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Waidyaratne G, Jalil S, Liu A, Liyanarachchi S, Makary MS, Rikabi A, Acharya C, Mendiratta V, Peng J, Ma J, Mumtaz K. Utility of Advanced Age as a Predictor of Outcomes in Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt. Dig Dis Sci 2025:10.1007/s10620-025-08940-0. [PMID: 40024959 DOI: 10.1007/s10620-025-08940-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 02/18/2025] [Indexed: 03/04/2025]
Abstract
INTRODUCTION Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for managing major complications of cirrhosis including refractory ascites, hydrothorax, and variceal bleed. The impact of advanced age on outcomes of TIPS has not been studied comprehensively. Therefore, we aimed to study optimal advanced age cutoff in context of MELD score for patients undergoing TIPS. METHODS A single-center retrospective analysis of all adult patients with cirrhosis, who underwent TIPS between 2002 and 2020 was performed. Univariate and multivariate analyses were conducted to determine the development of hepatic encephalopathy (HE) and mortality at 30 days and 1 year. The impact of various age groups (55, 60, 65, and 70 years) and MELD score cutoffs on mortality were elucidated. RESULTS A total of 225 patients were included. No significant associations were found between advanced age and short-term mortality (p = 0.410), short-term development of HE (p = 0.846), or secondary post-TIPS outcomes such as rebleed or need for paracentesis. However, advanced age was associated with significant differences in post TIPS mortality (p = 0.026) and inpatient development of HE (p = 0.032) at 1-year. These associations were confirmed in multivariate models. Area under the covariate adjusted receiver operating curve (AUROC) identified optimal age and MELD cutoffs as 60 years and 15 for 1-year mortality, respectively. An optimal age cutoff of 54 was identified for 1-year HE. CONCLUSIONS Advanced age is strongly associated with 1-year mortality and 1-year development of HE post-TIPS. Poorer post-TIPS outcomes were further observed in patients with higher MELD. Therefore, during selection of advanced age patients for TIPS, MELD score should be considered for better long-term outcomes.
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Affiliation(s)
- Gavisha Waidyaratne
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sajid Jalil
- Division of Gastroenterology and Hepatology, Stanford Medicine, Stanford, CA, USA
| | - Alex Liu
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandya Liyanarachchi
- College of Medicine and Comprehensive Cancer Center, Department of Molecular Medicine and Therapeutics, The Ohio State University, Columbus, OH, USA
| | - Mina S Makary
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ali Rikabi
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Chathur Acharya
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Vivek Mendiratta
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jing Peng
- Center for Biostatistics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jianing Ma
- Center for Biostatistics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Zhao Y, Wang Y, Xu J. Predictive Accuracy Comparison of Prognostic Scoring Systems for Survival in Patients Undergoing TIPS Placement: A Systematic Review and Meta-analysis. Acad Radiol 2024; 31:3688-3710. [PMID: 38000922 DOI: 10.1016/j.acra.2023.10.050] [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: 09/18/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023]
Abstract
RATIONALE AND OBJECTIVES 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. MATERIALS AND METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Yan Zhao
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yun Wang
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Junwang Xu
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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Büttner L, Pick L, Jonczyk M, Fehrenbach U, Collettini F, Auer TA, Schnapauff D, De Bucourt M, Wieners G, Gebauer B, Aigner A, Böning G. Shunt dysfunction and mortality after transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension. Insights Imaging 2024; 15:193. [PMID: 39112682 PMCID: PMC11306489 DOI: 10.1186/s13244-024-01768-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/07/2024] [Indexed: 08/10/2024] Open
Abstract
OBJECTIVES Transjugular intrahepatic portosystemic shunt (TIPS) is a catheter-based, minimally invasive procedure to reduce portal hypertension. The aim of the study was to investigate dysfunction and mortality after TIPS and to identify factors associated with these events. METHODS A retrospective analysis of 834 patients undergoing TIPS implantation in a single center from 1993-2018 was performed. Cumulative incidence curves were estimated, and frailty models were used to assess associations between potentially influential variables and time to dysfunction or death. RESULTS 1-, 2-, and 5-year mortality rates were 20.9% (confidence interval (CI) 17.7-24.1), 22.5% (CI 19.1-25.8), and 25.0% (CI: 21.1-28.8), 1-year, 2-year, and 5-year dysfunction rates were 28.4% (CI 24.6-32.3), 38.9% (CI 34.5-43.3), and 52.4% (CI 47.2-57.6). The use of covered stents is a protective factor regarding TIPS dysfunction (hazard ratio (HR) 0.47, CI 0.33-0.68) but does not play a major role in survival (HR 0.95, CI 0.58-1.56). Risk factors for mortality are rather TIPS in an emergency setting (HR 2.78, CI 1.19-6.50), a previous TIPS dysfunction (HR 2.43, CI 1.28-4.62), and an increased Freiburg score (HR 1.45, CI 0.93-2.28). CONCLUSION The use of covered stents is an important protective factor regarding TIPS dysfunction. Whereas previous TIPS dysfunction, emergency TIPS implantation, and an elevated Freiburg score are associated with increased mortality. Awareness of risk factors could contribute to a better selection of patients who may benefit from a TIPS procedure and improve clinical follow-up with regard to early detection of thrombosis/stenosis. CRITICAL RELEVANCE STATEMENT The use of covered stents reduces the risk of dysfunction after transjugular intrahepatic portosystemic shunt (TIPS). TIPS dysfunction, emergency TIPS placement, and a high Freiburg score are linked to higher mortality rates in TIPS patients. KEY POINTS The risk of dysfunction is higher for uncovered stents compared to covered stents. Transjugular intrahepatic portosystemic shunt dysfunction increases the risk of instantaneous death after the intervention. A higher Freiburg score increases the rate of death after the intervention. Transjugular intrahepatic portosystemic shunt implantations in emergency settings reduce survival rates.
