Gender Disparity in Inpatient Mortality After Transjugular Intrahepatic Portosystemic Shunt Creation in Patients Admitted With Hepatorenal Syndrome: A Nationwide Study

Evaluating outcomes of transjugular intrahepatic portosystemic shunt procedure among Native Americans

BACKGROUND

This study aims to explore racial disparities in immediate outcomes of Transjugular Intrahepatic Portosystemic Shunt (TIPS) among Native Americans, a group that have higher prevalence of liver cirrhosis but were the "invisible group" in previous TIPS studies due to their small population size.

METHODS

The study identified Native Americans and Caucasians who underwent TIPS in National/Nationwide Inpatient Sample (NIS) database from Q4 2015-2020. Preoperative factors, including demographics, indications for TIPS, comorbidities, etiologies for liver disease, primary payer status, and hospital characteristics, were matched by 1:5 propensity score matching. In-hospital post-TIPS outcomes were then compared between the two cohorts.

RESULTS

There were 6,658 patients who underwent TIPS, where 101 (1.52%) were Native Americans and 4,574 (68.70%) were Caucasians. Native Americans presented as younger, with a lower socioeconomic status, and displayed higher rates of alcohol abuse and related liver diseases. After propensity-score matching, Native Americans had comparable in-hospital post-TIPS outcomes including mortality (8.33% vs 9.09%, p = 1.00), hepatic encephalopathy (18.75% vs 25.84%, p = 0.19), acute kidney injury (28.13% vs 30.62%, p = 0.71), and other adverse events. Native Americans also had similar wait from admission to operation (2.15 ± 0.30 vs 2.87 ± 0.21 days, p = 0.13), hospital length of stay (7.43 ± 0.63 vs 8.62 ± 0.47 days, p = 0.13), and total costs (158,299 ± 14,218.2 vs 169,425 ± 8,600.7 dollars, p = 0.50).

CONCLUSION

Native Americans had similar immediate outcomes after TIPS compared to their propensity-matched Caucasians. While these results underscore effective healthcare delivery of TIPS to Native Americans, it is imperative to pursue further research for long-term post-procedure outcomes.

Higher risk of in-hospital mortality and hepatic encephalopathy during weekend admission in Transjugular Intrahepatic Portosystemic Shunt procedure

OBJECTIVES

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate portal hypertension in patients with decompensated liver cirrhosis. The weekend effect refers to a higher risk of adverse outcomes associated with procedures performed on weekends compared to weekdays. The goal of this study is to determine whether a weekend effect is evident in TIPS procedures.

MATERIALS AND METHOD

The study identified patients who underwent TIPS procedures in the NIS database from 2015 to 2020. Patients who were admitted on the weekday or weekends were classified into two cohorts. Preoperative variables, including demographics, comorbidities, primary payer status, and hospital characteristics, were noted. Multivariable analysis was used to assess outcomes.

RESULTS

Compared to patients admitted on the weekdays, weekend patients had higher in-hospital mortality (12.87 % vs. 7.96 %, aOR = 1.62, 95 CI 1.32-1.00, p < 0.01), hepatic encephalopathy (33.24 % vs. 26.18 %, aOR = 1.41, 95 CI 1.23-1.63, p < 0.01), acute kidney injury (39.03 % vs. 28.36 %, aOR = 1.68, 95 CI 1.46-1.93, p < 0.01), and transfer out (15.91 % vs. 12.76 %, aOR=1.33, 95 CI 1.11-1.60, p < 0.01). It was also found that weekend patients had longer wait from admission to operation (3.83 ± 0.15 days vs 2.82 ± 0.07 days, p < 0.01), longer LOS (11.22 ± 0.33 days vs 8.38 ± 0.15 days, p < 0.01), and higher total hospital charge (219,973 ± 7,352 dollars vs 172,663 ± 3,183 dollars, p < 0.01).

CONCLUSION

Our research unveiled a significant relationship between weekend admission and a higher risk of mortality and morbidity post-TIPS procedure. Eliminating delays in treatment associated with the weekend effect may mitigate this gap to deliver consistent and high-quality care to all patients.

The smoker's paradox in transjugular intrahepatic portosystemic shunt procedure: A national inpatient sample analysis from 2015 to 2020

OBJECTIVES

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Smoking can adversely impact liver function and has been shown to influence liver-related outcomes. This study aimed to examine the impact of smoking on the immediate outcomes of TIPS procedure.

