Short-Term Mortality is Reduced and Low-Grade Acute-on-Chronic Liver Failure Reversed by Transjugular Intrahepatic
Eduardo Cervantes-Alvarez1, Wenyi Gu1, Jonathan Byrtus2
1Department of Internal Medicine B, University Hospital Münster, Münster, Germany.
Introduction:
Portal hypertension characterizes decompensated cirrhosis and its complications. It may trigger acute-on-chronic liver failure (ACLF), which carries a high mortality. Transjugular intrahepatic portosystemic shunt (TIPS) is the most efficient therapy for most portal hypertension-related complications including fluid overload (FO) defined as refractory or recurrent ascites, hepatorenal syndrome, and/or hydrothorax. However, TIPS for FO in ACLF is questioned.
Methods:
In this case-control study, patients from the prospective cohorts CANONIC (n = 1,324) and German TIPS-Registry (n = 724) were screened for cases of FO and matched 1:1 by sex, age, Model for End-Stage Liver Disease (MELD) score, and presence and grade of ACLF. Clinical outcomes, ACLF status, and mortality were assessed.
Results:
The total population was 118 patients with ACLF of whom 59 received TIPS and 59 did not. The main indication for TIPS was hepatorenal syndrome (61.0%). Patients with ACLF who did not receive TIPS had a higher 28-day cumulative mortality rate (22.0% vs 5.1%, P = 0.009). At 28 days, TIPS insertion in ACLF was associated with a 78% mortality reduction (hazard ratio 0.22 [0.06-0.77]). It further led to improvement of hepatic encephalopathy and the MELD score. In addition, ACLF resolution occurred in 61% of TIPS patients with ACLF. The presence of coagulation and circulatory organ failures, and increased bilirubin, INR, MELD score, and CLIF-C OF were associated with 28-day mortality. The survival benefit of TIPS was no longer observed after 90 days.
Discussion:
TIPS decreased the 28-day mortality of patients with FO and ACLF. Thus, TIPS should be regarded as a bridging strategy-ideally for liver transplantation.
