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de Mattos AA, de Mattos AZ, Manica M, Tovo CV. Which patients benefit the most? An update on transjugular intrahepatic portosystemic shunt. World J Hepatol 2025; 17:99809. [PMID: 40027554 PMCID: PMC11866145 DOI: 10.4254/wjh.v17.i2.99809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 12/23/2024] [Accepted: 01/09/2025] [Indexed: 02/20/2025] Open
Abstract
This is a narrative review in which the advances in technical aspects, the main indications, limitations and clinical results of the transjugular intrahepatic portosystemic shunt (TIPS) in portal hypertension (PH) are addressed. With the emergence of the coated prosthesis, a better shunt patency, a lower incidence of hepatic encephalopathy (HE) and better survival when compared to TIPS with the conventional prosthesis are demonstrated. The main indications for TIPS are refractory ascites, acute variceal bleeding unresponsive to pharmacological/endoscopic therapy and, lastly, patients considered at high risk for rebleeding preemptive TIPS (pTIPS). Absolute contraindications to the use of TIPS are severe uncontrolled HE, systemic infection or sepsis, congestive heart failure, severe pulmonary arterial hypertension, and biliary obstruction. The control of hemorrhage due to variceal rupture can reach up to 90%-100% of cases, and 55% in refractory ascites. Despite evidences regarding pTIPS in patients at high risk for rebleeding, less than 20% of eligible patients are treated. TIPS may also decrease the incidence of future decompensation in cirrhosis and increase survival in selected patients. In conclusion, TIPS is an essential treatment for patients with PH, but is often neglected. It is important for the hepatologist to form a multidisciplinary team, in which the role of the radiologist with experience in interventional procedures is prominent.
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Affiliation(s)
- Angelo Alves de Mattos
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Angelo Zambam de Mattos
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Muriel Manica
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Cristiane Valle Tovo
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil.
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Liu DJ, Jia LX, Zeng FX, Zeng WX, Qin GG, Peng QF, Tan Q, Zeng H, Ou ZY, Kun LZ, Zhao JB, Chen WG. Machine learning prediction of hepatic encephalopathy for long-term survival after transjugular intrahepatic portosystemic shunt in acute variceal bleeding. World J Gastroenterol 2025; 31:100401. [PMID: 39877716 PMCID: PMC11718638 DOI: 10.3748/wjg.v31.i4.100401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2024] [Revised: 10/23/2024] [Accepted: 12/02/2024] [Indexed: 12/30/2024] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for managing complications of portal hypertension, particularly acute variceal bleeding (AVB). While effective in reducing portal pressure and preventing rebleeding, TIPS is associated with a considerable risk of overt hepatic encephalopathy (OHE), a complication that significantly elevates mortality rates. AIM To develop a machine learning (ML) model to predict OHE occurrence post-TIPS in patients with AVB using a 5-year dataset. METHODS This retrospective single-center study included 218 patients with AVB who underwent TIPS. The dataset was divided into training (70%) and testing (30%) sets. Critical features were identified using embedded methods and recursive feature elimination. Three ML algorithms-random forest, extreme gradient boosting, and logistic regression-were validated via 10-fold cross-validation. SHapley Additive exPlanations analysis was employed to interpret the model's predictions. Survival analysis was conducted using Kaplan-Meier curves and stepwise Cox regression analysis to compare overall survival (OS) between patients with and without OHE. RESULTS The median OS of the study cohort was 47.83 ± 22.95 months. Among the models evaluated, logistic regression demonstrated the highest performance with an area under the curve (AUC) of 0.825. Key predictors identified were Child-Pugh score, age, and portal vein thrombosis. Kaplan-Meier analysis revealed that patients without OHE had a significantly longer OS (P = 0.005). The 5-year survival rate was 78.4%, with an OHE incidence of 15.1%. Both actual OHE status and predicted OHE value were significant predictors in each Cox model, with model-predicted OHE achieving an AUC of 88.1 in survival prediction. CONCLUSION The ML model accurately predicts post-TIPS OHE and outperforms traditional models, supporting its use in improving outcomes in patients with AVB.
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Affiliation(s)
- De-Jia Liu
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
| | - Li-Xuan Jia
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
| | - Feng-Xia Zeng
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
| | - Wei-Xiong Zeng
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
| | - Geng-Geng Qin
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
| | - Qi-Feng Peng
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
| | - Qing Tan
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
| | - Hui Zeng
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
| | - Zhong-Yue Ou
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
| | - Li-Zi Kun
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
| | - Jian-Bo Zhao
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
| | - Wei-Guo Chen
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou 510151, Guangdong Province, China
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Commins N, Subhaharan D, Kurup R, Wickremeratne T, Mitchell J, Elmes J, Braund A, Funakoshi N, Langton J, Leschke P, O'Beirne J. Indications and outcomes of transjugular intrahepatic portosystemic shunt insertion in two regional Australian hepatology centres. Intern Med J 2024; 54:1302-1309. [PMID: 38654627 DOI: 10.1111/imj.16384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/13/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is an important therapy for complications of portal hypertension but remains underutilised in regional settings. AIMS The aim of this study is to explore the demographics, indications, outcomes and complications in patients undergoing TIPS in two regional hepatology centres. METHODS Retrospective analysis was undertaken of all patients undergoing TIPS at two regional centres between January 2017 and March 2023. The primary outcome measures were efficacy and complications of TIPS. Patient demographics (such as age, baseline liver severity scores and aetiology of liver disease) and indications for TIPS are detailed. RESULTS Forty-eight patients underwent TIPS. Median age was 56 years (interquartile range (IQR): 46-65). The most common indications for TIPS were refractory ascites (n = 17) and failure of secondary prophylaxis of variceal bleeding (n = 13). Cumulative survival at 3 months and 1 year was 93% and 77% respectively. There was no significant difference in outcomes based on TIPS indication. The median number of paracenteses in patients undergoing TIPS for refractory ascites 1 year pre- and post-TIPS were 10 (IQR: 4.5-16) and 2 (IQR: 0-4) respectively (P < 0.001). There were no procedure-related deaths. Inpatient management of liver disease complications had a mean cost of $32 874.67 (SEM: 7779) in 1 year pre-TIPS compared with $12 304.70 (SEM: 3531.1) in 1 year post-TIPS (P < 0.001). CONCLUSIONS TIPS is a safe and effective treatment to reduce complications of portal hypertension and can be performed successfully in the regional setting.