MATERIALS AND METHOD

The study compared smokers and non-smokers who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015 to 2020. Multivariable analysis was used to compare the in-hospital outcomes post-TIPS. Adjusted pre-procedural variables included sex, age, race, socioeconomic status, indications for TIPS, liver disease etiologies, comorbidities, and hospital characteristics.

RESULTS

Compared to non-smokers, smokers had lower risks of in-hospital mortality (7.36% vs 9.88 %, aOR 0.662, p < 0.01), acute kidney injury (25.57% vs 33.66 %, aOR 0.68, p < 0.01), shock (0.45% vs 0.98 %, aOR 0.467, p = 0.02), and transfer out to other hospital facilities (11.35% vs 14.78 %, aOR 0.732, p < 0.01). There was no difference in hepatic encephalopathy or bleeding. Also, smokers had shorter wait from admission to operation (2.76±0.09 vs 3.17±0.09 days, p = 0.01), shorter length of stay (7.50±0.15 vs 9.89±0.21 days, p < 0.01), and lower total hospital cost (148,721± 2,740.7 vs 204,911±4,683.5 US dollars, p < 0.01). Subgroup analyses revealed consistent patterns among both current and past smokers.

CONCLUSION

This study compared the immediate outcomes of smokers and non-smokers after undergoing the TIPS procedure. Interestingly, we observed a smokers' paradox, where smoker patients had better outcomes following TIPS. The underlying causes for this smoker's paradox warrant further in-depth exploration.

Advanced chronic renal disease is an independent risk factor for inpatient mortality following transjugular intrahepatic portosystemic shunt procedure

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate portal hypertension in patients with decompensated liver cirrhosis. However, the risks and outcomes associated with TIPS in patients with advanced chronic kidney disease (CKD) remain uncertain. This study aimed to investigate the perioperative outcomes of TIPS procedures in patients with advanced CKD using the National Inpatient Sample (NIS) database, a comprehensive all-payer inpatient database in the US.

METHODS

The study identified patients who underwent TIPS procedures in the NIS database from Q4 2015 to 2020. Patients with advanced CKD were identified using specific ICD-10-CM codes, and they were compared to patients without CKD. Preoperative variables, including demographics, indications for TIPS, comorbidities, APR-DRG subclass, primary payer status, and hospital characteristics, were noted. Perioperative outcomes were examined by multivariable logistic regression.

RESULTS

A total of 248 patients with advanced CKD and 5511 patients without CKD undergoing TIPS procedures were identified in the NIS database. Compared to non-CKD, patients with advanced CKD had higher mortality (13.70% vs. 8.60%, aOR = 1.56, P  = 0.03), acute kidney injury (51.21% vs. 29.34, aOR = 1.46, P  < 0.01), transfer out (25.00% vs. 12.84%, aOR = 1.88, P  < 0.01), and length of stay over 7 days (64.11% vs. 38.97%, aOR = 2.34, P  < 0.01). However, there was no difference in hepatic encephalopathy (31.85% vs. 27.19%, aOR = 1.12, P  = 0.42).

CONCLUSION

Advanced CKD patients undergoing TIPS are at higher risk of mortality and AKI compared to patients without CKD; HE was mildly elevated but NS. Long-term prognosis of patients with advanced CKD who had TIPS is needed in future studies.

Disparity Among African Americans in Transjugular Intrahepatic Portosystemic Shunt Procedure: A National Inpatient Sample Analysis from 2015 to 2020

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Racial disparities were present in TIPS where numerous studies suggested African American patients experience higher in-hospital mortality rates. However, the incidence of post-TIPS surgical complications, such as HE, has yet to be examined among African Americans. Therefore, this study aimed to provide a comprehensive examination of the disparities in TIPS procedures among African American patients.

METHODS

The study compared African American and Caucasian patients who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015-2020 after ICD-10 change. Preoperative variables, including demographics, comorbidities, primary payer status, and hospital characteristics, were examined and multivariable analysis was used to assess outcomes correcting preoperative variables with p < 0.1.

