Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study

Abstract

ObjectivesEarly placement of transjugular intrahepatic portosystemic shunt (TIPS) has been shown to improve survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10–13) with cirrhosis and acute variceal bleeding (AVB). However, early TIPS criteria may overestimate the mortality risk in a significant proportion of patients, and the survival benefit conferred by early TIPS in such patients has been questioned. Alternative criteria have been proposed to refine the criteria used to identify candidates for early TIPS. Nevertheless, the true survival benefit provided (or not) by early TIPS compared with standard treatment in the different risk categories has not been investigated in specifically designed comparative studies.DesignWe collected data on 1425 consecutive patients with cirrhosis and AVB who were admitted to 12 university hospitals in China between December 2010 and June 2016. Of these, 206 patients received early TIPS, and 1219 patients received standard treatment. The Fine and Gray competing risk regression model was used to compare the outcomes between the two groups that were stratified based on the currently available risk stratification systems after adjusting for liver disease severity and other potential confounders.ResultsOverall, early TIPS was associated with an 80% relative risk reduction (RRR) in mortality at 6 weeks (adjusted HR=0.20; 95% CI: 0.10 to 044; p<0.001) and 51% RRR at 1 year (adjusted HR=0.49, 95% CI: 0.32 to 0.73; p<0.001) compared with standard treatment. In stratification analyses, the RRRs in mortality did not significantly differ among the risk categories. However, the absolute risk reductions (ARRs) of mortality were more pronounced in high-risk patients. The ARRs at 6 weeks were −2.1%, −10.2% and −32.4% in Model for End-stage Liver Disease (MELD) ≤11, 12–18 and ≥19 patients and were −1.5%, −9.1% and −23.2% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). The ARRs for mortality at 1 year were −1.7%, −5.4% and −32.7% in MELD ≤11, 12–18 and ≥19 patients, respectively, and −3.6%, −5.2% and −20.3% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). After adjusting for liver disease severity and other potential confounders, a survival benefit was observed in MELD ≥19 or Child-Pugh C patients but not in MELD ≤11 or Child-Pugh A patients. In MELD 12–18 patients, a survival benefit was observed within 6 weeks but not at 1 year. In Child-Pugh B patients, a survival benefit was observed in those with active bleeding but not those without active bleeding. However, the evaluation of active bleeding was associated with a high interobserver variability. Furthermore, early TIPS was associated with a significantly reduced incidence of failure to control bleeding or rebleeding and new or worsening ascites, without increasing the risk of overt hepatic encephalopathy.ConclusionsEarly TIPS was associated with improved survival in patients with MELD ≥19 or Child-Pugh C ...

Precipitants of Acute‐on‐Chronic Liver Failure: An Opportunity for Preventative Measures to Improve Outcomes

“…Therefore, there may be an added role of NSBBs in the prevention of ACLF beyond just decreasing variceal hemorrhage . Also, preemptive TIPS in patients with Child C (≤13 points) seems to have a survival benefit . The mechanism of this protective effect is not clear, but given that ACLF is the strongest negative predictor for survival among patients with a GI bleed, there is suspicion that TIPS may prevent the development of ACLF .…”

Using transjugular intrahepatic portosystemic shunt as the first‐line therapy in secondary prophylaxis of variceal hemorrhage

“…[4][5][6] However, propranolol could only lower the level of HVPG by 10.1-23.2%, carvedilol by 18.6-27.7%. 8,9 TIPS is well known for significantly decreasing the level of PPG, 10,11 which is only considered as the treatment of choice when the first-line therapy failed currently. 2 Therefore, for patients with PPG ≥ 25 mmHg, neither EVL nor NSBB therapy is effective in reducing the mortality of them, even postpone the optimal timing of transjugular intrahepatic portosystemic shunt (TIPS) implantation.…”

“…2 Therefore, for patients with PPG ≥ 25 mmHg, neither EVL nor NSBB therapy is effective in reducing the mortality of them, even postpone the optimal timing of transjugular intrahepatic portosystemic shunt (TIPS) implantation. 8,9 TIPS is well known for significantly decreasing the level of PPG, 10,11 which is only considered as the treatment of choice when the first-line therapy failed currently. For patients with PPG ≥ 25 mmHg who have high risk of treatment failure and mortality, however, the primary goal should be reducing the level of PPG, which inspires the idea that maybe we should apply TIPS as the first-line therapy on this kind of patients to prevent variceal rehemorrhage.…”

Reply:

“…Besides, a recent Chinese multicenter observational study recently confirmed our data and demonstrated the survival benefit of Child-Pugh C (<14 points) patients admitted with acute variceal bleeding. (1) Of note, the metanalysis mentioned by Lo et al showed a trend toward a better survival in Child-Pugh C patients (odds ratio = 0.34; 95% confidence interval [CI] = 0.10-1.11; P = 0.074), despite a high heterogeneity between studies (P = 0.06; I 2 = 60%), suggesting that these data should be interpreted with caution. Indeed, when examining carefully the data, the study disagreeing the most was retrospective, using historical controls (that may have a different risk) and with a more permissive high-risk definition.…”

“…Acute and chronic variants of AIH exhibit variable degrees of fibrosis (stages I-IV) despite significant differences in the pattern of necroinflammation. (1) Diagnosing AIH in a patient presenting with first acute decompensation with no known history of cirrhosis is quite challenging. It may represent acute decompensation of previously undiagnosed compensated cirrhosis precipitated by extrahepatic bacterial infection, systemic inflammatory response syndrome (SIRS), alcohol consumption, drugs, toxins, or acute viral hepatitis.…”