Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting

doi:10.1016/S0016-5085(00)70422-7

Gastroenterology

Volume 118, Issue 1, January 2000, Pages 138-144

https://doi.org/10.1016/S0016-5085(00)70422-7 Get rights and content

Abstract

Background & Aims: Transjugular intrahepatic portosystemic shunt (TIPS) placement is effective in the treatment of complications of portal hypertension. This study evaluated the predictors of mortality in a group of cirrhotic patients with advanced liver disease after placement of TIPS. Methods: A retrospective analysis of all patients undergoing TIPS placement over a 2 ½-year period was undertaken.A retrospective analysis of all patients undergoing TIPS placement over a 2 ½-year period was undertaken. Results: Fifty-six patients had TIPS placement for variceal hemorrhage, 49 for refractory ascites, and 24 for hepatic hydrothorax (total, 129). Of 21 variables available before TIPS placement, variceal hemorrhage requiring emergent TIPS placement (relative risk [RR], 37.5;95% confidence interval [CI], 5.4-259) and bilirubin concentration > 3.0 mg/dL (RR, 5.4;95% CI, 1.4-10.2) were independent predictors of 30-day mortality. Variceal hemorrhage requiring emergent TIPS placement (hazard ratio [HR], 5.1, 95% CI, 2.2-9.1), alanine aminotransferase level > 100 IU/L (HR, 2.5;95% CI, 1.2-5.5), bilirubin level > 3.0 mg/dL (HR, 2.6;95% CI, 1.1-4.6), and pre-TIPS encephalopathy unrelated to bleeding (HR, 2.2;95% CI, 1.2-4.8) independently predicted death during the follow-up period. A model was developed that separated the patients into 3 groups with significantly different survival rates. Conclusions: A clinical index consisting of 4 pre-TIPS variables can reliably predict outcome after TIPS.

GASTROENTEROLOGY 2000;118:138-144

Section snippets

Materials and methods

The study was a retrospective analysis of all patients with cirrhosis who underwent TIPS placement from July 1, 1994, through December 31, 1996, at Emory University Hospital. Emory University Hospital is a tertiary care facility located in Atlanta, Georgia, and serves as a referral center for the southeastern United States. The TIPS procedures were performed using techniques previously described in detail.3, 5 Informed consent was obtained for every TIPS procedure. In general, the patency of

Results

During the study period, 147 patients underwent TIPS placement. Eighteen patients were excluded from this analysis (veno-occlusive disease, 6; splenorenal shunt soon after TIPS placement, 4; preoperative correction of portal hypertension for cardiac surgery, 2; hepatoma at the time of TIPS, 1; no follow-up, 5). The remaining 129 patients are the subjects of this report. Selected characteristics of the study group are shown in Table 1.

. Selected characteristics of the study group

Age (yr)

54.8 ±

Discussion

In a monograph on TIPS by Conn et al.,²⁹ the authors note that TIPS is a technology whose time has come; however, they also caution that its place in medicine is yet to be determined. Although evidence increasingly demonstrates the effectiveness of TIPS in the management of complications of portal hypertension, there is also evidence that TIPS has little effect on prognosis compared with other forms of therapy.12, 14, 17, 18, 19 If clinical factors that accurately predict outcome after TIPS

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Cited by (192)

