Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study

Riggio, Oliviero; Masini, Andrea; Efrati, C.; Nicolao, F.; Angeloni, S.; Salvatori, Filippo Maria; Bezzi, Mario; Attili, Adolfo Francesco; Merli, Manuela

doi:10.1016/j.jhep.2004.12.028

Cited by 198 publications

(149 citation statements)

References 27 publications

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“…Unfortunately, final PSG levels that may improve medically refractory ascites also increase the risk of hepatic encephalopathy (21,22). Although we found no independent predictors of hepatic encephalopathy, it should be noted that nearly all instances of hepatic encephalopathy were mild cases, graded at 0 or 1, which are generally treatable with dietary modification and medical therapy (23)(24)(25). Importantly, the occurrence of encephalopathy was not significantly associated with mortality in our cohort.…”

Section: Discussionmentioning

confidence: 52%

“…Patients with refractory ascites are typically characterized by cirrhotic liver disease and are vulnerable to hepatic decompensation following excess shunting of blood away from the liver (24). A low post-TIPS PSG predicted early mortality in our cohort; patients with a final PSG of <8 mmHg, as recommended by the AASLD, had a 33% mortality rate at 90 days in contrast to 11% in those with a PSG of ≥8 mmHg.…”

Section: Discussionmentioning

confidence: 81%

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Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Parvinian¹,

Bui²,

Knuttinen³

et al. 2013

Diagn Interv Radiol

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ORIGINAL ARTICLE PURPOSE This study was performed to assess the safety, efficacy, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation for treatment of medically refractory ascites and to identify prognostic factors for clinical response, morbidity, and mortality. MATERIALS AND METHODSIn this retrospective study, 80 patients (male:female, 52:28; mean age, 56 years; mean Model for End-Stage Liver Disease [MELD] score, 15.1) who underwent elective TIPS creation for refractory ascites between 1999-2012 were studied. A medical record review was performed to identify data on demographics, liver disease, procedures, and outcome. The influence of these parameters on 30-day, 90-day, and oneyear mortality was assessed using binary logistic regression. Overall survival was analyzed with Kaplan-Meier statistics. RESULTS TIPS was successfully created using covered (n=70) or bare metal (n=10) stents. Hemodynamic success was achieved in all cases. The mean final portosystemic pressure gradient (PSG) was 6.8 mmHg. Thirty-day complications included mild encephalopathy in 35% of patients. Clinical improvement in ascites occurred in 78% of patients, with complete resolution or a ≥50% decrease in 66% of patients. No predictors of response or optimal PSG threshold were identified. The 30-day, 90-day, and one-year mortality rates were 14%, 23%, and 33%, respectively. Patient age (P = 0.026) was associated with 30-day mortality, while final PSG was associated with 90-day (P = 0.020) and one year (P = 0.032) mortality. No predictors of overall survival were identified. CONCLUSION TIPS creation effectively treats medically refractory ascites with nearly 80% efficacy. The incidence of mild encephalopathy is nontrivial. Older age and final PSG are associated with mortality, and these factors should be considered in patient selection and procedure performance.T he development of medically refractory ascites is associated with a grave prognosis in patients with liver cirrhosis. One-year survival in this population is less than 50%, and there is an increased risk of complications such as spontaneous bacterial peritonitis, hepatorenal syndrome, and dilutional hyponatremia (1). Moreover, these patients typically have low Model for End-Stage Liver Disease (MELD) scores despite their high mortality rate, and thus hold low positions on national transplant listings (2, 3). Transjugular intrahepatic portosystemic shunt (TIPS) creation, an established treatment for complications of portal hypertension, has demonstrated utility in patients with refractory ascites (4). By diverting blood from the portal venous system to the systemic circulation, TIPS acts to lower hepatic sinusoidal pressure and increase effective circulatory flow, thereby reducing excess sodium retention and achieving ascites recurrence rates as low as 30% (5). Two recent studies revealed reduced mortality in patients undergoing TIPS placement, compared with those receiving serial large-volume paracentesis procedures, with one-year survival rates ra...

