impaired.

Hypercoagulability risks among adult living liver donors.

BACKGROUND: Review of the literature is limited with respect to thrombotic risk in the living liver donor. This study examines inherent coagulable changes that occur as a result of the surgery. MATERIALS AND METHODS: At our center, we have performed 353 orthotopic adult liver transplants in the past 4 years. Of these, 20 were adult-adult right lobe living donor transplants. All living donors are alive and doing well. Of these, eight living donors were followed preoperatively and postoperatively monitoring protein C, protein S, antithrombin III, and factor VIII levels. Levels were checked at 48 hours postoperatively, as well as at 2, 4, and 6 weeks. RESULTS: All eight patients had normal levels preoperatively, although significantly low levels were identified postoperatively of these coagulation markers: protein C decreased to as low as 0%, (range 0-29; normal 50-150) within 48 hours postoperatively; protein S decreased to 3% to 40% during the same time frame (normal 50-150), and antithrombin III levels decreased to 47% to 55% (normal range 50-150%). Factor VIII levels significantly increased to >200% (normal 50- 150). All coagulation levels returned to the normal range within 4 to 6 weeks. None of the patients developed a thromboembolic event. CONCLUSIONS: We observed an imbalance of low protein C, S, and antithrombin III and elevated factor VIII levels, which have been documented as thrombotic risks in adults. Our findings suggest that the imbalance in the coagulation profile after surgery may be an independent risk factor for thrombosis beyond the surgical event, a phenomenon that requires further exploration.

Sonographic differences in venous return between piggyback versus caval interposition in adult liver transplantations.

UNLABELLED: The piggyback technique (PT) is being used more frequently than caval interposition (CI) in adult orthotopic liver transplants (OLT). It is unclear whether PT alters venous return compared with CI, therefore leading to postoperative complications. The aim of our study was to analyze our experience with PT and CI by comparing ultrasound results of hepatic vein flow on the first postoperative day. PATIENTS AND METHODS: This retrospective analysis of consecutive OLTs performed between 2002 and 2005 included data from a single blinded radiologist who reviewed all postoperative day 1 ultrasound examinations. The hepatic vein waveforms were scored as all phasic, all flat, or partially phasic/flat. RESULTS: During the study period, we performed, 465 OLT among which 270 had available ultrasound examinations. The etiologies of liver disease were similar between the PT and CI cohorts, hepatitis C and alcoholic liver disease accounted for more than 60%. Two hundred eight (77%) had undergone PT and 62 (23%) CI. Among the PT, 60% were phasic, 31.1% were partially phasic/flat, and 8% were flat. When a CI was performed, 56.5% were phasic, 35.5% were partially phasic/flat, and 8% were flat. CONCLUSIONS: There was no significant difference between PT and CI with regard to an effect on hepatic vein waveforms on the first operative day. Therefore, there do not appear to be early hemodynamic benefits of performing CI versus PT anastamoses of OLTs. Further studies may be needed to determine whether long-term sequelae follow the piggyback technique.

Influence of hepatitis C on renal function after liver transplantation.

Liver transplantation (OLT) is often complicated by renal failure. Hepatitis C (HCV) is said to be a risk factor for renal failure after OLT, but few studies have analyzed this directly. We evaluated all patients who received a liver transplant from 1995 through 2003. There were 147 patients infected with HCV and 202 not infected. Patients with HCV were further divided into 114 patients with benign HCV and 33 patients with severe HCV defined by bridging fibrosis or cirrhosis. The groups were evaluated for the development of renal insufficiency defined as a creatinine above 1.8 mg/dL on three consecutive occasions or renal failure as defined by the need for dialysis or renal transplant. The incidence of renal failure in patients with HCV was 10.2% and in patients without HCV was 3.5% (P = .004). Patients with severe HCV had an incidence of 12.1% vs 9.7% for patients with mild HCV. The linear trend in renal failure from non-HCV to mild HCV to severe HCV was significant (P = .012). The incidence of renal insufficiency was 23.4% in patients with HCV and 14.9% in patients without HCV (P = .080). The incidence was 32.3% in patients with severe HCV and 20.6% in patients with mild HCV. The trend in renal insufficiency across the three groups was mildly significant (P = .042). On multivariate analysis, HCV was a risk factor for renal failure with a relative risk of 2.58 (P = .045). The study suggests that HCV and the severity of recurrent HCV are risk factors for renal dysfunction after liver transplantation.

Renal disease burden following liver transplantation.

UNLABELLED: Significant chronic kidney disease (CKD) occurs following orthotopic liver transplant (OLT). Since CKD is associated with increased cardiovascular events, mortality, and hepatic allograft dysfunction, early recognition of CKD and implementation of changes may improve the long-term outcome. The purpose of this study was to determine the burden of renal disease following OLT. PATIENTS AND METHODS: We retrospectively reviewed our OLT recipients from 1997 until 2004. We calculated glomerular filtration rates (GFR) using the Modification of Diet in Renal Disease study (MDRD) method. The GFRs were further subdivided into pre-MELD and post-MELD eras. RESULTS: During the study period, we performed 407 OLTs. We censored data from living donor liver transplants (n = 14), combined liver-kidney transplants (n = 12), and from patients whom we did not have complete data for 6 months after transplant (n = 40). Mean MELD score at the time of transplant was 18 +/- 7 (mean +/- standard deviation). The mean GFR at 6 months following OLT was 63.7 +/- 30.2 mL/min per 1.73 m(2). Only 14% (n = 47) of our patients had normal renal function at 6 months, while 78% (n = 266) of our patients had mild to moderate risk for renal failure. Eight percent (n = 28) had stage 4 or 5 CKD. There were no differences between the pre-MELD and post-MELD GFRs. CONCLUSIONS: The burden of renal disease is significant in our patient population at 6 months posttransplantation. It may be important to introduce CKD management as early as 6 months after transplant to impact the outcomes of OLT recipients.

