Management of portal hypertension severe complications

Zanetto, Alberto; Barbiero, Giulio; Battistel, Michele; Sciarrone, S.S.; Shalaby, Sarah; Pellone, M.; Battistella, Sara; Gambato, Martina; Germani, Giacomo; Russo, Francesco Paolo; Burra, P.; Senzolo, Marco

doi:10.23736/s2724-5985.20.02784-1

Cited by 8 publications

(8 citation statements)

References 98 publications

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“…In the only previous study that investigated the role of ROTEM ® in patients with ACLF, Seessle et al 41 found that CFT and MCF at INTEM test were significantly more altered in patients who bled (n = 9) than in those who did not (n = 13) and concluded that ROTEM ® could be helpful to estimate bleeding risk in ACLF. However, 60% of events were oesophageal variceal bleedings for which portal pressure, but not haemostatic failure, is responsible 42 . Therefore, it is likely that the association between a more profound derangement of ROTEM ® and bleeding merely reflected a more advanced liver dysfunction with higher portal hypertension in patients who bled 41 .…”

Section: Discussionmentioning

confidence: 99%

“…However, 60% of events were oesophageal variceal bleedings for which portal pressure, but not haemostatic failure, is responsible. 42 Therefore, it is likely that the association between a more profound derangement of ROTEM ® and bleeding merely reflected a more advanced liver dysfunction with higher portal hypertension in patients who bled. 41 By contrast, we carefully excluded all the bleeding events directly and primarily correlated with portal hypertension.…”

Section: Discussionmentioning

confidence: 99%

“…ACLF had longer INR (1.9 [1.5-2.5] vs 1.6 [1.3-1.9]; P = .007) and aPTT (44 seconds[35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54] vs 35 seconds[30][31][32][33][34][35][36][37][38][39][40][41][42]; P < .001) compared with patients with AD.…”

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confidence: 99%

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Coagulopathy is not predictive of bleeding in patients with acute decompensation of cirrhosis and acute‐on‐chronic liver failure

Campello

Zanetto

Bulato

et al. 2021

Liver International

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Background & Aims Understanding factors responsible for the increased bleeding tendency in acute‐on‐chronic liver failure (ACLF) would improve the management of these complications. We investigated coagulation alterations in ACLF and assessed whether they were predictive of bleeding. Methods Cirrhosis patients with ACLF (cases) and acute decompensation (AD, controls) were prospectively recruited and underwent an extensive haemostatic assessment including standard tests, pro and anticoagulant factors, thrombomodulin‐modified thrombin generation (TG) and thromboelastometry (ROTEM®). In study part 1 (case‐control), we compared coagulation in ACLF vs AD. In study part 2 (prospective), all patients were followed for bleeding, and predictors of outcome were assessed. Results Ninety‐one patients were included (51 with ACLF, 40 with AD). Infections and ascites/renal dysfunction were the most common precipitating and decompensating events. Platelet count was lower while INR and activated partial thrombin time were longer in ACLF cohort vs AD. Regarding clotting factors, fibrinogen and factor VIII were comparable between groups while protein C and antithrombin were significantly reduced in ACLF. Endogenous thrombin potential by TG was comparable between groups. Clotting formation time and clot stability by ROTEM® were significantly lower in ACLF, indicative of a more hypocoagulable state. No haemostasis alteration could discriminate between patients who had bleeding complications during hospitalization and those who did not. Conclusion We found coagulation changes in ACLF to largely overlap with that of AD and evidence of preserved coagulation capacity in both groups. ROTEM alterations were indicative of a more pronounced hypocoagulable state in ACLF; however, no correlation was found between such alterations and bleeding.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Coagulopathy is not predictive of bleeding in patients with acute decompensation of cirrhosis and acute‐on‐chronic liver failure

Campello

Zanetto

Bulato

et al. 2021

Liver International

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“…The main driver for development of esophageal VH is clinically significant portal hypertension [10]. In a way, the acute loss of intravascular volume due to bleeding reduces splanchnic pressure and may lead to self-limitation or self-interruption of active hemorrhage.…”

