Transjugular intrahepatic portosystemic shunt does not independently increase risk of death in high model for end stage liver disease patients

Abstract

Physicians often exclude patients with a model for end‐stage liver disease (MELD) score ≥ 18 from a transjugular intrahepatic portosystemic shunt (TIPS) procedure due to the concern for higher risk of death. We aimed to determine if TIPS increased the risk of death in these patients. We analyzed the interaction between TIPS and MELD in 106 patients with TIPS and 79 with intractable ascites without TIPS. We performed Cox proportional hazard regression, including both TIPS and MELD as time‐dependent covariates together with their interaction, to calculate the impact of TIPS on the risk of death associated with a high MELD score. We found a negative interaction between a high MELD score and a history of TIPS, with potentially important effect sizes. Patients with MELD scores ≥18 had a 51% lower incremental risk of death (lower risk than would be expected from the combined independent risks of MELD and needing/receiving TIPS) associated with TIPS than patients with MELD scores <18 (hazard ratio for TIPS, 0.49; 95% confidence interval, 0.10‐2.45) in the first 6 months following TIPS. There was an 80% lower incremental risk of death among patients with a MELD score ≥18 (hazard ratio for TIPS, 0.20; 95% confidence interval, 0.03‐1.23) 6 months after the TIPS procedure. Conclusion: Risk of death is associated with underlying disease severity as shown by the MELD score and the need for TIPS, and both history of TIPS and high MELD score independently increased the risk of mortality. However, the risk of death after TIPS was progressively lower than expected as the MELD score increased. (Hepatology Communications 2017;1:460–468)

Beyond MELD Predictors of Post TIPSS Acute Liver Failure the Lesson Learned

“…The positive outcome and decrease in incremental risk of death ultimately benefit this subgroup of patients as well as demonstrated in some of the newer studies. 15 …”

Transjugular Intrahepatic Portosystemic Shunt Placement for Refractory Ascites: Review and Update of the Literature

“…31 Similarly, Spengler et al recently analyzed the interaction between MELD score and TIPS placement in patients with refractory ascites. 32 Compared with those who did not receive a TIPS, as MELD increased, the risk of death was progressively lower than expected in patients who received TIPS. Patients with high MELD scores (>18) who received a TIPS had a mortality risk that was 51% lower than expected in the first 6 months following TIPS placement.…”

LVP vs TIPS for Refractory Ascites: Where Do We Stand?

“…MELD score classifies candidates undergoing TIPS based on objective laboratory findings, in contradistinction to the Child-Pugh classification which contains a subjective assessment that can lead to inter-observer variability based on clinicians' judgement. 29 30 31 32 Prior studies have shown that a MELD score of ≥18 is considered a high threshold cut-off for TIPS placement due to elective post-TIPS mortality, compared with a MELD <18 33 . However, a recent single center, retrospective study concluded that the mortality was ∼50% lower than expected when TIPS was performed in patients with MELD scores >18, suggesting the need for a prospective RCT.…”