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Affiliation(s)
- Laura Büttner
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany.
| | - Lisa Pick
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Jonczyk
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Uli Fehrenbach
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Federico Collettini
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Timo Alexander Auer
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Dirk Schnapauff
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Maximilian De Bucourt
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Gero Wieners
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Bernhard Gebauer
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Annette Aigner
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Georg Böning
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
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Cai W, Lin X, Guo Y, Lin X, Chen C. A nomogram for predicting prognosis in patients with transjugular intrahepatic portosystemic shunt creation based on deep learning-derived spleen volume-to-platelet ratio. Br J Radiol 2024; 97:600-606. [PMID: 38288507 DOI: 10.1093/bjr/tqad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 11/09/2023] [Accepted: 12/21/2023] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVES The objective of our study was to develop a nomogram to predict post-transjugular intrahepatic portosystemic shunt (TIPS) survival in patients with cirrhosis based on CT images. METHODS This retrospective cohort study included patients who had received TIPS operation at the Wenzhou Medical University First Affiliated Hospital between November 2013 and April 2017. To predict prognosis, a nomogram and Web-based probability were developed to assess the overall survival (OS) rates at 1, 3, and 5 years based on multivariate analyses. With deep learning algorithm, the automated measurement of liver and spleen volumes can be realized. We assessed the predictive accuracy and discriminative ability of the nomogram using the concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). RESULTS Age, total bilirubin, and spleen volume-to-platelet ratio (SVPR) were identified as the independent risk factors for OS. The nomogram was constructed based on the above risk factors. The C-index (0.80, 0.74, 0.70), ROC curve (area under curve: 0.828, 0.761, 0.729), calibration curve, and DCA showed that nomogram good at predictive value, stability, and clinical benefit in the prediction of 1-, 3-, 5-year OS in patients with TIPS creation. CONCLUSIONS We constructed a nomogram for predicting prognosis in patients with TIPS creation based on risk factors. The nomogram can help clinicians in identifying patients with poor prognosis, eventually facilitating earlier treatment and selecting suitable patients before TIPS. ADVANCES IN KNOWLEDGE This study developed the first nomogram based on SVPR to predict the prognosis of patients treated with TIPS. The nomogram could help clinician in non-invasive decision-making.
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Affiliation(s)
- Weimin Cai
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Xinran Lin
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Yu Guo
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Xiuqing Lin
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Chao Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
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Lv YF, Zhu B, Meng MM, Wu YF, Dong CB, Zhang Y, Liu BW, You SL, Lv S, Yang YP, Liu FQ. Development of a new Cox model for predicting long-term survival in hepatitis cirrhosis patients underwent transjugular intrahepatic portosystemic shunts. World J Gastrointest Surg 2024; 16:491-502. [PMID: 38463355 PMCID: PMC10921221 DOI: 10.4240/wjgs.v16.i2.491] [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: 11/21/2023] [Revised: 12/23/2023] [Accepted: 01/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) placement is a procedure that can effectively treat complications of portal hypertension, such as variceal bleeding and refractory ascites. However, there have been no specific studies on predicting long-term survival after TIPS placement. AIM To establish a model to predict long-term survival in patients with hepatitis cirrhosis after TIPS. METHODS A retrospective analysis was conducted on a cohort of 224 patients who underwent TIPS implantation. Through univariate and multivariate Cox regression analyses, various factors were examined for their ability to predict survival at 6 years after TIPS. Consequently, a composite score was formulated, encompassing the indication, shunt reasonability, portal venous pressure gradient (PPG) after TIPS, percentage decrease in portal venous pressure (PVP), indocyanine green retention rate at 15 min (ICGR15) and total bilirubin (Tbil) level. Furthermore, the performance of the newly developed Cox (NDC) model was evaluated in an internal validation cohort and compared with that of a series of existing models. RESULTS The indication (variceal bleeding or ascites), shunt reasonability (reasonable or unreasonable), ICGR15, postoperative PPG, percentage of PVP decrease and Tbil were found to be independent factors affecting long-term survival after TIPS placement. The NDC model incorporated these parameters and successfully identified patients at high risk, exhibiting a notably elevated mortality rate following the TIPS procedure, as observed in both the training and validation cohorts. Additionally, in terms of predicting the long-term survival rate, the performance of the NDC model was significantly better than that of the other four models [Child-Pugh, model for end-stage liver disease (MELD), MELD-sodium and the Freiburg index of post-TIPS survival]. CONCLUSION The NDC model can accurately predict long-term survival after the TIPS procedure in patients with hepatitis cirrhosis, help identify high-risk patients and guide follow-up management after TIPS implantation.
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Affiliation(s)
- Yi-Fan Lv
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Bing Zhu
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Ming-Ming Meng
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yi-Fan Wu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Cheng-Bin Dong
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yu Zhang
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Bo-Wen Liu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Shao-Li You
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Sa Lv
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Yong-Ping Yang
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Fu-Quan Liu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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Ferrarese A, Bucci M, Zanetto A, Senzolo M, Germani G, Gambato M, Russo FP, Burra P. Prognostic models in end stage liver disease. Best Pract Res Clin Gastroenterol 2023; 67:101866. [PMID: 38103926 DOI: 10.1016/j.bpg.2023.101866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/13/2023] [Accepted: 08/18/2023] [Indexed: 12/19/2023]
Abstract
Cirrhosis is a major cause of death worldwide, and is associated with significant health care costs. Even if milestones have been recently reached in understanding and managing end-stage liver disease (ESLD), the disease course remains somewhat difficult to prognosticate. These difficulties have already been acknowledged already in the past, when scores instead of single parameters have been proposed as valuable tools for short-term prognosis. These standard scores, like Child Turcotte Pugh (CTP) and model for end-stage liver disease (MELD) score, relying on biochemical and clinical parameters, are still widely used in clinical practice to predict short- and medium-term prognosis. The MELD score, which remains an accurate, easy-to-use, objective predictive score, has received significant modifications over time, in order to improve its performance especially in the liver transplant (LT) setting, where it is widely used as prioritization tool. Although many attempts to improve prognostic accuracy have failed because of lack of replicability or poor benefit with the comparator (often the MELD score or its variants), few scores have been recently proposed and validated especially for subgroups of patients with ESLD, as those with acute-on-chronic liver failure. Artificial intelligence will probably help hepatologists in the near future to fill the current gaps in predicting disease course and long-term prognosis of such patients.