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Affiliation(s)
- Natalie Commins
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Deloshaan Subhaharan
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
- Department of Hepatology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Rajiv Kurup
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Tehara Wickremeratne
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Jonathan Mitchell
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Julie Elmes
- Department of Hepatology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Alicia Braund
- Department of Hepatology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Natalie Funakoshi
- Department of Hepatology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Jonathan Langton
- Department of Interventional Radiology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Paul Leschke
- Department of Interventional Radiology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - James O'Beirne
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
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Mamone G, Comelli A, Porrello G, Milazzo M, Di Piazza A, Stefano A, Benfante V, Tuttolomondo A, Sparacia G, Maruzzelli L, Miraglia R. Radiomics Analysis of Preprocedural CT Imaging for Outcome Prediction after Transjugular Intrahepatic Portosystemic Shunt Creation. Life (Basel) 2024; 14:726. [PMID: 38929709 PMCID: PMC11204649 DOI: 10.3390/life14060726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
PURPOSE To evaluate the role of radiomics in preoperative outcome prediction in cirrhotic patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) using "controlled expansion covered stents". MATERIALS AND METHODS This retrospective institutional review board-approved study included cirrhotic patients undergoing TIPS with controlled expansion covered stent placement. From preoperative CT images, the whole liver was segmented into Volumes of Interest (VOIs) at the unenhanced and portal venous phase. Radiomics features were extracted, collected, and analyzed. Subsequently, receiver operating characteristic (ROC) curves were drawn to assess which features could predict patients' outcomes. The endpoints studied were 6-month overall survival (OS), development of hepatic encephalopathy (HE), grade II or higher HE according to West Haven Criteria, and clinical response, defined as the absence of rebleeding or ascites. A radiomic model for outcome prediction was then designed. RESULTS A total of 76 consecutive cirrhotic patients undergoing TIPS creation were enrolled. The highest performances in terms of the area under the receiver operating characteristic curve (AUROC) were observed for the "clinical response" and "survival at 6 months" outcome with 0.755 and 0.767, at the unenhanced and portal venous phase, respectively. Specifically, on basal scans, accuracy, specificity, and sensitivity were 66.42%, 63.93%, and 73.75%, respectively. At the portal venous phase, an accuracy of 65.34%, a specificity of 62.38%, and a sensitivity of 74.00% were demonstrated. CONCLUSIONS A pre-interventional machine learning-based CT radiomics algorithm could be useful in predicting survival and clinical response after TIPS creation in cirrhotic patients.
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Affiliation(s)
- Giuseppe Mamone
- Radiology Unit, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Tricomi 5, 90127 Palermo, Italy; (M.M.); (A.D.P.); (G.S.); (L.M.); (R.M.)
| | - Albert Comelli
- Ri.MED Foundation, Via Bandiera 11, 90133 Palermo, Italy; (A.C.); (V.B.)
| | - Giorgia Porrello
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D), University of Palermo, Via del Vespro 127, 90127 Palermo, Italy;
| | - Mariapina Milazzo
- Radiology Unit, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Tricomi 5, 90127 Palermo, Italy; (M.M.); (A.D.P.); (G.S.); (L.M.); (R.M.)
| | - Ambra Di Piazza
- Radiology Unit, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Tricomi 5, 90127 Palermo, Italy; (M.M.); (A.D.P.); (G.S.); (L.M.); (R.M.)
| | - Alessandro Stefano
- Institute of Molecular Bioimaging and Physiology, National Research Council (IBFM-CNR), 90015 Cefalù, Italy;
| | - Viviana Benfante
- Ri.MED Foundation, Via Bandiera 11, 90133 Palermo, Italy; (A.C.); (V.B.)
- Institute of Molecular Bioimaging and Physiology, National Research Council (IBFM-CNR), 90015 Cefalù, Italy;
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Molecular and Clinical Medicine, University of Palermo, 90127 Palermo, Italy;
| | - Antonino Tuttolomondo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Molecular and Clinical Medicine, University of Palermo, 90127 Palermo, Italy;
| | - Gianvincenzo Sparacia
- Radiology Unit, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Tricomi 5, 90127 Palermo, Italy; (M.M.); (A.D.P.); (G.S.); (L.M.); (R.M.)
| | - Luigi Maruzzelli
- Radiology Unit, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Tricomi 5, 90127 Palermo, Italy; (M.M.); (A.D.P.); (G.S.); (L.M.); (R.M.)
| | - Roberto Miraglia
- Radiology Unit, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Tricomi 5, 90127 Palermo, Italy; (M.M.); (A.D.P.); (G.S.); (L.M.); (R.M.)
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Friis KH, Thomsen KL, Laleman W, Montagnese S, Vilstrup H, Lauridsen MM. Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis. J Clin Med 2023; 13:14. [PMID: 38202028 PMCID: PMC10779844 DOI: 10.3390/jcm13010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its' complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7-61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures.