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Section: Discussionmentioning

confidence: 52%

Section: Discussionmentioning

confidence: 81%

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Parvinian¹,

Bui²,

Knuttinen³

et al. 2013

Diagn Interv Radiol

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“…Bearing in mind these limitations, the incidence of overt episodic or recurrent HE post-TIPS varies between 15 and 67% in a 2-year follow-up. The incidence of persistent overt HE is around 8% [80] and that of de-novo, covert HE around 35% [14,26,[81][82][83][84][85][86][87][88]. [31,81,82,84] • Baseline arterial hypotension (1a) [4,83] • High serum creatinine and hyponatriemia (Na < 130) (1a) [4, 80,82] • Low serum albumin levels (1b) [80] • Bare vs. covered stent (2b) [85] • Very low porto-systemic pressure gradient after TIPS (<5 mmHg) (1a) [25,[78][79][80][81][82][83]87] a Child A risk of HE close to 0, in Child B up to 33%, in Child C up to 89%.…”

Section: Is There a Risk For Hepatic Encephalopathy After Tips?mentioning

confidence: 99%

Consensus conference on TIPS management: Techniques, indications, contraindications

Fagiuoli

Bruno

Venon

et al. 2017

Digestive and Liver Disease

130

120

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a b s t r a c tThe trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.

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“…2,3 Creation of a TIPS increases the risk of hepatic encephalopathy but the prophylactic use of nonabsorbable disaccharides or antibiotics does not appear to reduce this risk and is not recommended. 4 The value of TIPS versus a surgical shunt in the prevention of variceal rebleeding in patients who have failed medical therapy has been clarified by the publication of a controlled trial comparing TIPS to distal splenorenal shunt (DSRS). 5 Both were effective in preventing rebleeding (rebleeding incidence in 5.5% of DSRS versus 10.5% of TIPS; not significant) with no difference in encephalopathy or survival.…”

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confidence: 99%

the Role of Transjugular Intrahepatic Portosystemic Shunt (Tips) in the Management of Portal Hypertension: Update 2009

Boyer¹,

Haskal²

2010

Hepatology

494

314

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The 2009 update of the American Association for the Study of Liver Diseases (AASLD) Practice Guideline "The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension" is now posted online at www.aasld.org. This is the first update of the original guideline published in 2005. 1 The key changes in the 2009 guidelines are new recommendations on the use of covered versus bare stents in the creation of the TIPS. Use of expanded polytetrafluoroethylene (ePTFE)-covered stents is now preferred. The lower risk of shunt dysfunction and perhaps improved outcomes using covered as opposed to bare stents are the basis for this recommendation. 2,3 Creation of a TIPS increases the risk of hepatic encephalopathy but the prophylactic use of nonabsorbable disaccharides or antibiotics does not appear to reduce this risk and is not recommended. 4 The value of TIPS versus a surgical shunt in the prevention of variceal rebleeding in patients who have failed medical therapy has been clarified by the publication of a controlled trial comparing TIPS to distal splenorenal shunt (DSRS). 5 Both were effective in preventing rebleeding (rebleeding incidence in 5.5% of DSRS versus 10.5% of TIPS; not significant) with no difference in encephalopathy or survival. The patients in whom TIPS was performed required significantly more interventions to maintain patency because of the use of bare stents. A cost analysis showed TIPS to be slightly more cost effective than DSRS at year 5, 6 and these two approaches are now considered to be of equal efficacy in the prevention of variceal rebleeding.The other significant change to the guidelines is how TIPS should be used in the management of patients with Budd-Chiari syndrome. A large (221 patients) retrospective study was published in which patients who failed to improve with use of anticoagulation had a TIPS created (133 patients). One-year and 10-year transplant-free survival was 88% and 69%, respectively, which is better than predicted. 7 TIPS patency was best in those who received a covered stent. The recommendation now is for creation of a TIPS in those who fail to improve with anticoagulation.

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Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study

Cited by 198 publications

References 27 publications

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Consensus conference on TIPS management: Techniques, indications, contraindications

the Role of Transjugular Intrahepatic Portosystemic Shunt (Tips) in the Management of Portal Hypertension: Update 2009

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