RESULTS

Compared to Caucasians, African Americans had higher in-hospital mortality (16.18 vs 8.22%, aOR 1.781, p < 0.01), hepatic encephalopathy (33.09 vs 27.44%, aOR 1.300, p = 0.05), and acute kidney injury (45.59 vs 29.60%, aOR 2.019, p < 0.01). Using the generalized linear model, African Americans have longer length of stay (11.04 ± 0.77 days vs 8.54 ± 0.16 days, p < 0.01).

CONCLUSION

Despite a higher prevalence of cirrhosis, African Americans continue to have marked underrepresentation in TIPS procedures in recent years. Their underrepresentation, in conjunction with higher mortality, morbidity, and increased comorbidity conditions, could imply disparity in accessing care. This finding underscores the necessity for improved access to diagnostic and therapeutic services for African Americans with liver cirrhosis.

Transjugular intrahepatic portosystemic shunts for adults with hepatorenal syndrome

BACKGROUND

Hepatorenal syndrome is a condition that occurs in people with chronic liver disease (such as alcoholic hepatitis, advanced cirrhosis, or fulminant liver failure) and portal hypertension. The prognosis is dismal, often with a survival of weeks to months. Hepatorenal syndrome is characterised by the development of intense splanchnic vasodilation favouring ascites and hypotension leading to renal vasoconstriction and acute renal failure. Therefore, treatment attempts focus on improving arterial pressure through the use of vasopressors, paracentesis, and increasing renal perfusion pressure. Several authors have reported that the placement of transjugular intrahepatic portosystemic shunts (TIPS) may be a therapeutic option because it decreases portal pressure and improves arterial and renal pressures. However, the evidence is not clearly documented and TIPS may cause adverse events. Accordingly, it is necessary to evaluate the evidence of the benefits and harms of TIPS to assess its value in people with hepatorenal syndrome.

OBJECTIVES

To evaluate the benefits and harms of transjugular intrahepatic portosystemic shunts (TIPS) in adults with hepatorenal syndrome compared with sham, no intervention, conventional treatment, or other treatments.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 2 June 2023.

SELECTION CRITERIA

We included only randomised clinical trials with a parallel-group design, which compared the TIPS placement with sham, no intervention, conventional therapy, or other therapies, in adults aged 18 years or older, regardless of sex or ethnicity, diagnosed with chronic liver disease and hepatorenal syndrome. We excluded trials of adults with kidney failure due to causes not related to hepatorenal syndrome, and we also excluded data from quasi-randomised, cross-over, and observational study designs as we did not design a separate search for such studies.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. morbidity due to any cause, and 3. serious adverse events. Our secondary outcomes were 1. health-related quality of life, 2. non-serious adverse events, 3. participants who did not receive a liver transplant, 4. participants without improvement in kidney function, and 5. length of hospitalisation. We performed fixed-effect and random-effects meta-analyses using risk ratio (RR) or Peto odds ratio (Peto OR), with 95% confidence intervals (CI) for the dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) for the continuous outcomes. We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included two randomised clinical trials comparing TIPS placement (64 participants) versus conventional treatment (paracentesis plus albumin 8 g/L of removed ascites) (66 participants). The co-interventions used in the trials were dietary treatment (sodium less than 60 mmoL/day), spironolactone (300 mg/day to 400 mg/day), and furosemide (120 mg/day). Follow-up was up to 24 months. Both were multicentre trials from Spain and the USA, and Germany, conducted between 1993 and 2002. Most participants were men (aged 18 to 75 years). We are uncertain about the effect of TIPS placement compared with conventional treatment, during the first 24 months of follow-up, on all-cause mortality (RR 0.88, 95% CI 0.55 to 1.38; 2 trials, 130 participants; I2 = 58%; very low-certainty evidence) and on the development of any serious adverse event (RR 1.60, 95% CI 0.10 to 24.59; 2 trials, 130 participants; I2 = 78%; very low-certainty evidence). The use of TIPS may or may not result in a decrease in overall morbidity such as bacterial peritonitis, encephalopathy, or refractory ascites, during the first 24 months of follow-up, compared with the conventional treatment (RR 0.95, 95% CI 0.77 to 1.18; 2 trials, 130 participants; I2 = 0%; low-certainty evidence). We are uncertain about the effect of TIPS placement versus conventional treatment on the number of people who did not receive a liver transplant (RR 1.03, 95% CI 0.93 to 1.14; 2 trials, 130 participants; I2 = 0%; very low-certainty evidence) or on the length of hospitalisation (MD -20.0 days, 95% CI -39.92 to -0.08; 1 trial, 60 participants; very low-certainty evidence). Kidney function may improve in participants with TIPS placement (RR 0.53, 95% CI 0.27 to 1.02; 1 trial, 70 participants; low-certainty evidence). No trials reported health-related quality of life, non-serious adverse events, or number of participants with improvement in liver function associated with the TIPS placement. Funding No trials reported sources of commercial funding or conflicts of interest between researchers. Ongoing studies We found one ongoing trial comparing TIPS with conventional therapy (terlipressin plus albumin) and listed one study as awaiting classification as no full-text article could be found.