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Affiliation(s)
- A Ferrarese
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Bucci
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - A Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - G Germani
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Gambato
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - F P Russo
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - P Burra
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy.
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Liu Y, Zhang J, Xu Y, Lu X. Letter to the editor: Reflection on the unsatisfactory model predicting mortality after transjugular intrahepatic portosystemic shunt in patients with cirrhosis. Hepatology 2023; 77:E55-E56. [PMID: 36102279 DOI: 10.1002/hep.32785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/08/2022]
Affiliation(s)
- Yaoge Liu
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases , Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
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Bayona Molano MDP, Barrera Gutierrez JC, Landinez G, Mejia A, Haskal ZJ. Updates on the Model for End-Stage Liver Disease Score and Impact on the Liver Transplant Waiting List: A Narrative Review. J Vasc Interv Radiol 2023; 34:337-343. [PMID: 36539154 DOI: 10.1016/j.jvir.2022.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 12/07/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
The model for end-stage liver disease (MELD) score is an established indicator of cirrhosis severity and a predictor of morbidity and mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation and for allocation in liver transplantation. Since the adoption of the score, its use has been expanded to multiple new indications requiring model modifications, including relevant clinical and demographic variables, to increase predictive accuracy. The purpose of this report is to provide an update on the modifications made to the MELD score, comparing their performance with C statistics, advantages and disadvantages, and impact on mortality at 3 months after placing a TIPS or awaiting liver transplantation.
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Affiliation(s)
| | | | - Gina Landinez
- Interventional Radiology Section, University of California San Francisco, San Francisco, California
| | - Alejandro Mejia
- Hepatobiliary and Transplant Surgery, Methodist Dallas Medical Center, Dallas, Texas
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging, University of Virginia School of Medicine, Charlottesville, Virginia
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Yang C, Xiong B. A comprehensive review of prognostic scoring systems to predict survival after transjugular intrahepatic portosystemic shunt placement. PORTAL HYPERTENSION & CIRRHOSIS 2022; 1:133-144. [DOI: 10.1002/poh2.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/05/2022] [Indexed: 09/01/2023]
Abstract
AbstractPatient prognosis after transjugular intrahepatic portosystemic shunt (TIPS) placement is relatively poor and highly heterogeneous; therefore, a prognostic scoring system is essential for survival prediction and risk stratification. Conventional scores include the Child–Turcotte–Pugh (CTP) and model for end‐stage liver disease (MELD) scores. The CTP score was created empirically and displayed a high correlation with post‐TIPS survival. However, the inclusion of subjective parameters and the use of discrete cut‐offs limit its utility. The advantages of the MELD score include its statistical validation and objective and readily available predictors that contribute to its broad application in clinical practice to predict post‐TIPS outcomes. In addition, multiple modifications of the MELD score, by incorporating additional predictors (e.g., MELD‐Sodium and MELD‐Sarcopenia scores), adjusting coefficients (recalibrated MELD score), or combined (MELD 3.0), have been proposed to improve the prognostic ability of the standard MELD score. Despite several updates to conventional scores, a prognostic score has been proposed (based on contemporary data) specifically for outcome prediction after TIPS placement. However, this novel score (the Freiburg index of post‐TIPS survival, FIPS) exhibited inconsistent discrimination in external validation studies, and its superiority over conventional scores remains undetermined. Additionally, several tools display potential for application in specific TIPS indications (e.g., bilirubin‐platelet grade for refractory ascites), and biomarkers of systemic inflammation, nutritional status, liver disease progression, and cardiac decompensation may provide additional value, but require further validation. Future studies should consider the effect of TIPS placement when exploring predictors, as TIPS is a pathophysiological approach that substantially alters systemic hemodynamics and ameliorates bacterial translocation and malnutrition.
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Affiliation(s)
- Chongtu Yang
- Department of Radiology Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Province Key Laboratory of Molecular Imaging Wuhan China
| | - Bin Xiong
- Department of Radiology Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Province Key Laboratory of Molecular Imaging Wuhan China
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Fürschuß L, Rainer F, Effenberger M, Niederreiter M, Portugaller RH, Horvath A, Fickert P, Stadlbauer V. A novel score predicts mortality after transjugular intrahepatic portosystemic shunt: MOTS - Modified TIPS Score. Liver Int 2022; 42:1849-1860. [PMID: 35261130 PMCID: PMC9539997 DOI: 10.1111/liv.15236] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 02/04/2022] [Accepted: 03/02/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS The high risk for severe shunting-related post-interventional complications demands a stringent selection of candidates for transjugular intrahepatic portosystemic shunt (TIPS). We aimed to develop a simple and reliable tool to accurately predict early post-TIPS mortality. METHODS 144 cases of TIPS implantation were retrospectively analysed. Using univariate and multivariate Cox regression analysis of factors predicting mortality within 90 days after TIPS, a score integrating urea, international normalized ratio (INR) and bilirubin was developed. The Modified TIPS-Score (MOTS) ranges from 0 to 3 points: INR >1.6, urea >71 mg/dl and bilirubin >2.2 mg/dl account for one point each. Additionally, MOTS was tested in an external validation cohort (n = 187) and its performance was compared to existing models. RESULTS Modified TIPS-Score achieved a significant prognostic discrimination reflected by 90-day mortality of 8% in patients with MOTS 0-1 and 60% in patients with MOTS 2-3 (p < .001). Predictive performance (area under the curve) of MOTS was accurate (c = 0.845 [0.73-0.96], p < .001), also in patients with renal insufficiency (c = 0.830 [0.64-1.00], p = .02) and in patients with refractory ascites (c = 0.949 [0.88-1.00], p < .001), which are subgroups with particular room for improvement of post-TIPS mortality prediction. The results were reproducible in the validation cohort. CONCLUSIONS Modified TIPS-Score is a novel, practicable tool to predict post-TIPS mortality, that can significantly simplify clinical decision making. Its practical applicability should be further investigated.
