*8.3. Automated Low-Flow Ascites Pump (Alfapump)*

The Alfapump is a subcutaneously implanted battery-powered programmable pump connected to catheters that move ascites from the peritoneal cavity to the bladder, from which it is eliminated with urine. It could be considered, in experienced centers, for patients with RA and contraindications to TIPS placement. The available evidence shows that Alfapump can reduce the need for LVPs and improve patients' quality of life and nutritional status [71,72]. However, important side effects have been reported and deserve consideration. First, device-related infective complications are relatively frequent (mainly SBPs and urinary tract infections) [73]; the routine use of antibiotic prophylaxis reduced their occurrence, but long-term antibiotic administration remains a debated issue in patients with decompensated cirrhosis. Second, renal impairment or failure develop in a proportion of patients [73,74], probably as a form of PICD due to the continuous ascites tapping without albumin use. Intermittent albumin administration has been proposed but its efficacy (as well as its dose and timing) needs to be demonstrated in clinical trials. Moreover, no survival benefit of Alfapump has been showed so far [73]. In conclusion the routine use of Alfapump is currently not an established option in patients with cirrhosis and refractory ascites.

#### **9. Conclusions**

Currently recommended treatments for ascites are based on symptomatic measures, aiming to excrete the excess of water and sodium by the kidney (with diuretics) or directly drain ascites from the abdomen (with LVPs). Alternative approaches, like vasoconstrictors (i.e., midodrine) or automated drainage systems (i.e., alfapump) present some promising aspects but did not show clear and undoubted beneficial effects, so far.

Future research should focus on pathophysiological treatments, able to treat or prevent ascites in a wider context, ideally modifying the long-term clinical course of the disease, thus improving survival and quality of life for patients [75]. Such measures could derive from a better knowledge—and extended use—of currently available treatment (e.g., TIPS and albumin administration), from the repurposing or repositioning of existing drugs [76], or even from the development of innovative approaches or molecules.

**Author Contributions:** Writing—original draft preparation, G.Z.; writing—review and editing, M.T.; writing—review and editing, G.I.; writing—review and editing, P.C. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research has received funding from the European Union's Horizon 2020 Research and Innovation Programme under Grant Agreement No 731875 "Simvastatin and Rifaximin as new therapy for patients with decompensated cirrhosis—LIVERHOPE Project".

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** No new data were created or analyzed in this study. Data sharing is not applicable to this article.

**Conflicts of Interest:** Zaccherini is part of the speakers' bureau for Grifols SA and Octapharma SA, outside the submitted work. Tufoni is part of the speakers' bureau for Grifols SA and Octapharma SA, outside the submitted work. Iannone has nothing to disclose. Caraceni is part of the speakers' bureau for Grifols SA, Octapharma SA, Kedrion Biopharma SpA, Mallinkrodt SA, Gilead SA and Takeda SA, outside the submitted work.

#### **References**