Portal Vein Inflow From Enlarged Coronary Vein in Liver Transplantation: Surgical Approach and Technical Tips: A Case Report.

Portal vein thrombosis is common in patients with end-stage liver disease, with an incidence as high as 26% in liver transplant candidates. It is known to be associated with a high risk of morbidity and mortality posttransplantation, and its management can be challenging. The management options range from a simple thrombendvenectomy to multivisceral transplantation in cases with diffuse portomesenteric thrombosis. We report a case of liver transplantation in which we performed a rare reconstruction of the portal vein. Briefly, the patient had diffuse portomesenteric thrombosis, calcified aneurysmosis, and a large collateral coronary vein, to which we directly anastomosed the donor portal vein in an end-to-side fashion. This report describes a unique surgical approach for similar cases of severe portal vein thrombosis in liver transplant candidates.

A national study of burnout among American transplant surgeons.

This study examines burnout in a national sample of transplant surgeons. Data analyses were conducted on a sample of 209 actively practicing transplant surgeons. Measures included the Maslach Burnout Inventory, a demographic survey, and the Surgeon Coping Inventory. Burnout was reflected in 38% of surgeons scoring high on the Emotional Exhaustion dimension, whereas 27% showed high levels of Depersonalization, and 16% had low levels of Personal Accomplishment. Several significant predictors of emotional exhaustion were identified and included questioning one's career choice, giving up activities, and perceiving oneself as having limited control over the delivery of medical services (R2= 0.43). Those who perceived themselves as having a higher ability to control delivery of medical services and who felt more appreciated by patients had lower levels of depersonalization and were less likely to question their career choice (R2= 0.16). Surgeons with high personal accomplishment experienced greater professional growth opportunities, perceived their institution as supportive, felt more appreciated by patients, and were less likely to question their career (R2= 0.24). The prioritization of goals to reflect both professional and personal values accounted for a significant amount of the variance in predicting both emotional exhaustion and personal accomplishment in separate regression equations. Recommendations to decrease burnout would include greater institutional support, increased opportunities for professional growth, and greater surgeon control over important services to facilitate efficient work. Coping strategies to moderate stress and burnout are also beneficial and should include prioritizing goals to reflect both professional and personal values.

Comparison of long-term actual renal allograft survival in mycophenolate mofetil and azathioprine-based triple drug immunosuppression protocols.

INTRODUCTION: The use of mycophenolate mofetil (MMF) in renal transplantation results in a 50% lower incidence of acute rejection compared to azathioprine (AZA). However, the graft survival reports are conflicting: the European trial and US database analysis suggest better survival with MMF, an observation that was not seen in the US and tricontinental studies. METHODS: We retrospectively reviewed our single-center experience (60% African-Americans) comparing the serum creatinine (SCr) values and 3-year actual graft survival with MMF versus AZA-based immunosuppression. Group I included patients transplanted between January 1990 and December 1992 on cyclosporine (CSA), AZA, and steroids; group II subjects, from January 1996 to December 1998 on CSA, MMF, and steroids. We analyzed SCr and all causes of graft losses at 3, 6, 12, 18, 24, and 36 months posttransplantation. RESULTS: The patient demographics were similar in both groups as was the mean SCr values at different times. The time-group interaction for SCr, the Kruskal-Wallis test for SCr for different categories (<1.5, 1.5 to 2.0, 2.0 to 2.5, and >2.5 mg/dL) and the all-cause graft loss between the two groups were not significantly different. CONCLUSION: Our results failed to show better long-term actual graft survival despite the 6-year interval between the two groups. These findings agree with the results of the United States and the tricontinental studies. A lower incidence of acute rejection early after transplantation observed with MMF may not always translate into a long-term benefit, possibly due to the influence of nonimmunological factors, such as hypertension, calcineurin inhibitor toxicity, more frequent cytomegalovirus infections, and increased attempts to withdraw steroids using MMF-based protocols.

Transjugular intrahepatic portosystemic shunts for refractory ascites after liver transplantation.

PURPOSE: To study the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) in the management of refractory ascites after liver transplantation. PATIENTS AND METHODS: Between January 1995 and December 2003, 309 primary adult liver transplants were performed. Refractory ascites was defined as active interventions (salt restriction, diuretic use, repeated paracentesis) needed beyond 30 days after transplantation. These patients were managed with TIPS placement. RESULTS: Eight TIPS were placed in 8 patients at a mean of 11.5 months after transplantation (range, 2-36 months). There were 5 males and 3 females, age 54 +/- 8.2 years. Hepatitis C was the primary diagnosis in 7 patients and primary biliary cirrhosis in 1. Indications for TIPS included refractory ascites (8), associated variceal bleeding (2), and various degrees of hepatic vein outflow stenosis (3). Seven patients had resolution of ascites and associated findings of portal hypertension, and 1 patient with persistent ascites had severe hepatic vein outflow stenosis and associated hepatitis C in the allograft. Two patients required retransplantation for recurrent hepatitis C. There were 3 deaths: liver failure (1), organ failure after retransplantation (1), and lung cancer 5 months after TIPS (1). Currently, 5 patients are alive without clinical evidence of ascites 9, 13, 15, 24, and 70 months after TIPS. CONCLUSIONS: The TIPS device can be used safely and effectively to control refractory ascites after liver transplantation. In the setting of organ dysfunction, these patients should be considered sooner for retransplantation.