Prior decompensation Identifies Patients at High Mortality Risk Despite Standard Therapy After Variceal Hemorrhage:...

Area of Science:

• Hepatology
• Gastroenterology
• Clinical Medicine

Background:

• Non-selective beta-blockers plus endoscopic variceal ligation (NSBB + EVL) are standard for preventing recurrent variceal hemorrhage (VH) in eligible patients.
• Preemptive transjugular intrahepatic portosystemic shunt (TIPS) is considered when NSBB + EVL is insufficient or contraindicated.

Purpose of the Study:

• To investigate the association between prior decompensating events and outcomes in patients with cirrhosis treated with NSBB + EVL for VH.
• To identify patient subgroups at higher risk of mortality or further decompensation after VH.

Main Methods:

• Systematic review and individual participant data meta-analysis (IPD-MA) of 13 studies (5 RCTs, 8 observational) involving 1659 patients with Child-Pugh class A-B cirrhosis and VH.
• Analysis of all-cause mortality and new or worsening decompensation using cause-specific Cox models and random-effects IPD-MA.

Main Results:

• Patients with prior decompensation had significantly higher 2-year mortality (25.1% vs 13.5%, p<0.0001) compared to those without.
• Prior ascites and encephalopathy were associated with increased mortality risk (aHRs 1.8 and 1.7, respectively).
• Prior decompensation was linked to a 1.4-fold increased mortality risk (aHR 1.4, CI 1.1-1.7) and a 1.7-fold increased risk of new/worsening decompensation (aHR 1.7, CI 1.15-2.44).

Conclusions:

• Prior decompensation identifies a subgroup of patients with cirrhosis at increased risk of mortality after VH, despite NSBB + EVL treatment.
• The findings suggest that preemptive TIPS may be a beneficial consideration for these high-risk patients.
• Further investigation into the role of TIPS in managing VH in patients with prior decompensation is warranted.