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Affiliation(s)
- Luisa Fürschuß
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
| | - Florian Rainer
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
| | - Maria Effenberger
- Department of Internal Medicine I, Gastroenterology, Hepatology and Endocrinology & Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Niederreiter
- Department of Internal Medicine I, Gastroenterology, Hepatology and Endocrinology & Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert H Portugaller
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Angela Horvath
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
- Centre for Biomarker Research in Medicine (CBmed), Graz, Austria
| | - Peter Fickert
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
- Centre for Biomarker Research in Medicine (CBmed), Graz, Austria
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11
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Boike JR, Thornburg BG, Asrani SK, Fallon MB, Fortune BE, Izzy MJ, Verna EC, Abraldes JG, Allegretti AS, Bajaj JS, Biggins SW, Darcy MD, Farr MA, Farsad K, Garcia-Tsao G, Hall SA, Jadlowiec CC, Krowka MJ, Laberge J, Lee EW, Mulligan DC, Nadim MK, Northup PG, Salem R, Shatzel JJ, Shaw CJ, Simonetto DA, Susman J, Kolli KP, VanWagner LB. North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension. Clin Gastroenterol Hepatol 2022; 20:1636-1662.e36. [PMID: 34274511 PMCID: PMC8760361 DOI: 10.1016/j.cgh.2021.07.018] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/01/2021] [Accepted: 07/13/2021] [Indexed: 02/07/2023]
Abstract
Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.
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Affiliation(s)
- Justin R. Boike
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bartley G. Thornburg
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Michael B. Fallon
- Department of Medicine, Division of Gastroenterology and Hepatology, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Brett E. Fortune
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Manhal J. Izzy
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth C. Verna
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Juan G. Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
| | - Andrew S. Allegretti
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Jasmohan S. Bajaj
- Department of Internal Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA, USA
| | - Scott W. Biggins
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Washington Medical Center, Seattle, WA, USA
| | - Michael D. Darcy
- Department of Radiology, Division of Interventional Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Maryjane A. Farr
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Khashayar Farsad
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Guadalupe Garcia-Tsao
- Department of Digestive Diseases, Yale University, Yale University School of Medicine, and VA-CT Healthcare System, CT, USA
| | - Shelley A. Hall
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, TX, USA
| | - Caroline C. Jadlowiec
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Michael J. Krowka
- Department of Pulmonary and Critical Care Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeanne Laberge
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Edward W. Lee
- Department of Radiology, Division of Interventional Radiology, University of California-Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - David C. Mulligan
- Department of Surgery, Division of Transplantation, Yale University School of Medicine, New Haven, CT, USA
| | - Mitra K. Nadim
- Department of Medicine, Division of Nephrology and Hypertension, University of Southern California, Los Angeles, California, USA
| | - Patrick G. Northup
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Riad Salem
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR, USA
| | - Cathryn J. Shaw
- Department of Radiology, Division of Interventional Radiology, Baylor University Medical Center, Dallas, TX, USA
| | - Douglas A. Simonetto
- Department of Physiology, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Susman
- Department of Radiology, Division of Interventional Radiology, Columbia University Irving Medical Center, New York, NY, USA
| | - K. Pallav Kolli
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Lisa B. VanWagner
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Address for correspondence: Lisa B. VanWagner MD MSc FAST FAHA, Assistant Professor of Medicine and Preventive Medicine, Divisions of Gastroenterology & Hepatology and Epidemiology, Northwestern University Feinberg School of Medicine, 676 N. St Clair St - Suite 1400, Chicago, Illinois 60611 USA, Phone: 312 695 1632, Fax: 312 695 0036,
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12
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Yang C, Chen Q, Zhou C, Liu J, Huang S, Wang Y, Wang C, Ju S, Chen Y, Li T, Bai Y, Yao W, Xiong B. FIPS Score for Prediction of Survival After TIPS Placement: External Validation and Comparison With Traditional Risk Scores in a Cohort of Chinese Patients With Cirrhosis. AJR Am J Roentgenol 2022; 219:255-267. [PMID: 35138134 DOI: 10.2214/ajr.21.27301] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Various prognostic scores for patients with chronic liver disease have been applied for predicting survival after TIPS placement. In 2021, the Freiburg index of post-TIPS survival (FIPS) score was developed specifically for predicting survival after TIPS placement. The score has exhibited variable performance in initial investigations conducted in German and U.S. cohorts. OBJECTIVE. The purpose of this study was to compare the utility of the FIPS score and traditional scoring systems for predicting post-TIPS survival in a cohort of Chinese patients with cirrhosis. METHODS. This retrospective validation study compared four prognostic scores (model for end-stage liver disease [MELD], sodium MELD [MELD-Na], Chronic Liver Failure Consortium acute decompensation [CLIF-C AD], and FIPS) in 383 patients (mean age, 54.9 ± 11.7 years; 249 men, 134 women) with cirrhosis who underwent TIPS placement (341 for variceal bleeding, 42 for refractory ascites) at Wuhan Union Hospital between January 2016 and August 2021. Model performance was assessed in terms of discrimination (using concordance index) and calibration (using Brier score and observed-to-predicted ratios) for 6-, 12-, and 24-month post-TIPS survival. Discrimination was further stratified by TIPS indication. Risk stratification was performed using previously proposed cutoffs for each score. RESULTS. During postprocedural follow-up, 72 (18.8%) patients died. Discriminative performance for 6-month survival was highest for FIPS score (concordance index, 0.784), followed by CLIF-C AD (0.743), MELD-Na (0.699), and MELD (0.694). FIPS score also showed the highest calibration in terms of lower Brier scores and observed-to-predicted ratios closer to 1 and showed the strongest prognostic performance for 12- and 24-month survival and in subgroups of patients who underwent TIPS placement for either variceal bleeding or refractory ascites (except for similar performance of FIPS and CLIF-C AD in the refractory ascites subgroup). When prior cutoffs were applied, further application of FIPS score was significantly associated with survival among patients classified as low risk by the other scores. CONCLUSION. FIPS score outperformed traditional risk scores in predicting post-TIPS survival in patients with cirrhosis. CLINICAL IMPACT. The findings support utility of FIPS score in differentiating patients who are optimal candidates for TIPS placement versus those at high risk who may instead warrant close monitoring and early liver transplant.