AUTHORS' CONCLUSIONS

TIPS placement was compared with conventional treatment, with a follow-up of 24 months, in adults with hepatorenal syndrome type 2. Based on two trials with insufficient sample size and trial limitations, we assessed the overall certainty of evidence as low or very low. We are unsure if TIPS may decrease all-cause mortality, serious adverse events, the number of people who did not receive a liver transplant, and the days of hospitalisation because of the very low-certainty evidence. We are unsure if TIPS, compared with conventional treatment, has better effects on overall morbidity (bacterial peritonitis, encephalopathy, or refractory ascites). TIPS may improve kidney function, but the certainty of evidence is low. The trials included no data on health-related quality of life, non-serious adverse events, and liver function associated with the TIPS placement. We identified one ongoing trial and one study awaiting classification which may contribute to the review when information becomes available.

Kidney disease in patients with chronic liver disease: Does sex matter?

Kidney disease in patients with liver disease is serious and increases mortality. Up to 50% of patients hospitalized experience an episode of acute kidney injury. In general, men with liver disease are thought to be at increased risk of kidney disease. However, this association should be considered with caution because most studies use creatinine-based inclusion criteria, which is negatively biased against women. In this review, we synthesize data on sex differences in kidney disease in patients with chronic liver disease in the clinical setting and discuss potential physiologic underpinnings.

Inpatient Mortality Benefit with Transjugular Intrahepatic Portosystemic Shunt for Hospitalized Hepatorenal Syndrome Patients

BACKGROUND

It has been reported that transjugular intrahepatic portosystemic shunting (TIPS) might be utilized as a salvage option for hepatorenal syndrome (HRS), while randomized controlled trials are pending and real-world contemporary data on inpatient mortality is lacking.

METHODS

We conducted an observational retrospective cohort study from the National Inpatient Sample from 2005 to 2014. We included all adult patients admitted with HRS and cirrhosis, using ICD 9-CM codes. We excluded cases with variceal bleeding, Budd-Chiari, end-stage renal disease, liver transplant and transfers to acute-care facilities. TIPS' association with inpatient mortality was assessed using multivariable mixed-effects logistic regression, as well as exact-matching, thus mitigating for TIPS selection bias. The exact-matched analysis was repeated among TIPS-only versus dialysis-only patients.

RESULTS

A total of 79,354 patients were included. Nine hundred eighteen (1.2%) underwent TIPS. Between TIPS and non-TIPS groups, mean age (58 years) and gender (65% males) were similar. Overall mortality was 18% in TIPS and 48% in dialysis-only cases (n = 10,379; 13.1%). Ninety six (10.5%) TIPS patients underwent dialysis. In-hospital mortality in TIPS patients was twice less likely than in non-TIPS patients (adjusted odds ratio [aOR] = 0.43, 95% CI 0.30-0.62; p < 0.001), with similar results in matched analysis [exact-matched (em) OR = 0.39, 95% CI 0.17-0.89; p < 0.024; groups = 96; unweighted n = 463]. Head-to-head comparison showed that TIPS-only patients were 3.3 times less likely to succumb inpatient versus dialysis-only patients (contrast aOR = 0.31, 95% CI 0.20-0.46; p < 0.001), with similar findings post-matching (emOR = 0.22, 95% CI 0.15-0.33; p < 0.001; groups = 54, unweighted n = 1457).

CONCLUSIONS

Contemporary, real-world data reveal that TIPS on its own, and when compared to dialysis, is associated with decreased inpatient mortality when utilized in non-bleeders-HRS patients. Further randomized studies are needed to establish the long-term benefit of TIPS in these patients.