A novel score predicts mortality after transjugular intrahepatic portosystemic shunt: MOTS ‐ Modified TIPS Score

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.

EASL Clinical Practice Guidelines on the management of hepatic encephalopathy

“…with particular reference to overt HE history 192 ; liver and kidney function, focusing on bilirubin levels, international normalised ratio and urea levels 193 ; a neurological and neuropsychological examination to detect HE, to rule out and manage large spontaneous porto-systemic shunts 194 ; and, finally, microbiome analysis could also help with decision-making in patients with TIPS at risk of overt HE. 195 In summary, new bouts of post-TIPS HE could be modulated by using covered stents 196 and promoting early placement of TIPS.…”

A modified model for predicting mortality after transjugular intrahepatic portosystemic shunt: A multicentre study

“…We evaluated the performance of Model MT in comparison to previous models 10–12,14,19,20 with respect to discrimination, according to the Delong test, NRI and IDI. Model MT demonstrated significant improvement over the previous models in the training data set (Table 3, Supplementary Figure S1A): ALBI (AUC = .557, p < .001); BILI‐PLT (AUC = .548, p < .001); MELD‐Na (AUC = .742, p < .001); MOTS (AUC = .671, p < .001); FIPS (AUC = .747, p = .001); MELD (AUC = .758, p = .001); and CLIF‐C AD (AUC = .763, p = .001).…”

“…With the evolution of TIPS technology and changes in the target population, prediction models are continuously being developed. FIPS and MOTS have been created recently 10,14 . However, FIPS did not show consistent performance in the external validation (.713 vs. .574), and MOTS was based on a smaller data set and did not show a statistically significant difference over other models.…”

“…We evaluated the performance of Model MT in comparison to previous models [10][11][12]14,19,20 and CLIF-C AD (AUC = .757, p = .022).…”

“…Over the past 30 years, several researchers have established predictive models for this purpose and have contributed greatly to the prediction of mortality in TIPS. [9][10][11][12] However, to enhance performance, some aspects still need attention. First, the models should be developed specifically for patients undergoing TIPS, rather than relying on models built for patients with cirrhosis or hepatocellular carcinoma (HCC).…”