Section: Blood Transfusion Strategymentioning

confidence: 99%

Recent Advances in the Management of Acute Variceal Hemorrhage

Zanetto

Shalaby

Feltracco

et al. 2021

JCM

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Gastrointestinal bleeding is one of the most relevant causes of death in patients with cirrhosis and clinically significant portal hypertension, with gastroesophageal varices being the most frequent source of hemorrhage. Despite survival has improved thanks to the standardization on medical treatment aiming to decrease portal hypertension and prevent infections, mortality remains significant. In this review, our goal is to discuss the most recent advances in the management of esophageal variceal hemorrhage in cirrhosis with specific attention to the treatment algorithms involving the use of indirect measurement of portal pressure (HVPG) and transjugular intrahepatic portosystemic shunt (TIPS), which aim to further reduce mortality in high-risk patients after acute variceal hemorrhage and in the setting of secondary prophylaxis.

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“…The mortality of variceal bleeding, especially rupture, is very high. According to the American Association for the Study of Liver Diseases (AASLD) guidelines, transjugular intrahepatic portosystemic shunt (TIPS) is only recommended as a salvage treatment option ( 1 , 2 ). TIPS is used in the treatment of complications of portal hypertension in decompensated cirrhotic patients, but there are potential postoperative complications with non-negligible results ( 3 , 4 ).…”

Section: Introductionmentioning

confidence: 99%

Hepatic venous pressure gradient (HVPG) predicts liver failure after transjugular intrahepatic portal shunt: a retrospective cohort study

Yao¹,

Fernandes²,

Ramírez-Fernández³

et al. 2022

Ann Transl Med

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Background: Esophagogastric variceal bleeding is a serious complication of decompensated cirrhosis.Transjugular intrahepatic portal shunt (TIPS) is a salvage treatment with clear hemostatic results. However, various complications may occur after TIPS, including postoperative liver failure, and the prognosis is very poor once occurs. Liver failure is a common symptom of severe liver disease with a high mortality rate. This study investigated the incidence of liver failure after TIPS treatment for varicose bleeding.Methods: We analyzed the data of patients admitted to the First Affiliated Hospital of Soochow University between January 2013 and December 2018 with portal hypertension with an episode of acute gastroesophageal variceal bleeding. A total of 121 patients were referred to the regional liver unit for TIPS.Hepatic venous pressure gradient (HVPG) and clinical data were collected. Patients with incomplete data were excluded, and 93 patients were ultimately enrolled in the study. Primary outcomes were morbidity and hospital mortality within 4 weeks of surgery. The data were retrospectively and consecutively collected and evaluated by univariate and multivariate analyses to identify risk factors of liver failure. Results:The patients included 58 males (62.37%) and 35 females (37.63%), and the mean age was 58.43±11.85 years. The main cause was hepatitis B virus (HBV), which was found in 50.54% of patient. The overall surgical success rate was 83.87% (78/93). Of 15 treatment-failure patients, 9 (9.68%) died in hospital.Four patients died of liver failure, accounting for 44.44% of postoperative all-cause deaths. Univariate logistic regression analysis showed that only hepatic venous pressure gradient (HVPG) was an independent risk factor for post-TIPS morbidity [relative risk (RR) 1.156; 95% confidence interval (CI): 1.041 to 1.283; P=0.006]. In addition, HVPG was an independent risk factor for hospital mortality within 4 weeks (RR 1.133; 95% CI: 1.021 to 0.539; P=0.016).Conclusions: Post-TIPS liver failure is a serious complication in patients with cirrhosis. Pre-TIPS HVPG level may be used as a predictor of potential short-term postoperative adverse events.

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Management of portal hypertension severe complications

Cited by 8 publications

References 98 publications

Coagulopathy is not predictive of bleeding in patients with acute decompensation of cirrhosis and acute‐on‐chronic liver failure

Coagulopathy is not predictive of bleeding in patients with acute decompensation of cirrhosis and acute‐on‐chronic liver failure

Recent Advances in the Management of Acute Variceal Hemorrhage

Hepatic venous pressure gradient (HVPG) predicts liver failure after transjugular intrahepatic portal shunt: a retrospective cohort study

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