Predictive Accuracy Comparison of Prognostic Scoring Systems for Survival in Patients Undergoing TIPS Placement: A Systematic Review and Meta-analysis
2023, Academic Radiology
This meta-analysis aimed to evaluate the performance of different risk assessment models (RAMs) for survival after Transjugular Intrahepatic Portosystemic Shunt (TIPS) in patients with cirrhotic portal hypertension.
A systematic search of PubMed, WOS, Embase, Cochrane, and CNKI from inception to February 2023 was conducted. We comprehensively reviewed and aggregated data from numerous studies covering prevalent RAMs such as Child-Turcotte-Pugh, the Model for End-Stage Liver Disease (MELD), MELD-Sodium (MELD-Na), the Freiburg Index of Post-TIPS Survival (FIPS), Bilirubin-platelet, Chronic Liver Failure Consortium Acute Decompensation score, and Albumin-Bilirubin grade across different timeframes. For this study, short-term is defined as outcomes within a year while long-term refers to outcomes beyond one year. The area under the receiver operating characteristic (AUC) curve or Concordance Statistics was chosen as the metric to assess predictive capacity for mortality outcomes across six predetermined time intervals. Mean effect sizes at various time points were determined using robust variance estimation.
MELD consistently stood out as a primary short-term survival predictor, particularly for 1 month (± 2 weeks) (AUC: 0.72) and 3 months of (± 1 month) survival (AUC: 0.72). MELD-Na showed the best long-term predictive ability, with an AUC of 0.70 at 3.5 years (± 1.5 years). FIPS performed well for 6 months of (± 2 months) survival (AUC: 0.68) and overall transplant-free survival (AUC: 0.75). Efficacy nuances were observed in RAMs when applied to particular subgroups. Meta-regression emphasized the potential predictor overlaps in models like MELD and FIPS.
This meta-analysis underscores the MELD score as the premier predictor for short-term survival following TIPS. Meanwhile, the FIPS score and MELD-Na model exhibit potential in forecasting long-term outcomes. The study accentuates the significance of RAM selection for enhancing patient outcomes and advocates for additional research to corroborate these findings and fine-tune risk assessment in TIPS.
Prognosis of patients undergoing salvage TIPS is still poor in the preemptive TIPS era
2021, Clinics and Research in Hepatology and Gastroenterology
Salvage transjugular intrahepatic portosystemic shunts (TIPS) are associated with poor prognosis, especially in patients with Child-Pugh C cirrhosis. Since preemptive TIPS improved prophylaxis of variceal bleeding in those patients, recourse to salvage TIPS may now affect patients with a better prognosis.
To assess the impact of the preemptive TIPS policy on outcomes after salvage TIPS placement.
We conducted a retrospective monocentric study on cirrhotic patients undergoing salvage TIPS with polytetrafluoroethylene-covered stents from 2002 to 2017 (period 1 until February 2011; period 2 after the preemptive TIPS policy in March 2011). The primary endpoint was one-year transplant-free survival.
We included 106 patients (period 1/2 = 53/53 patients, male gender 82%, age 54 ± 9 years, alcoholic cirrhosis 70%, Child-Pugh score B/C 94%). One-year transplant-free survival was 46.0% during period 1 compared to 40.2% during period 2 (p = 0.65). Amongst 61 patients with history of variceal bleeding, 32 (52.5%) had an inadequate secondary prophylaxis, including 19 (59.4%) with a previous indication of preemptive TIPS. One-year transplant-free survival was 33.2% if inadequate secondary prophylaxis vs 65.2% if adequate (p = 0.008). Independent factors associated with survival were a lower Child-Pugh or MELD score, infection, failure to control bleeding, and hepatic encephalopathy after TIPS.
Prognosis after salvage TIPS remained poor in our series. Optimizing secondary prophylaxis, including preemptive TIPS placement, should be the main concern to improve prognosis.
Ethnoracial Disparity in Hospital Survival following Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Variceal Bleeding in the United States
2021, Journal of Vascular and Interventional Radiology
Citation Excerpt :
In the sensitivity analysis, a study of the subset of patients with a maximum Child-Pugh score of 13 showed that Black race was not significantly associated with higher mortality. Additionally, Black patients had a significantly higher rate of liver failure after TIPS creation, a complication known to be associated with a degree of an underlying hepatic dysfunction (23,24). Alternatively, it is possible that more severe disease (Child-Pugh score > 13) had a disproportionately negative impact on survival for Black patients as opposed to the impact on survival for White patients undergoing TIPS creation.