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Affiliation(s)
- Chongtu Yang
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Qingyong Chen
- Department of Emergency Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chen Zhou
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jiacheng Liu
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Songjiang Huang
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yingliang Wang
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chaoyang Wang
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Shuguang Ju
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yang Chen
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Tongqiang Li
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yaowei Bai
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Wei Yao
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Bin Xiong
- Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave #1277, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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13
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Büttner L, Aigner A, Pick L, Brittinger J, Steib CJ, Böning G, Streitparth F. 25 years of experience with transjugular intrahepatic portosystemic shunt (TIPS): changes in patient selection and procedural aspects. Insights Imaging 2022; 13:73. [PMID: 35416547 PMCID: PMC9008097 DOI: 10.1186/s13244-022-01216-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/21/2022] [Indexed: 12/15/2022] Open
Abstract
Background TIPS is an established treatment for portal hypertension. The aim was to analyze how patient selection for TIPS implantation and procedural aspects have changed over 25 years. Routinely collected demographic, clinical, laboratory, and procedural data of 835 patients treated with TIPS in a single center were used. Time trends over the observational period from 1993 to 2018 were retrospectively analyzed. Descriptive statistical analysis was performed. Results The most common indication for TIPS implantation has changed significantly from secondary prevention of variceal hemorrhage in the early years to treatment of recurrent ascites. During the observation period, increasingly more severely ill patients became TIPS candidates. There was little change in MELD scores over this period (in total median 13.00; IQR 10.00–18.00). The proportion of patients with Child–Pugh C cirrhosis increased. The most frequent underlying diseases in total were alcohol-related liver disease (66.5%) and viral hepatitis (11.9%). However, shares of cryptogenic liver cirrhosis, autoimmune hepatitis, and NASH increased over time. The proportion of patients post liver transplant also increased. While bare metal stents were standard in the past, use of covered stents increased. The success rate of TIPS (defined by successful implantation and a decrease in the portosystemic pressure gradient ≤ 12 mmHg) increased significantly over time. The total success rate according to this definition was 84.9%. Conclusion The results of our analysis reflect technical developments in TIPS, especially in terms of stent material and gains in clinical experience, particularly regarding indications and patient selection for TIPS implantation.
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Affiliation(s)
- Laura Büttner
- Department of Radiology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Annette Aigner
- Institute of Biometry, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Lisa Pick
- Department of Radiology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Josefine Brittinger
- Department of Radiology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Christian J Steib
- Medical Clinic II, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Georg Böning
- Department of Radiology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Florian Streitparth
- Department of Radiology, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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14
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Prognostic value of neutrophil-to-lymphocyte ratio in cirrhosis patients undergoing transjugular intrahepatic portosystemic shunt. Eur J Gastroenterol Hepatol 2022; 34:435-442. [PMID: 34750323 DOI: 10.1097/meg.0000000000002295] [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 The neutrophil-to-lymphocyte-ratio (NLR) is used as an inflammatory index and has proven to be an accurate prognostic indicator for decompensated cirrhotics; however, its role in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) has not been evaluated. We examined whether NLR is associated with mortality in decompensated cirrhosis patients undergoing TIPS. METHODS We performed a retrospective review of 268 decompensated cirrhotics who underwent TIPS from January 2011 to December 2015 at an academic medical center. NLR, patient demographics, manifestations of cirrhosis, TIPS indications and mortality were recorded. Univariate and multivariate Cox regression analyses for prognostic factors associated with 30-day and 90-day post TIPS mortality were performed. RESULTS A total of 129 (48%) patients received TIPS for refractory ascites with 79 (29%) for variceal bleeding, 14 (5%) for hepatic hydrothorax, and 46 (17%) for other indications. Cirrhosis etiology included hepatitis C (36%), alcohol (28%), nonalcoholic steatohepatitis (20%), or other (15%). Median NLR was 4.42 (IQR 2.75-7.19). Univariate and multivariate analysis showed NLR as an independent predictive factor of 30-day and 90-day mortality. Furthermore, in patients with a Model of End-Stage Liver Disease (MELD) ≤ 15, NLR is superior to MELD/MELD-Na score in predicting 30-day and 90-day mortality. In patients with MELD > 15, MELD/MELD-Na score is superior to NLR. CONCLUSION Our data indicate that elevated NLR independently predicts 30-day and 90-day mortality. In patients with a MELD ≤ 15, NLR is a better prognostic factor than MELD or MELD-Na in predicting short-term mortality.
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15
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Stockhoff L, Muellner-Bucsics T, Markova AA, Schultalbers M, Keimburg SA, Tergast TL, Hinrichs JB, Simon N, Gerbel S, Manns MP, Mandorfer M, Cornberg M, Meyer BC, Wedemeyer H, Reiberger T, Maasoumy B. Low Serum Cholinesterase Identifies Patients With Worse Outcome and Increased Mortality After TIPS. Hepatol Commun 2022; 6:621-632. [PMID: 34585537 PMCID: PMC8870033 DOI: 10.1002/hep4.1829] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/29/2021] [Accepted: 08/30/2021] [Indexed: 12/14/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension-related complications. However, careful selection of patients is crucial. The aim of this study was to evaluate the prognostic value of serum cholinesterase (CHE) for outcomes and mortality after TIPS insertion. In this multicenter study, 389 consecutive patients with cirrhosis receiving a TIPS at Hannover Medical School, University Hospital Essen, or Medical University of Vienna were included. The Hannover cohort (n = 200) was used to initially explore the role of CHE, whereas patients from Essen and Vienna served as a validation cohort (n = 189). Median age of the patients was 58 years and median Model for End-Stage Liver Disease (MELD) score was 12. Multivariable analysis identified MELD score (hazard ratio [HR]: 1.16; P < 0.001) and CHE (HR: 0.61; P = 0.008) as independent predictors for 1-year survival. Using the Youden Index, a CHE of 2.5 kU/L was identified as optimal threshold to predict post-TIPS survival in the Hannover cohort (P < 0.001), which was confirmed in the validation cohort (P = 0.010). CHE < 2.5 kU/L was significantly associated with development of acute-on-chronic liver failure (P < 0.001) and hepatic encephalopathy (P = 0.006). Of note, CHE was also significantly linked to mortality in the subgroup of patients with refractory ascites (P = 0.001) as well as in patients with high MELD scores (P = 0.012) and with high-risk FIPS scores (P = 0.004). After propensity score matching, mortality was similar in patients with ascites and CHE < 2.5 kU/L if treated by TIPS or by paracentesis. Contrarily, in patients with CHE ≥ 2.5 kU/L survival was significantly improved by TIPS as compared to treatment with paracentesis (P < 0.001). Conclusion: CHE is significantly associated with mortality and complications after TIPS insertion. Therefore, we suggest that CHE should be evaluated as an additional parameter for selecting patients for TIPS implantation.