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Affiliation(s)
- Karina Holm Friis
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, 3000 Leuven, Belgium
| | - Sara Montagnese
- Department of Medicine, University of Padova, 35122 Padova, Italy
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
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Hu XH, Chen L, Wu H, Tang YB, Zheng QM, Wei XY, Wei Q, Huang Q, Chen J, Xu X. Cell therapy in end-stage liver disease: replace and remodel. Stem Cell Res Ther 2023; 14:141. [PMID: 37231461 DOI: 10.1186/s13287-023-03370-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 04/26/2023] [Indexed: 05/27/2023] Open
Abstract
Liver disease is prevalent worldwide. When it reaches the end stage, mortality rises to 50% or more. Although liver transplantation has emerged as the most efficient treatment for end-stage liver disease, its application has been limited by the scarcity of donor livers. The lack of acceptable donor organs implies that patients are at high risk while waiting for suitable livers. In this scenario, cell therapy has emerged as a promising treatment approach. Most of the time, transplanted cells can replace host hepatocytes and remodel the hepatic microenvironment. For instance, hepatocytes derived from donor livers or stem cells colonize and proliferate in the liver, can replace host hepatocytes, and restore liver function. Other cellular therapy candidates, such as macrophages and mesenchymal stem cells, can remodel the hepatic microenvironment, thereby repairing the damaged liver. In recent years, cell therapy has transitioned from animal research to early human studies. In this review, we will discuss cell therapy in end-stage liver disease treatment, especially focusing on various cell types utilized for cell transplantation, and elucidate the processes involved. Furthermore, we will also summarize the practical obstacles of cell therapy and offer potential solutions.
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Affiliation(s)
- Xin-Hao Hu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, China
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Lan Chen
- Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Hao Wu
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, 310003, China
| | - Yang-Bo Tang
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, 310003, China
| | - Qiu-Min Zheng
- Life Sciences Institute, Zhejiang University, Hangzhou, 310058, China
| | - Xu-Yong Wei
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Qiang Wei
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Qi Huang
- Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Jian Chen
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China.
| | - Xiao Xu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, China.
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China.
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Yin L, Chu SL, Lv WF, Zhou CZ, Liu KC, Zhu YJ, Zhang WY, Wang CX, Zhang YH, Lu D, Cheng DL. Contributory roles of sarcopenia and myosteatosis in development of overt hepatic encephalopathy and mortality after transjugular intrahepatic portosystemic shunt. World J Gastroenterol 2023; 29:2875-2887. [PMID: 37274064 PMCID: PMC10237102 DOI: 10.3748/wjg.v29.i18.2875] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/08/2023] [Accepted: 04/17/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Skeletal muscle abnormalities, such as muscle mass depletion (sarcopenia) and fatty infiltration of the muscle (myosteatosis), are frequent complications in cirrhotic patients scheduled for transjugular intrahepatic portosystemic shunt (TIPS).
AIM To investigate the association and predictive value of sarcopenia and myosteatosis for overt hepatic encephalopathy (HE) and mortality after TIPS.
METHODS The records of cirrhotic patients who underwent the TIPS procedure at our hospital between January 2020 and June 2021 were retrospectively retrieved. The transversal psoas muscle thickness (TPMT) and psoas muscle attenuation (PMA) measured from the unenhanced abdominal computed tomography (CT) at the level of the third lumbar vertebrae were used to analyze the sarcopenia and myosteatosis, respectively. The area under curve (AUC) was used to evaluate the discriminative power of TPMT, PMA, and relevant clinical parameters. Fur-thermore, log-rank test was performed to compare the incidence of overt HE and survival between the different groups, and the association of risk factors with overt HE and mortality was analyzed using Cox proportional hazards regression models.
RESULTS A total of 108 patients were collected. Among these patients, 45.4% of patients developed overt HE after TIPS treatment. Furthermore, 32.4% and 28.7% of these patients were identified to have myosteatosis and sarcopenia, respectively. Myosteatosis (51.0% vs 16.9%, P < 0.001) and sarcopenia (40.8 vs 18.6%, P = 0.011) were found to be more frequent in patients with overt HE, when compared to patients without overt HE. The receiver operating characteristics analysis indicated that the predictive power of TPMT and PMA in overt HE (AUC = 0.713 and 0.778, respectively) was higher when compared to the neutrophil lymphocyte ratio (AUC = 0.636). The cumulative incidence of overt HE was the highest in patients with concomitant sarcopenia and myosteatosis, followed by patients with myosteatosis or sarcopenia, while this was the lowest in patients without sarcopenia and myosteatosis. In addition, sarcopenia and myosteatosis were inde-pendently associated with overt HE and mortality after adjusting for confounding factors in post-TIPS patients.
CONCLUSION CT-based estimations for sarcopenia and myosteatosis can be used as reliable predictors for the risk of developing overt HE and mortality in cirrhotic patients after TIPS.