To investigate the magnitude of racial/ethnic differences in hospital mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation for acute variceal bleeding and whether hospital care processes contribute to them.
Patients aged ≥18 years undergoing TIPS creation for acute variceal bleeding in the United States (n = 10,331) were identified from 10 years (2007–2016) available in the National Inpatient Sample. Hierarchical logistic regression was used to examine the relationship between patient race and inpatient mortality, controlling for disease severity, treatment utilization, and hospital characteristics.
A total of 6,350 (62%) patients were White, 1,780 (17%) were Hispanic, and 482 (5%) were Black. A greater proportion of Black patients were admitted to urban teaching hospitals (Black, n = 409 (85%); Hispanic, n = 1,310 (74%); and White, n = 4,802 (76%); P < .001) and liver transplant centers (Black, n = 215 (45%); Hispanic, n = 401 (23%); and White, n = 2,267 (36%); P < .001). Being Black was strongly associated with mortality (Black, 32% vs non-Black, 15%; odds ratio, 3.0 [95% confidence interval, 1.6–5.8]; P = .001), as assessed using the risk-adjusted regression model. This racial disparity disappeared in a sensitivity analysis including only patients with a maximum Child-Pugh score of 13 (odds ratio 1.2 [95% confidence interval, 0.4–3.6]; P = .68), performed to compensate for the absence of Model for End-stage Liver Disease scores. Ethnoracial differences in access to teaching hospitals, liver transplant centers, first-line endoscopy, and transfusion did not significantly contribute (P > .05) to risk-adjusted mortality.
Black patients have a 2-fold higher inpatient mortality than non-Black patients following TIPS creation for acute variceal bleeding, possibly related to greater disease severity before the procedure.
Pleural Effusion: Hepatic Hydrothorax
2021, Encyclopedia of Respiratory Medicine, Second Edition
TIPS for management of portal-hypertension-related complications in patients with cirrhosis
2020, Clinics and Research in Hepatology and Gastroenterology
Portal hypertension is primarily due to liver cirrhosis, and is responsible for complications that include variceal bleeding, ascites and hepatorenal syndrome. The transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the portal vein and the hepatic vein, created by interventional radiology, that aims to reduce portal pressure. TIPS is a potential treatment for severe portal-hypertension-related complications, including esophageal and gastric variceal bleeding. TIPS is currently indicated as salvage therapy in this setting when patients fail to respond to standard endoscopic and medical treatment. More recently, early TIPS has been shown to be effective in decreasing risk of rebleeding after variceal hemorrhage and mortality in Child-Pugh B patients with active hemorrhage at endoscopy, and in Child-Pugh C patients. TIPS is also an efficient treatment for refractory ascites and hepatic hydrothorax. In contrast, the role of TIPS in the hepatorenal syndrome has not been precisely defined. The aim of this review was to specifically describe the current role of TIPS in management of portal hypertension in patients with cirrhosis.
Role of Transjugular Intrahepatic Portosystemic Shunt in the Management of Portal Hypertension: Review and Update of the Literature
2019, Clinics in Liver Disease

View all citing articles on Scopus

^☆: Thomas D. Boyer, M.D., Department of Medicine, Emory University School of Medicine, 1639 Pierce Drive, Room 2101 WMB, Atlanta, Georgia 30322. e-mail: [email protected]; fax: (404) 727-5767.

^☆☆: Supported in part by National Institutes of Health grant DK50680.

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Liver, Pancreas, and Biliary TractDeterminants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting☆,☆☆

Abstract

Section snippets

Materials and methods

Results

Discussion

Am J Surg

J Hepatol

Gastroenterology

Gastroenterology

Gastroenterology

Lancet

Gastroenterology

Gastroenterology

Hepatology

Gastroenterology

Transjugular intrahepatic portal-systemic shunts: the state of the art

Hepatology

Transjugular portal venography and radiological portacaval shunt: an experimental study

Radiology

Creation of an intrahepatic portosystemic shunt with a Gruntzig balloon catheter

Can Med Assoc J

Transjugular intrahepatic portosystemic shunt: a nonoperative approach to life threatening variceal bleeding

Can J Surg

Creation of intrahepatic portosystemic shunts with the wallstent prosthesis: results in 100 patients

Radiology

Liver, Pancreas, and Biliary Tract
Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting☆,☆☆