Research Letters

Transjugular intrahepatic portosystemic stent-shunt for hepatorenal syndrome

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

Patients with cirrhosis and refractory ascites have physiologic and hormonal dysregulation that contributes to decreased kidney function. Placement of a transjugular intrahepatic portosystemic shunt (TIPS) can reverse these changes and potentially improve kidney function. We sought to evaluate change in estimated glomerular filtration rate (eGFR) following TIPS placement.

Retrospective, matched cohort analysis.

Patients who underwent first-time TIPS placement for refractory ascites in 1995 to 2014. Frequency matching was used to generate a comparator group of patients with cirrhosis and ascites treated with serial large-volume paracentesis (LVP) in a 1:1 fashion.

TIPS placement compared to serial LVP.

Change in eGFR over 90 days’ follow-up.

Multivariable regression stratified by baseline eGFR < 60 versus ≥60 mL/min/1.73 m²; analysis of effect modification between TIPS placement and baseline eGFR.

276 participants (TIPS, n = 138; serial LVP, n = 138) were analyzed. After 90 days, eGFRs increased significantly after TIPS placement in participants with baseline eGFRs < 60 mL/min/1.73 m² compared to treatment with serial LVP (21 [95% CI, 13-29] mL/min/1.73 m²; P < 0.001) and was no different in those with eGFRs ≥ 60 mL/min/1.73 m² (1 [95% CI, −9 to 12] mL/min/1.73 m²; P = 0.8). There was significant effect modification between TIPS status and baseline eGFR (P = 0.001) in a model that included all participants.

Outcomes restricted by clinically recorded data; clinically important differences may still exist between the TIPS and LVP cohorts despite good statistical matching.

TIPS placement was associated with significant improvement in kidney function. This was most prominent in participants with baseline eGFRs < 60 mL/min/1.73 m². Prospective studies of TIPS use in populations with eGFRs < 60 mL/min/1.73 m² are needed to evaluate these findings.

A transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment of refractory ascites and variceal bleeding. However, it is unclear whether a TIPS affects long-term survival. We investigated whether a TIPS is associated with survival in patients with cirrhosis awaiting liver transplantation.

By using the United Network for Organ Sharing registries from 2002 to 2013, we followed up a cohort of transplant-naive adults with cirrhosis (N = 97,063) from the time of transplant listing until the time of death or transplantation. We used Cox proportional hazards and competing-risks analyses to compare these primary outcomes between patients with a TIPS (n = 7475; 7.7%) and without a TIPS (n = 89,588; 92.3%) at the time of listing, adjusting for baseline characteristics.

During an average follow-up period of 1.61 years, 23,305 (24%) patients died before undergoing transplantation, 47,563 (49%) underwent transplantation, and the remaining 26,195 (27%) still were alive without having received a liver transplant. Compared with patients without a TIPS, patients with a TIPS had a lower risk of death (adjusted subhazard ratio, 0.95; 95% confidence interval, 0.9–0.99), transplantation (adjusted subhazard ratio, 0.92, 95% confidence interval, 0.88–0.95), or the combined outcome of death or transplantation (adjusted hazard ratio, 0.85; 95% confidence interval, 0.83–0.88).

Among patients with cirrhosis awaiting liver transplantation, patients with a TIPS had a lower mortality rate than patients without a TIPS.

Le syndrome hépatorénal est une complication sévère de la maladie hépatique au stade terminal. Au cours du syndrome hépatorénal, la vasodilatation splanchnique et périphérique, et donc la réduction du volume artériel efficace, induisent l’activation de molécules vasoconstrictrices rénales, d’où l’insuffisance rénale fonctionnelle. Le diagnostic de syndrome hépatorénal est un diagnostic d’exclusion et n’est retenu qu’après avoir éliminé toutes les autres causes d’insuffisance rénale aiguë (en particulier prérénale). La péritonite bactérienne spontanée est un des facteurs déclenchants, et doit être recherchée chez tout patient ayant une maladie hépatique sévère et une insuffisance rénale aiguë. Sa prise en charge rapide par antibiothérapie parentale et perfusion d’albumine diminue significativement le risque. L’utilisation combinée d’albumine par voie intraveineuse, de vasoconstricteurs splanchniques et périphériques, et/ou d’épuration extrarénale, permet parfois de temporiser jusqu’à la transplantation hépatique (ou combinée foie–rein chez des patients sélectionnés). La transplantation est, en effet, le seul moyen d’améliorer le pronostic à long terme.

Hepatorenal syndrome is a severe complication of end-stage liver disease. The pathophysiological hallmark is severe renal vasoconstriction, resulting from peripheral and splanchnic vasodilation as well as activation of renal vasoconstrictor molecules, which induce the effective arterial volume reduction and the functional renal failure. The diagnosis of hepatorenal syndrome is currently based on the exclusion of other causes of renal failure (especially prerenal). Spontaneous bacterial peritonitis is one of the triggering factors and should be sought in all patients with severe liver disease and acute renal failure. Quickly treating patients with parental antibiotics and albumin infusion significantly decreases the risk. The combined use of intravenous albumin, splanchnic and peripheral vasoconstrictor and/or renal replacement therapy sometimes enables a delay until liver transplantation (or combined liver–kidney in selected patients). Transplantation is in fact the only way to improve the long-term prognosis.