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Affiliation(s)
- Lena Stockhoff
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Theresa Muellner-Bucsics
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Antoaneta A Markova
- Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Marie Schultalbers
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Simone A Keimburg
- Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Tammo L Tergast
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Jan B Hinrichs
- Institute for Diagnostic and Interventional RadiologyHannover Medical SchoolHannoverGermany
| | - Nicolas Simon
- Center for Information Management (ZIMt)Hannover Medical SchoolHannoverGermany
| | - Svetlana Gerbel
- Center for Information Management (ZIMt)Hannover Medical SchoolHannoverGermany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Mattias Mandorfer
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Bernhard C Meyer
- Institute for Diagnostic and Interventional RadiologyHannover Medical SchoolHannoverGermany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany.,Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Thomas Reiberger
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
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16
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Zhang B, Cai W, Gao F, Lin X, Qian T, Gu K, Song B, Chen T. Prediction of Patient Survival with Psoas Muscle Density Following Transjugular Intrahepatic Portosystemic Shunts: A Retrospective Cohort Study. Med Sci Monit 2022; 28:e934057. [PMID: 35031594 PMCID: PMC8767767 DOI: 10.12659/msm.934057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Psoas muscle density (PMD) as a nutritional indicator is a tool to evaluate sarcopenia, which is commonly diagnosed in patients with liver cirrhosis. However, there are limited data on its role in patients who have received a transjugular intrahepatic portosystemic shunt (TIPS). We aimed to determine the utility of PMD in predicting mortality of patients with TIPS implantation and to compare the clinical value of PMD, Child-Pugh score, model for end-stage liver disease (MELD) score, and MELD paired with serum sodium measurement (MELD-Na) score in predicting post-TIPS survival in 1 year. Material/Methods This retrospective study included 273 patients who met the criteria for study inclusion. All participants underwent computed tomography (CT) scans, Child-Pugh score evaluation, MELD-Na scoring, and MELD scoring. Post-TIPS survival time was estimated using the Kaplan-Meier survival curve. The prognostic values of scoring models such as the Child-Pugh score, MELD, MELD-Na, and PMD were evaluated using receiver operating characteristic curves. Results During the 1-year follow-up period, 31 of 273 (11.36%) post-TIPS patients died. Multivariate analysis identified PMD as an independent protective factor. PMD showed a good ability to predict the occurrence of an endpoint within 1 year after TIPS. The area under the receiver operating characteristic curves for PMD, Child-Pugh score, MELD score, and MELD-Na for predicting mortality were, respectively, 0.72 (95% confidence interval [CI]: 0.663–0.773), 0.59 (95% CI: 0.531–0.651), 0.60 (95% CI: 0.535–0.655), and 0.58 (95% CI: 0.487–0.608). Conclusions PMD has appreciable clinical value for predicting the mortality of patients with TIPS implantation. In addition, PMD is superior to established scoring systems for identifying high-risk patients with a poor prognosis.
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Affiliation(s)
- Biyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Weimin Cai
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Feng Gao
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Xinran Lin
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Ting Qian
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Kaier Gu
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Bingxin Song
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Tanzhou Chen
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
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17
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Decision making for transjugular intrahepatic portosystemic stent shunt in refractory ascites and variceal bleeding: MELD, or not MELD, that is the question. Eur J Gastroenterol Hepatol 2021; 33:e214-e222. [PMID: 33230020 PMCID: PMC8734626 DOI: 10.1097/meg.0000000000002009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE The model of end-stage liver disease (MELD) score has been shown to predict 3-month prognosis following transjugular intrahepatic portosystemic stent shunt (TIPS) in liver cirrhosis; however, that score was derived from a mixed cohort, including patients with refractory ascites and variceal bleeding. This study re-evaluates the role of the MELD score and focuses on differences between both groups of patients. METHODS A total of 301 patients (192 male and 109 female) received TIPS, 213 because of refractory ascites and 88 because of variceal bleeding. Univariate and multivariate Cox analyses were performed to identify predictors of mortality and area under the receiver operator characteristics (AUROC) were used to assess the prognostic capacity of the MELD score and of the results of predictors of the multivariate analyses. RESULTS In refractory ascites, age, bilirubin and albumin were independent predictors of mortality. In variceal bleeding, emergency TIPS during ongoing bleeding, concomitant grade III ascites, history of hepatic encephalopathy, spontaneous bacterial peritonitis, bilirubin and platelet count proved significant. AUROCs of the MELD score for 3-month survival yielded 0.543 and 0.836 for refractory ascites and variceal bleeding, respectively (P < 0.001). For 1-year survival, the respective AUROCs yielded 0.533 and 0.767 (P < 0.001). In contrast to MELD, the AUROCs based on the calculated risk scores of this study resulted in 0.660 and 0.876 for 3-month survival, and 0.665 and 0.835 for 1-year survival in patients with ascites and variceal bleeding, respectively. CONCLUSION In refractory ascites, the prognostic capability of MELD is significantly inferior compared to variceal bleeding. The results of our multivariate analyses and AUROC calculations corroborate the impact of different prognostic variables in patients undergoing TIPS for ascites and variceal bleeding.