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Affiliation(s)
- Liang Yin
- Department of Interventional Radiology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230022, Anhui Province, China
| | - Sen-Lin Chu
- Department of Interventional Radiology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230022, Anhui Province, China
| | - Wei-Fu Lv
- Department of Interventional Radiology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230022, Anhui Province, China
| | - Chun-Ze Zhou
- Department of Interventional Radiology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230022, Anhui Province, China
| | - Kai-Cai Liu
- Infection Hospital, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230000, Anhui Province, China
| | - Yi-Jiang Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230022, Anhui Province, China
| | - Wen-Yue Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230022, Anhui Province, China
| | - Cui-Xia Wang
- Department of Interventional Radiology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230022, Anhui Province, China
| | - Yong-Hui Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230022, Anhui Province, China
| | - Dong Lu
- Department of Interventional Radiology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230022, Anhui Province, China
| | - De-Lei Cheng
- Department of Interventional Radiology, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230022, Anhui Province, China
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Skladaný Ľ, Líška D, Liptáková E, Tapajčiková T, Vnenčaková J, Koller T. Comparison of the quality of life of patients with liver cirrhosis before and during the COVID-19 lockdown in Slovakia. Sci Rep 2023; 13:2463. [PMID: 36774367 PMCID: PMC9918821 DOI: 10.1038/s41598-023-29510-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 02/06/2023] [Indexed: 02/13/2023] Open
Abstract
Liver cirrhosis is associated with a poor quality of life (QOL). The COVID-19 pandemic has led to several restriction measures and psychosocial consequences whose impact on QOL has combined with that of cirrhosis in an unknown way. Therefore, we have used our cirrhosis registry to assess the quality of life before the pandemic (on the first admission to the tertiary liver unit) and during the most pronounced phase of the first lockdown. In this cross-sectional study conducted during the first lockdown in Slovakia (from April to May 2020), we have repeated the QOL measurement of QOL in cirrhotic patients previously enrolled in the RH7 registry. Patients who were alive (according to the national registry of deaths) were identified and contacted by phone with a structured and standardized interview led by trained professionals. The tool used for both QOL measurements (at enrolment in RH7 and during lockdown) was a standardized and validated EuroQOL-5D (EQ-5D) questionnaire. The study included 97 patients, of which 37 (38.1%) were women and 60 (61.9%) were men. Responses were achieved from 75 patients (68.18%). In general, patients scored their quality of life significantly higher during the pandemic compared to examination at admission to RH7 (that is, at admission to our tertiary liver unit with cirrhosis) (p = 0.005). In particular, of the domains included in EQ-5D: (1) self-care was better during lockdown compared to the first record on admission to RH7 (p < 0.001). (2) the ability to perform daily activities has also improved during lockdown (p = 0.002). On the other hand, (3) pain and discomfort did not change significantly during the lockdown compared to the previous measurement (p = 0.882). (4) anxiety and depression were lower during lockdown compared to admission to RH7 (p = 0.01). The quality of life in patients with liver cirrhosis was better during the lockdown of SARS-CoV-2 compared to the previous measurement at admission to the tertiary liver unit.
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Affiliation(s)
- Ľ Skladaný
- HEGITO (Div Hepatology, Gastroenterology and Liver Transplant), 2nd Department of Internal Medicine, Faculty of Medicine, Slovak Medical University, F. D. Roosevelt Teaching Hospital, Banská Bystrica, Slovakia
- 2nd Department of Internal Medicine, Faculty of Medicine, P. J. Safarik University, Kosice, Slovakia
| | - D Líška
- Department of Physical Education and Sports, Faculty of Arts, Matej Bel University, Tajovského 40, 974 01, Banská Bystrica, Slovakia.
| | - E Liptáková
- Department of Applied Mathematics and Business Informatics, Faculty of Economics, Technical University of Košice, Košice, Slovakia
| | - T Tapajčiková
- Faculty of Healthcare, Slovak Medical University in Bratislava, Banská Bystrica, Slovakia
| | - J Vnenčaková
- HEGITO (Div Hepatology, Gastroenterology and Liver Transplant), 2nd Department of Internal Medicine, Faculty of Medicine, Slovak Medical University, F. D. Roosevelt Teaching Hospital, Banská Bystrica, Slovakia
| | - T Koller
- Gastroenterology and Hepatology Subdiv, 5th Department of Internal Medicine, University Hospital Bratislava, Comenius University Faculty of Medicine, Bratislava, Slovakia
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Xu X, Fu Y, Jiang M, Wu M, Wu J, Meng Q. The effects and safety of anticoagulation or antiplatelet therapy following TIPS in cirrhotic patients with portal hypertension: A meta-analysis. Front Pharmacol 2023; 14:1116177. [PMID: 36891262 PMCID: PMC9986321 DOI: 10.3389/fphar.2023.1116177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/24/2023] [Indexed: 02/22/2023] Open
Abstract
Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) is an effective way to improve portal hypertension, however, the role of anticoagulation or antiplatelet therapy following TIPS remains controversial. We conducted this study to evaluate the efficacy and safety of anticoagulation or antiplatelet therapy following TIPS. Methods: A literature search was conducted on anticoagulation or antiplatelet therapy after TIPS using Pubmed, Web of Science, EMBASE, and Cochrane. The retrieval period was from the earliest accessible date in the database to 31 October 2022. We collected information on the incidence of stent dysfunction, bleeding, hepatic encephalopathy, the new occurrence of portal vein thrombosis, and the survival rate. Stata was analyzed in RevMan. Results: 1. Four studies received anticoagulation or antiplatelet therapy after TIPS without control groups. According to the single-group rate meta-analysis, stent dysfunction occurred at 27% [95% CI (0.19, 0.38)], bleeding occurred at 21% [95% CI (0.14, 0.29)], new portal vein thrombosis occurred at 17% [(95%CI(0.04.0.71)], hepatic encephalopathy occurred at 47% [95%CI (0.34, 0.63)], and death occurred at 31% [95% CI (0.22, 0.42)]. 2. Eight studies, including 1025 patients, compared anticoagulation and antiplatelet therapy after TIPS to TIPS alone. In terms of stent dysfunction, bleeding, and hepatic encephalopathy, there were no significant differences between the two groups. The use of anticoagulation or antiplatelet therapy may result in a significant decrease in the incidence of new portal vein thrombosis and mortality over 1 year. Discussion: Anticoagulant or antiplatelet therapy may not improve the patency rate of TIPS, but may effectively prevent new portal vein thrombosis after TIPS. Following TIPS, the use of anticoagulants or antiplatelet drugs does not lead to an increase in bleeding or death.
