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Xu X, Yang Y, Tan X, Zhang Z, Wang B, Yang X, Weng C, Yu R, Zhao Q, Quan S. Hepatic encephalopathy post-TIPS: Current status and prospects in predictive assessment. Comput Struct Biotechnol J 2024; 24:493-506. [PMID: 39076168 PMCID: PMC11284497 DOI: 10.1016/j.csbj.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 07/05/2024] [Accepted: 07/05/2024] [Indexed: 07/31/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an essential procedure for the treatment of portal hypertension but can result in hepatic encephalopathy (HE), a serious complication that worsens patient outcomes. Investigating predictors of HE after TIPS is essential to improve prognosis. This review analyzes risk factors and compares predictive models, weighing traditional scores such as Child-Pugh, Model for End-Stage Liver Disease (MELD), and albumin-bilirubin (ALBI) against emerging artificial intelligence (AI) techniques. While traditional scores provide initial insights into HE risk, they have limitations in dealing with clinical complexity. Advances in machine learning (ML), particularly when integrated with imaging and clinical data, offer refined assessments. These innovations suggest the potential for AI to significantly improve the prediction of post-TIPS HE. The study provides clinicians with a comprehensive overview of current prediction methods, while advocating for the integration of AI to increase the accuracy of post-TIPS HE assessments. By harnessing the power of AI, clinicians can better manage the risks associated with TIPS and tailor interventions to individual patient needs. Future research should therefore prioritize the development of advanced AI frameworks that can assimilate diverse data streams to support clinical decision-making. The goal is not only to more accurately predict HE, but also to improve overall patient care and quality of life.
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Affiliation(s)
- Xiaowei Xu
- Department of Gastroenterology Nursing Unit, Ward 192, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Yun Yang
- School of Nursing, Wenzhou Medical University, Wenzhou 325001, China
| | - Xinru Tan
- The First School of Medicine, School of Information and Engineering, Wenzhou Medical University, Wenzhou 325001, China
| | - Ziyang Zhang
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550025, China
| | - Boxiang Wang
- The First School of Medicine, School of Information and Engineering, Wenzhou Medical University, Wenzhou 325001, China
| | - Xiaojie Yang
- Wenzhou Medical University Renji College, Wenzhou 325000, China
| | - Chujun Weng
- The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu 322000, China
| | - Rongwen Yu
- Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou 325000, China
| | - Qi Zhao
- School of Computer Science and Software Engineering, University of Science and Technology Liaoning, Anshan 114051, China
| | - Shichao Quan
- Department of Big Data in Health Science, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
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Larrue H, Allaire M, Weil-Verhoeven D, Barge S, Thabut D, Payance A, Moga L, Jézéquel C, Artru F, Archambeaud I, Elkrief L, Oberti F, Roux C, Laleman W, Rudler M, Dharancy S, Laborde N, Minello A, Mouillot T, Desjonquères E, Wandji LCN, Bourlière M, Ganne-Carrié N, Bureau C. French guidelines on TIPS: Indications and modalities. Liver Int 2024; 44:2125-2143. [PMID: 38758295 DOI: 10.1111/liv.15976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/19/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) has become essential in the treatment or prevention of portal hypertension-related complications. In the early 1990s, the primary indication was refractory bleeding. It is now proposed for the treatment of ascites for the prevention of bleeding and in patients with vascular diseases of the liver. Thus, there are a growing number of patients being treated with TIPS all over the world. The broadening of indications, the involvement of multiple stakeholders, the need for an accurate selection, the positioning in relation to transplantation and the lack of standardization in pre-therapeutic assessment, in the procedure itself and in the follow-up have led the board of the French Association for the Study of the Liver to establish recommendations.