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18
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Verma R, Jain N, Arora A, Gamangatti S, Chaturvedi S. Beyond MELD Predictors of Post TIPSS Acute Liver Failure the Lesson Learned. Indian J Radiol Imaging 2021; 31:618-622. [PMID: 34790307 PMCID: PMC8590541 DOI: 10.1055/s-0041-1736403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
TIPSS is safe and effective procedure for relieving portal hypertension by creating a low resistance portosystemic shunt. TIPSS reduces portal perfusion by 80 to 100% which then gradually gets partially compensated by increased flow from hepatic artery. Post TIPSS liver function shows brief deterioration which tends to start recovering in few weeks. However, progressive liver failure requiring emergency transplant or death remains a serious concern after TIPSS creation. The causes of post TIPSS liver failure are diverse and difficult to predict. Due to its rarity the definition of post TIPSS liver decompensation is also not well described in literature. Till date MELDNa score has been considered as the most reliable predictor of post TIPSS liver decompensation. In common practice post TIPSS liver failure is less likely in patients with model for end-stage liver disease (MELD) score less than 18. We have experienced two unusual cases of post-TIPSS liver failure (PTLF) in patients with initial acceptable/low MELD score and the importance of non-MELD factors that may negatively influence post TIPSS outcome. Most of these can be routinely investigated prior to creating shunt thereby identifying patients at high risk of developing PTLF.
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Affiliation(s)
- Ritu Verma
- Department of Radio-Diagnosis, Max Super specialty Hospital and Max Institute of Cancer Care, Vaishali, Ghaziabad, Uttar Pradesh, India
| | - Nishchint Jain
- Argim Group of Neurosciences, Artemis Hospital, Gurugram, Haryana, India
| | - Abhishek Arora
- Department of Radio-diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Shivanand Gamangatti
- Department of Radio-diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Shailendra Chaturvedi
- Department of Radio-Diagnosis, Max Super specialty Hospital and Max Institute of Cancer Care, Vaishali, Ghaziabad, Uttar Pradesh, India
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19
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Enzymatic liver function measured by LiMAx is superior to current standard methods in predicting transplant-free survival after TIPS implantation. Sci Rep 2021; 11:13834. [PMID: 34226640 PMCID: PMC8257751 DOI: 10.1038/s41598-021-93392-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/22/2021] [Indexed: 12/13/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is one of the main treatment options in patients with decompensated liver cirrhosis but is still associated with partly severe complications. For adequate patient selection, prognostic parameters are of crucial importance. The liver maximum capacity (LiMAx) breath test measures enzymatic liver function and could potentially represent an efficient prognostic marker. We therefore aimed to assess the role of LiMAx in predicting survival of TIPS patients in a prospective analysis. LiMAx was performed for patients who underwent TIPS implantation between October 2016 and February 2018. Associations with transplant-free survival after 24 weeks were assessed by logistic regression. A total number of 30 patients were included, of whom seven received liver transplantation (N = 2) or died (N = 5) during follow-up. LiMAx values after (P = 0.01, OR = 1.24, 95% CI = 1.04-1.47) and before (P = 0.03, OR 1.21, 95% CI = 1.02-1.43) TIPS implantation and MELD score (P = 0.03, OR = 0.79, 95% CI = 0.63-0.98) were significantly associated with transplant-free survival according to univariate logistic regression. In AUROC analysis, LiMAx at day one after TIPS (sensitivity 85.7%, specificity 78.3%, AUROC 0.85, cut-off ≤ 165 µg/kg/h), LiMAx value at the day before TIPS (sensitivity 100%, specificity 73.9%, AUROC 0.82, cut-off ≤ 205 µg/kg/h) and MELD score (sensitivity 71.4%, specificity 73.9%, AUROC 0.82, cut-off ≥ 15) had the highest prognostic accuracy. LiMAx values prior and after TIPS procedure seem to be good prognostic parameters regarding prediction of transplant-free survival of patients undergoing TIPS implantation.
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20
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Garcia-Pagan JC, Francoz C, Montagnese S, Senzolo M, Mookerjee RP. Management of the major complications of cirrhosis: Beyond guidelines. J Hepatol 2021; 75 Suppl 1:S135-S146. [PMID: 34039484 DOI: 10.1016/j.jhep.2021.01.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/17/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023]
Abstract
Along with a growing understanding of the pathophysiology of cirrhosis and its complications, new therapies and management strategies have emerged in recent years. Many of these advances have helped inform the current EASL clinical practice guidelines1 on the management of some of the key complications of cirrhosis, such as ascites, variceal bleeding and infection. However, there are still some aspects of management where the evidence base is less clear, and/or where opinions amongst practitioners remain divided. Some of these more controversial areas are explored in this section, wherein we present evidence culminating in a suggested management approach based on expert opinion and extending beyond the current guidelines.
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Affiliation(s)
- Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain
| | - Claire Francoz
- Hepatology and Liver Intensive Care Unit, Hôpital Beaujon, INSERM. Clichy; France
| | | | - Marco Senzolo
- Gastroenterology, Multi-visceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Italy
| | - Rajeshwar P Mookerjee
- Institute for Liver and Digestive Health, University College London, UK; Department of Hepatology and Gastroenterology, Aarhus University, Denmark.