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Affiliation(s)
- Xiaotong Xu
- Department of Oncology, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Yunlai Fu
- Department of Oncology, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Minjie Jiang
- Department of Oncology, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Muchen Wu
- Department of Oncology, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Jing Wu
- Department of Hepatology, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Qinghua Meng
- Department of Oncology, Beijing You An Hospital, Capital Medical University, Beijing, China
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10
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Liu J, Yuan Z, Wang Q. Pluripotent Stem Cell-derived Strategies to Treat Acute Liver Failure: Current Status and Future Directions. J Clin Transl Hepatol 2022; 10:692-699. [PMID: 36062278 PMCID: PMC9396313 DOI: 10.14218/jcth.2021.00353] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 01/17/2022] [Accepted: 02/12/2022] [Indexed: 12/04/2022] Open
Abstract
Liver disease has long been a heavy health and economic burden worldwide. Once the disease is out of control and progresses to end-stage or acute organ failure, orthotopic liver transplantation (OLT) is the only therapeutic alternative, and it requires appropriate donors and aggressive administration of immunosuppressive drugs. Therefore, hepatocyte transplantation (HT) and bioartificial livers (BALs) have been proposed as effective treatments for acute liver failure (ALF) in clinics. Although human primary hepatocytes (PHs) are an ideal cell source to support these methods, the large demand and superior viability of PH is needed, which restrains its wide usage. Thus, a finding alternative to meet the quantity and quality of hepatocytes is urgent. In this context, human pluripotent stem cells (PSC), which have unlimited proliferative and differential potential, derived hepatocytes are a promising renewable cell source. Recent studies of the differentiation of PSC into hepatocytes has provided evidence that supports their clinical application. In this review, we discuss the recent status and future directions of the potential use of PSC-derived hepatocytes in treating ALF. We also discuss opportunities and challenges of how to promote such strategies in the common applications in clinical treatments.
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Affiliation(s)
- Jingfeng Liu
- Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Science, Shenzhen, Guangdong, China
- Shenzhen Key Laboratory of Immunity and Inflammatory Diseases, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
- Department of Rheumatism and Immunology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Zhiming Yuan
- Department of Gastroenterology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Qingwen Wang
- Shenzhen Key Laboratory of Immunity and Inflammatory Diseases, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
- Department of Rheumatism and Immunology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
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11
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Will V, Rodrigues SG, Berzigotti A. Current treatment options of refractory ascites in liver cirrhosis - A systematic review and meta-analysis. Dig Liver Dis 2022; 54:1007-1014. [PMID: 35016859 DOI: 10.1016/j.dld.2021.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/24/2021] [Accepted: 12/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Refractory ascites is a severe complication of liver cirrhosis and treatment options consist in large volume paracentesis, transjugular intrahepatic portosystemic shunt, alfapump®, peritoneovenous shunt and permanent indwelling peritoneal catheter. AIM Our aim was to assess the efficacy, mortality and complications of each treatment. METHODS We performed a systematic review using Pubmed and Embase. Frequencies were summarized with Comprehensive Meta-Analysis Software. RESULTS Seventy-seven studies were included. In patients with transjugular intrahepatic portosystemic shunt, 1-year mortality was 33% (95% CI 0.29-0.39, I2=82.1; τ2 = 0.37; p<0.001) with lower mortality in newer studies (26% vs. 44%). At 6 months, mortality in patients with alfapump® was 24% (95% CI 0.16-0.33, I2=0.00; τ2 = 0.00; p = 0.83), 31% developed acute kidney injury (95% CI 0.18-0.48, I2=44.0; τ2 = 0.22; p = 0.15). Mortality at 12 months was 44% (95% CI 32%-58%, I2=76.7, τ2 = 0.44, p<0.001) in peritoneovenous shunts and 45% (95% CI 38%-53%, I2=61.4, τ2 = 0.18, p = 0.003) in large volume paracentesis, respectively. Overall mortality in patients with permanent indwelling catheters was 66% (95% CI 33%-89%, I2=82.5, τ2 = 1.57, p = 0.001). DISCUSSION Mortality in patients with transjugular intrahepatic portosystemic shunt was lower in newer studies, probably due to a better patient selection. Acute kidney injury was frequent in patients with alfapump®. Permanent indwelling catheters seemed to be a good option in a palliative setting.
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Affiliation(s)
- Valerie Will
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Susana G Rodrigues
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Annalisa Berzigotti
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland.
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12
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Jeyanesan D, Balachandrakumar VK, Hogan B. Guideline review: transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension-a BSG guideline. Frontline Gastroenterol 2022; 13:531-534. [PMID: 36250168 PMCID: PMC9555133 DOI: 10.1136/flgastro-2022-102151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 05/03/2022] [Indexed: 02/04/2023] Open
Abstract
The decision-making around transjugular intrahepatic portosystemic shunt (TIPSS) placement in the management of patients with chronic liver disease and portal hypertension (PH) is a regular challenge for hepatologists. In the UK, access has improved, with more than 35 hospitals now offering this service. However, its role in acute variceal bleeding, refractory ascites and other complications of PH continues to be redefined and expanded. In particular, the role of pre-emptive TIPSS has become more established and requires re-evaluation of pathways to enable equitable access for patients. Here, we summarise the key recommendations from the recently published British Society of Gastroenterology guidelines and expand on the challenges posed.
