Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study

Abstract

Background-Recent small studies on hepatorenal syndrome (HRS) indicate some clinical benefit after transjugular intrahepatic portosystemic stent-shunt (TIPS) but suYcient long term data are lacking. Aim-We studied prospectively feasibility, safety, and long term survival after TIPS in 41 non-transplantable cirrhotics with HRS (phase II study). Patients and methods-HRS was diagnosed using current criteria (severe (type I) HRS, n=21; moderate (type II) HRS, n=20). Thirty one patients (14 type I, 17 type II) received TIPS (8-10 mm) while advanced liver failure excluded shunting in 10. During follow up (median 24 months) we analysed renal function and survival (Kaplan-Meier). Results-TIPS markedly reduced the portal pressure gradient (21 (5) to 13 (4) mm Hg (mean (SD)); p<0.001) with one procedure related death (3.2%). Renal function deteriorated without TIPS but improved (p<0.001) within two weeks after TIPS (creatinine clearance 18 (15) to 48 (42) ml/min; sodium excretion 9 (16) to 77 (78) mmol/24 hours) and stabilised thereafter. Following TIPS, three, six, 12, and 18 month survival rates were 81%, 71%, 48%, and 35%, respectively. As only 10% of non-shunted patients survived three months, total survival rates were 63%, 56%, 39%, and 29%, respectively. Multivariate Cox regression analysis revealed bilirubin (p<0.001) and HRS type (p<0.05) as independent survival predictors after TIPS. Conclusions-TIPS provides long term renal function and probably survival benefits in the majority of non-transplantable cirrhotics with HRS. These data warrant controlled trials evaluating TIPS in the management of HRS. (Gut 2000;47:288-295)

Acute decompensation boosts hepatic collagen type III deposition and deteriorates experimental and human cirrhosis

“…Inclusion criteria were age between 20 and 80 years, cirrhosis due to alcohol or viral hepatitis, and decompensated liver cirrhosis with indication for TIPS (bleeding in n = 41, refractory ascites in n = 51, or both in n = 18). Exclusion criteria were contraindications for TIPS placement,20, 21 i.e., serum levels of bilirubin >5 mg/dL, spontaneous bacterial peritonitis and manifest hepatic encephalopathy, pulmonary arterial hypertension, and cardiac insufficiency. An invasive control of the TIPS was performed as part of the routine in 74 patients 1‐3 weeks after TIPS insertion 10.…”

“…TIPS (8‐10 mm Wallstent; Boston Scientific) placement was performed as described 20, 21. A single shot of antibiotic prophylaxis of cefuroxime (1.5 g) was administered at TIPS placement.…”

Review article: Acute kidney injury in critical illness

“…84 For refractory ascites and progressive HRS, small clinical studies in selected patients have found that transjugular intrahepatic portosystemic shunting may attenuate and/or improve kidney function over several weeks to months. [85][86][87] In a small clinical trial, extracorporeal liver support with the molecular adsorbents recirculation system was shown to improve both kidney function and to extend survival in advanced cirrhosis with established HRS; however, confirmatory data are pending. 88 In progressive HRS, extracorporeal RRT in eligible patients can be used to support loss of kidney function and as a bridge until liver transplantation.…”

Fifteen years’ experience with transjugular intrahepatic portosystemic shunt (TIPS) using bare stents: retrospective review of clinical and technical aspects

“…Indicazioni più rare ed oggetto di studi non controllati condotti su piccoli gruppi di pazienti, alcune delle quali non uniformemente accettate sono: la trombosi portale, la sindrome di Budd-Chiari, l'ascite pleurica [8][9][10], la sindrome epato-polmonare (HPS) [11], la sindrome epato-renale (HRS) [3,[12][13][14][15][16][17], la profilassi del sanguinamento intraoperatorio in pazienti cirrotici con ipertensione portale candidati ad interventi di chirurgia addominale maggiore [8,18,19] e la tutela della pervietà portale pre-trapianto epatico (OLT) [20,21].…”

“…Less common indications, some of which are not universally accepted, have been investigated by uncontrolled studies conducted on small patient series. These include portal thrombosis, Budd-Chiari syndrome, pleural ascites [8][9][10], hepatopulmonary syndrome (HPS) [11], hepatorenal syndrome (HRS) [3,[12][13][14][15][16][17], prophylaxis of intraoperative bleeding in cirrhotic patients with portal hypertension who are candidates for major abdominal surgery [8,18,19] and maintenance of portal vein patency prior to orthotopic liver transplantation (OLT) [20,21].…”