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21
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Sturm L, Praktiknjo M, Bettinger D, Huber JP, Volkwein L, Schmidt A, Kaeser R, Chang J, Jansen C, Meyer C, Thomas D, Thimme R, Trebicka J, Schultheiß M. Prognostic Value of the CLIF-C AD Score in Patients With Implantation of Transjugular Intrahepatic Portosystemic Shunt. Hepatol Commun 2021; 5:650-660. [PMID: 33860123 PMCID: PMC8034565 DOI: 10.1002/hep4.1654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/10/2020] [Accepted: 11/22/2020] [Indexed: 12/18/2022] Open
Abstract
Prognostic assessment of patients with liver cirrhosis allocated for implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a challenging task in clinical practice. The aim of our study was to assess the prognostic value of the CLIF-C AD (Acute Decompensation) score in patients with TIPS implantation. Transplant-free survival (TFS) and 3-month mortality were reviewed in 880 patients who received de novo TIPS implantation for the treatment of cirrhotic portal hypertension. The prognostic value of the CLIF-C AD score was compared with the Model for End-Stage Liver Disease (MELD) score, Child-Pugh score, and albumin-bilirubin (ALBI) score using Harrell's C concordance index. The median TFS after TIPS implantation was 40.0 (34.6-45.4) months. The CLIF-C AD score (c = 0.635 [0.609-0.661]) was superior in the prediction of TFS in comparison to MELD score (c = 0.597 [0.570-0.623], P = 0.006), Child-Pugh score (c = 0.579 [0.552-0.606], P < 0.001), and ALBI score (c = 0.573 [0.545-0.600], P < 0.001). However, the CLIF-C AD score did not perform significantly better than the MELD-Na score (c = 0.626 [0.599-0.653], P = 0.442). There were no profound differences in the scores' ranking with respect to indication for TIPS implantation, stent type, or underlying liver disease. Subgroup analyses revealed that a CLIF-C AD score >45 was a predictor of 3-month mortality in the supposed low-risk group of patients with a MELD score ≤12 (14.7% vs. 5.1%, P < 0.001). Conclusion: The CLIF-C AD score is suitable for prognostic assessment of patients with cirrhotic portal hypertension receiving TIPS implantation. In the prediction of TFS, the CLIF-C AD score is superior to MELD score, Child-Pugh score, and ALBI score but not the MELD-Na score.
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Affiliation(s)
- Lukas Sturm
- Department of Medicine IIMedical Center University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany.,Berta-Ottenstein-ProgrammeFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Michael Praktiknjo
- Department of Medicine IMedical Center University of BonnFaculty of MedicineUniversity of BonnBonnGermany
| | - Dominik Bettinger
- Department of Medicine IIMedical Center University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany.,Berta-Ottenstein-ProgrammeFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Jan P Huber
- Department of Medicine IIMedical Center University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Lara Volkwein
- Department of Medicine IIMedical Center University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Arthur Schmidt
- Department of Medicine IIMedical Center University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Rafael Kaeser
- Department of Medicine IIMedical Center University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Johannes Chang
- Department of Medicine IMedical Center University of BonnFaculty of MedicineUniversity of BonnBonnGermany
| | - Christian Jansen
- Department of Medicine IMedical Center University of BonnFaculty of MedicineUniversity of BonnBonnGermany
| | - Carsten Meyer
- Department of RadiologyMedical Center University of BonnFaculty of MedicineUniversity of BonnBonnGermany
| | - Daniel Thomas
- Department of RadiologyMedical Center University of BonnFaculty of MedicineUniversity of BonnBonnGermany
| | - Robert Thimme
- Department of Medicine IIMedical Center University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Jonel Trebicka
- Department of Medicine IMedical Center University of BonnFaculty of MedicineUniversity of BonnBonnGermany.,Department of Medicine IMedical Center University of FrankfurtFaculty of MedicineUniversity of FrankfurtFrankfurt am MainGermany
| | - Michael Schultheiß
- Department of Medicine IIMedical Center University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany
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22
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E Frenk N, Bochnakova T, Ganguli S, Mercaldo N, S Allegretti A, S Pratt D, Yamada K. Small-diameter TIPS combined with splenic artery embolization in the management of refractory ascites in cirrhotic patients. Diagn Interv Radiol 2021; 27:232-237. [PMID: 33517259 DOI: 10.5152/dir.2021.19530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE Maximally decreasing portal pressures with transjugular intrahepatic portosystemic shunt (TIPS) is associated with improved ascites control but also increased encephalopathy incidence. Since splenic venous flow contributes to portal hypertension, we assessed if combining small-diameter TIPS with splenic artery embolization could improve ascites while minimizing encephalopathy. METHODS Fifty-five patients underwent TIPS creation for refractory ascites. Subjects underwent creation of 8 mm TIPS followed by proximal splenic artery embolization (group A, n=8), or of 8 mm (group B, n=6) or 10 mm TIPS (group C, n=41) without splenic embolization. Data were retrospectively reviewed. RESULTS In group A, median portosystemic gradient decreased from 19 mmHg to 9 mmHg after TIPS, and 8 mmHg after subsequent splenic artery embolization. In groups B and C, gradient decreased from 15 mmHg to 8 mmHg and 16 mmHg to 6 mmHg. All patients except for one in group A and two in C had greater than 50% reduction in the number of paracenteses in 3 months. Any postprocedural encephalopathy incidence was 62%, 50%, 83% in groups A, B, and C, respectively. Overall, 20% of subjects with 10 mm TIPS required TIPS reduction/closure compared to 7% of subjects with 8 mm TIPS. CONCLUSION We found that 8 mm diameter TIPS provided similar ascites control compared to 10 mm TIPS regardless of splenic embolization. While more patients with 10 mm TIPS required reduction/closure for severe encephalopathy, the study was underpowered for definitive assessment. Splenic embolization might have the potential to further decrease portosystemic gradient and ascites as an alternative to dilation of TIPS to 10 mm minimizing the risk of encephalopathy, but larger studies are warranted.
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Affiliation(s)
- Nathan E Frenk
- Division of Interventional Radiology, Department of Radiology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Teodora Bochnakova
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Oregon, USA
| | - Suvranu Ganguli
- Division of Interventional Radiology, Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Nathaniel Mercaldo
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel S Pratt
- Liver Center and Division of Gastrointestinal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kei Yamada
- Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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23
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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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24
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Pandhi MB, Kuei AJ, Lipnik AJ, Gaba RC. Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding. Semin Intervent Radiol 2020; 37:3-13. [PMID: 32139965 DOI: 10.1055/s-0039-3402015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.
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Affiliation(s)
- Mithil B Pandhi
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Kuei
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Illinois
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