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Affiliation(s)
- Dhaarica Jeyanesan
- Institute of Liver Studies, King's College Hospital Liver Unit, London, UK
| | | | - Brian Hogan
- Institute of Liver Studies, King's College Hospital Liver Unit, London, UK
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13
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Transjugular intrahepatic portosystemic shunt with transhepatic portal vein puncture guided by ultrasound: a technical alternative. Eur J Gastroenterol Hepatol 2022; 34:112-116. [PMID: 34748302 DOI: 10.1097/meg.0000000000002174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Evaluation of an alternative technique to perform transjugular intrahepatic portosystemic shunt (TIPS), using abdominal ultrasound to guide portal puncture. METHODS Retrospective analysis of TIPS performed from January 2014 to December 2018 in an interventional radiology service. TIPS were performed according to the classic technique, except at the moment of portal branch puncture, when abdominal ultrasound was used to guide it, visualized its path within the parenchyma in real-time. Qualitative and quantitative variables were analyzed considering a 95% confidence interval and application of the Student's t-test with a significance level of P < 0.05. RESULTS Forty-one TIPS were performed. The technical success rate of ultrasound guidance in portal puncture was 100.0%. After its performance, a reduction in the portosystemic pressure gradient was observed, with an initial gradient average of 18.8 mmHg (12-25 ± 3.6 mmHg) and a final gradient of 9.2 mmHg (5-14 ± 2.4 mmHg). The mean values for the TIPS execution time, fluoroscopy time and the radiation dose, verified through the dose area product, were 65.2 ± 46.7 min, 25 ± 14.1 min and 85.6 ± 70 Gy cm2, respectively. There were no complications related to the inadvertent puncture of nontarget structures or deaths due to complications resulting from TIPS. CONCLUSION The results demonstrate that the portal transhepatic puncture guided by the abdominal ultrasound is an effective and safe procedure and results in time of execution, time of fluoroscopy and radiation dose below the current reference values of the conventional procedure.
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14
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Portal decompression with transjugular intrahepatic portosystemic shunt prior to nonhepatic surgery: a single-center case series. Eur J Gastroenterol Hepatol 2021; 33:e254-e259. [PMID: 33323758 DOI: 10.1097/meg.0000000000002026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Cirrhosis increases perioperative and postoperative mortality in nonhepatic surgery. Transjugular intrahepatic portosystemic shunt (TIPSS), by reducing portal pressure, may reduce intraoperative bleeding and postoperative decompensation. We report our experience of prophylactic TIPSS in nonhepatic surgery. METHODS Patients who underwent prophylactic TIPSS before nonhepatic surgery were identified from database with retrospective data collection via an e-patient record system. Primary outcome was discharged without hepatic decompensation after a planned surgery. RESULTS Twenty-one patients [age (median, range): 55, 33-76 years, Child's score: 6, 5-9] who underwent prophylactic TIPSS before nonhepatic surgery over a period of 9 years were included. All patients underwent successful TIPSS with a reduction in portal pressure gradient from 21.5 (11-35) to 16 (7-25) mmHg (P < 0.001). Immediate post-TIPSS complications were seen in 7 (33%) patients including hepatic encephalopathy in four. Eighteen patients (86%) underwent planned surgical intervention. Significant postoperative complications included hepatic encephalopathy (3), sepsis (2) and bleed (1). Two patients died postoperatively with multi-organ failure. The primary outcome was achieved in 12 (57%) patients. Post-TIPSS portal pressure gradient was significantly higher in patients with the adverse primary outcome. Over a follow-up period of 11 (1-78) months; 1-, 6- and 12-months' survival was 90, 80 and 76%, respectively. CONCLUSION Prophylactic TIPSS is associated with complications in up to one-third of patients, with 57% achieving the primary outcome. Careful patient selection in a multidisciplinary team setting is essential. Multicentre studies are necessary before the universal recommendation of prophylactic TIPSS.
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15
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Cell therapy for advanced liver diseases: Repair or rebuild. J Hepatol 2021; 74:185-199. [PMID: 32976865 DOI: 10.1016/j.jhep.2020.09.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/18/2020] [Accepted: 09/14/2020] [Indexed: 12/15/2022]
Abstract
Advanced liver disease presents a significant worldwide health and economic burden and accounts for 3.5% of global mortality. When liver disease progresses to organ failure the only effective treatment is liver transplantation, which necessitates lifelong immunosuppression and carries associated risks. Furthermore, the shortage of suitable donor organs means patients may die waiting for a suitable transplant organ. Cell therapies have made their way from animal studies to a small number of early clinical trials. Herein, we review the current state of cell therapies for liver disease and the mechanisms underpinning their actions (to repair liver tissue or rebuild functional parenchyma). We also discuss cellular therapies that are on the clinical horizon and challenges that must be overcome before routine clinical use is a possibility.
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16
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de Wit K, Schaapman JJ, Nevens F, Verbeek J, Coenen S, Cuperus FJC, Kramer M, Tjwa ETTL, Mostafavi N, Dijkgraaf MGW, van Delden OM, Beuers UHW, Coenraad MJ, Takkenberg RB. Prevention of hepatic encephalopathy by administration of rifaximin and lactulose in patients with liver cirrhosis undergoing placement of a transjugular intrahepatic portosystemic shunt (TIPS): a multicentre randomised, double blind, placebo controlled trial (PEARL trial). BMJ Open Gastroenterol 2020; 7:e000531. [PMID: 33372103 PMCID: PMC7783616 DOI: 10.1136/bmjgast-2020-000531] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/12/2020] [Accepted: 11/26/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Cirrhotic patients with portal hypertension can suffer from variceal bleeding or refractory ascites and can benefit from a transjugular intrahepatic portosystemic shunt (TIPS). Post-TIPS hepatic encephalopathy (HE) is a common (20%-54%) and often severe complication. A prophylactic strategy is lacking. METHODS AND ANALYSIS The Prevention of hepatic Encephalopathy by Administration of Rifaximin and Lactulose in patients with liver cirrhosis undergoing placement of a TIPS (PEARL) trial, is a multicentre randomised, double blind, placebo controlled trial. Patients undergoing covered TIPS placement are prescribed either rifaximin 550 mg two times per day and lactulose 25 mL two times per day (starting dose) or placebo 550 mg two times per day and lactulose 25 mL two times per day from 72 hours before and until 3 months after TIPS placement. Primary endpoint is the development of overt HE (OHE) within 3 months (according to West Haven criteria). Secondary endpoints include 90-day mortality; development of a second episode of OHE; time to development of episode(s) of OHE; development of minimal HE; molecular changes in peripheral and portal blood samples; quality of life and cost-effectiveness. The total sample size is 238 patients and recruitment period is 3 years in six hospitals in the Netherlands and one in Belgium. ETHICS AND DISSEMINATION This study protocol was approved in the Netherlands by the Medical Research Ethics Committee of the Academic Medical Centre, Amsterdam (2018-332), in Belgium by the Ethics Committee Research UZ/KU Leuven (S62577) and competent authorities. This study will be conducted in accordance with Good Clinical Practice guidelines and the principles of the Declaration of Helsinki. Study results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBERS ClinicalTrials.gov (NCT04073290) and EudraCT database (2018-004323-37).
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Affiliation(s)
- K de Wit
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - J J Schaapman
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - F Nevens
- Gastroenterology and Hepatology, University Hospitals KU Leuven, Leuven, Belgium
| | - J Verbeek
- Gastroenterology and Hepatology, University Hospitals KU Leuven, Leuven, Belgium
| | - S Coenen
- Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - F J C Cuperus
- Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - M Kramer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - E T T L Tjwa
- Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N Mostafavi
- Biostatistics Unit, Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - M G W Dijkgraaf
- Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - O M van Delden
- Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - U H W Beuers
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - M J Coenraad
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - R B Takkenberg
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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Will V, Rodrigues SG, Stirnimann G, Gottardi AD, Bosch J, Berzigotti A. Transjugular intrahepatic portosystemic shunt and alfapump® system for refractory ascites in liver cirrhosis: Outcomes and complications. United European Gastroenterol J 2020; 8:961-969. [PMID: 32588789 DOI: 10.1177/2050640620938525] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Treatment of refractory ascites in liver cirrhosis is challenging. Transjugular intrahepatic portosystemic shunt and alfapump® have been proposed for the management, but few data comparing both exist. AIMS The aim of this study was to evaluate the characteristics and outcomes of patients treated with transjugular intrahepatic portosystemic shunt and alfapump® for refractory ascites at our centre. METHODS All consecutive patients were retrospectively reviewed for baseline characteristics, efficacy of treatment, complications and survival. RESULTS In total, 19 patients with transjugular intrahepatic portosystemic shunt and 40 patients with alfapump® were included. Patients with transjugular intrahepatic portosystemic shunt had better liver function and less hepatic encephalopathy at baseline. Fifty-eight per cent of patients developed hepatic encephalopathy in the first six months after transjugular intrahepatic portosystemic shunt. In patients with alfapump®, renal function decreased and 58% developed prerenal impairment and 43% hepatorenal syndrome in the first six months. Alfapump® patients with new catheters required less reinterventions (26% versus 57% with old catheters, p = 0.049). Transplant-free survival at 1 year was 25% in alfapump® and 65% in transjugular intrahepatic portosystemic shunt. Hepatic encephalopathy predicted transplant-free survival in patients with alfapump® (hazard ratio 2.00, 95% confidence interval 0.99-4.02, p = 0.05). In a sensitivity analysis comparing patients with similar liver function, the rate of hepatorenal syndrome and prerenal impairment was higher in patients with alfapump® and these patients were hospitalised more frequently, whereas the rate of hepatic encephalopathy was similar in both treatment groups. CONCLUSIONS Both transjugular intrahepatic portosystemic shunt and alfapump® were effective treatments for refractory ascites in cirrhosis. Patients treated with transjugular intrahepatic portosystemic shunt had a better one-year transplant-free survival but had less negative prognostic factors at baseline. Selecting patients without hepatic encephalopathy prior to implantation of an alfapump® might improve transplant-free survival.
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Affiliation(s)
- Valerie Will
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland
| | - Susana G Rodrigues
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland
| | - Guido Stirnimann
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland
| | - Andrea De Gottardi
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland
| | - Jaime Bosch
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland.,Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Annalisa Berzigotti
- Hepatology, University Clinic for Visceral Surgery and Medicine, Bern, Switzerland
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18
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Santos S, Dantas E, Veloso Gomes F, Luz JH, Vasco Costa N, Bilhim T, Calinas F, Martins A, Coimbra É. Retrospective Study of Transjugular Intrahepatic Portosystemic Shunt Placement for Cirrhotic Portal Hypertension. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:5-12. [PMID: 33564700 DOI: 10.1159/000507894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 04/13/2020] [Indexed: 12/14/2022]
Abstract
Background and Aims Transjugular intrahepatic portosystemic shunt (TIPS) is used for decompressing clinically significant portal hypertension. The aims of this study were to evaluate clinical outcomes and adverse events associated with this procedure. Methods Retrospective single-center study including 78 patients submitted to TIPS placement between January 2015 and November 2018. Follow-up data were missing in 27 patients, and finally 51 patients were included in the study sample. Data collected from individual registries included demographics, comorbidities, laboratory results, complications, and clinical results according to the indication. Results Average pre-TIPS portosystemic pressure gradient decreased from 18.1 ± 5 to 6 ± 3 mm Hg after TIPS placement. Indications for TIPS were refractory ascites (63%, n = 49), recurrent or uncontrolled variceal bleeding (36%, n = 28), and Budd-Chiari syndrome (1.3%, n = 1). TIPS-related adverse events occurred in 29/51 (56.8%) patients, with hepatic encephalopathy (HE) in 21 (41%) patients, sepsis in 3, liver failure in 2, hemolytic anemia in 1, acute pulmonary edema in 1, and capsular perforation in 1 patient. Mean follow-up was 15.7 ± 15 months. First-month mortality was 11.7% (n = 6) (sepsis, n = 3; acute liver failure, n = 2; and recurrence of variceal bleeding, n = 1) and was significantly higher for patients with Child-Pugh >9 points (p = 0.01), model of end-stage liver disease (MELD) scores >19 (p = 0.02), and for patients with a history of HE before the procedure (p = 0.001). Older age (p = 0.006) and higher levels of creatinine (p = 0.008) were significantly higher in patients developing HE after TIPS. Ascites persisted in 21.2% (7/33 patients) and was more frequent in patients with lower baseline albumin levels (p = 0.003). Recurrent variceal bleeding occurred in 22% (n = 4/18 patients) and was more frequent in patients with lower baseline hemoglobin levels (p = 0.03). Conclusion TIPS is effective in up to 80% of patients presenting with variceal bleeding or refractory ascites. Careful patient selection based on age and HE history may reduce adverse events after TIPS.
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Affiliation(s)
- Sara Santos
- Gastroenterology and Hepatology Department, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Eduardo Dantas
- Gastroenterology and Hepatology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Filipe Veloso Gomes
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - José Hugo Luz
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Nuno Vasco Costa
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Tiago Bilhim
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Filipe Calinas
- Gastroenterology and Hepatology Department, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Américo Martins
- Surgery Department, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Élia Coimbra
- Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
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Bucher JN, Hollenbach M, Strocka S, Gaebelein G, Moche M, Kaiser T, Bartels M, Hoffmeister A. Segmental intrahepatic cholestasis as a technical complication of the transjugular intrahepatic porto-systemic shunt. World J Gastroenterol 2019; 25:6430-6439. [PMID: 31798279 PMCID: PMC6881513 DOI: 10.3748/wjg.v25.i43.6430] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/25/2019] [Accepted: 11/07/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Segmental intrahepatic cholestasis caused by transjugular intrahepatic portosystemic shunt (TIPS) (SIC-T), is a rare complication of this technique and only referred by case reports. Thus, we conducted a systematic, retrospective analysis to provide evidence regarding prevalence and consequences of this TIPS-induced bile duct compression.
AIM To assess prevalence and outcome of SIC-T in a large TIPS-cohort.
METHODS In this retrospective cohort study, we screened the institutional databases for all consecutive patients that were treated by TIPS-placement or TIPS-revision between January 2005 and August 2013. We analyzed radiologic images for signs of biliary congestion. Cases that were indicative of SIC-T were reviewed by two independent radiologists and additional patient data was collected. Descriptive statistics of patient demographics, indications for TIPS and procedural details were registered. Logistic regression analysis was performed to identify predictors for the development of SIC-T.
RESULTS We analyzed 135 cirrhotic patients who underwent TIPS (mean age 55 years, 79% male gender). Etiology of cirrhosis was alcohol in most cases and indications for TIPS were mainly refractory ascites and recurrent variceal bleeding. TIPS revision was necessary in 31 patients. We identified 4 cases (2.9%) of SIC-T in direct proximity of the TIPS-stent. Diagnosis was confirmed by CT-scan, MRI or endoscopic retrograde cholangio pancreaticography (ERCP). In two patients TIPS was implanted via the right and in one through the medial hepatic vein. One patient received TIPS-prolongation by multiple revisions. Most patients were asymptomatic but one cholangitic abscess necessitated a transhepatic drain. Logistic regression analysis identified TIPS-placement other than from medial hepatic vein to right portal vein as risk factor (OR 21.0) for SIC-T.
CONCLUSION SIC-T ads to (mostly late) complications in the interventional treatment of cirrhotic portal hypertensions and can lead to cholangitic abscesses. Patients, particularly with multiple interventions, should be screened for SIC-T.
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Affiliation(s)
- Julian Nikolaus Bucher
- Department of Surgery, Munich University Hospital at Großhadern, Bavaria, Munich 81377, Germany
| | - Marcus Hollenbach
- Medical Department II–Gastroenterology, Hepatology, Infectious Diseases, Pulmonology, University of Leipzig Medical Center, Saxony, Leipzig 04103, Germany
| | - Steffen Strocka
- Department of Diagnostic and Interventional Radiology, University of Leipzig Medical Center, Saxony, Leipzig 04103, Germany
| | - Gereon Gaebelein
- Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Saarland, Homburg 66421, Germany
| | - Michael Moche
- Department of Diagnostic and Interventional Radiology, Bavaria, Nuernberg 90411, Germany
| | - Thorsten Kaiser
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center, Saxony, Leipzig 04310, Germany
| | - Michael Bartels
- Department for General and Visceral Surgery, Helios Park-Klinikum Leipzig, Saxony, Leipzig 04289, Germany
| | - Albrecht Hoffmeister
- Medical Department II–Gastroenterology, Hepatology, Infectious Diseases, Pulmonology, University of Leipzig Medical Center, Leipzig 04103, Saxony, Germany
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