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Affiliation(s)
- Hélène Larrue
- Service d'Hépatologie Hopital Rangueil CHU Toulouse et Université Paul Sabatier, Toulouse, France
| | - Manon Allaire
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Delphine Weil-Verhoeven
- Service d'Hépatologie et Soins intensifs digestifs, CHU Jean Minjoz, Besançon, France
- Université de Franche-Comté, CHU Besançon, EFS, INSERM, UMR RIGHT, Besançon, France
| | - Sandrine Barge
- Service d'Hépato-gastro-entérologie, Centre Hospitalier Intercommunal de Créteil, Creteil, France
| | - Dominique Thabut
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Audrey Payance
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Université de Paris, Paris, France
| | - Lucile Moga
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Université de Paris, Paris, France
| | | | - Florent Artru
- Service des Maladies du Foie, CHU Rennes, Rennes, France
| | - Isabelle Archambeaud
- Hépato-Gastro-Entérologie et Assistance Nutritionnelle-Institut des Maladies de l'Appareil Digestif (IMAD), CHU Nantes-Inserm CIC 1413, Nantes, France
| | - Laure Elkrief
- Service d'Hépato-Gastroentérologie, Hôpital Trousseau, CHRU de Tours et Faculté de Médecine de Tours, Tours, France
| | - Frédéric Oberti
- Service d'Hépato-Gastroentérologie, CHU Angers, Angers, France
| | - Charles Roux
- Service de Radiologie Intervent.ionnelle, AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Wim Laleman
- Service de Gastroentérologie et Hépatologie, Hôpital Universitaire Gasthuisberg, KU Leuven, Louvain, Belgium
| | - Marika Rudler
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Sébastien Dharancy
- CHU Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, 2 Rue Michel Polonovski, Lille, France
| | - Nolwenn Laborde
- Gastro-Entérologie, Hépatologie, Nutrition, Maladies Héréditaires du Métabolisme Pédiatriques, Centre de Compétence Maladies Rares du Foie, Hôpital des Enfants, CHU, Toulouse, France
| | - Anne Minello
- Service D'hépato-Gastroentérologie et Oncologie Médicale, CHU F. Mitterrand, Dijon, France
| | - Thomas Mouillot
- Service D'hépato-Gastroentérologie et Oncologie Médicale, CHU F. Mitterrand, Dijon, France
| | - Elvire Desjonquères
- AP-HP Sorbonne Paris Nord, Hôpitaux Universitaire Paris Seine Saint-Denis, Service d'Hépatologie, Bobigny, France
| | - Line Caroll Ntandja Wandji
- Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, University of Lille, Lille, France
| | - Marc Bourlière
- Département d'Hépatologie et Gastroentérologie, Hôpital Saint Joseph, Marseille, France
| | - Nathalie Ganne-Carrié
- AP-HP Sorbonne Paris Nord, Hôpitaux Universitaire Paris Seine Saint-Denis, Service d'Hépatologie, Bobigny, France Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Paris, France
| | - Christophe Bureau
- Service d'Hépatologie Hopital Rangueil CHU Toulouse et Université Paul Sabatier, Toulouse, France
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Delgado MG, Mertineit N, Bosch J, Baumgartner I, Berzigotti A. Combination of Model for End-Stage Liver Disease (MELD) and Sarcopenia predicts mortality after transjugular intrahepatic portosystemic shunt (TIPS). Dig Liver Dis 2024; 56:1544-1550. [PMID: 38555198 DOI: 10.1016/j.dld.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/21/2024] [Accepted: 03/01/2024] [Indexed: 04/02/2024]
Abstract
TIPS is the most effective treatment for portal hypertension. Patient selection remains important to achieving optimal post-TIPS outcomes. The study evaluates 1-year mortality factors in cirrhotic patients receiving TIPS. METHODS 87 cirrhotic patients received a TIPS between 2015 - 2021. Predictors of 1-year and overall mortality were assessed by estimating cumulative incidence functions and Grey's test to adjust for liver transplantation as a risk competing with mortality. Variables with p < 0.05 were checked for collinearity and included in the multivariate Cox proportional hazards model. Model discrimination was evaluated by calculating the area under the ROC curve. RESULTS 87 patients were included (68% men; 22% ≥70 years). ALD was the primary cirrhosis cause. Most patients were Child-Pugh class B, MELD-Na score was 13.6 ± 6.0 points. The most frequent indication for TIPS was bleeding (51.7%), followed by refractory ascites (42.5%). The variables positively associated with mortality in univariate analysis were ascites, clinically overt sarcopenia and MELD-Na score, while ongoing nutritional supplementation improved survival. In the multivariate analysis, only clinically overt sarcopenia and MELD-Na score remained independently associated with mortality. A MELD-Na/sarcopenia model demonstrated a good discrimination, AUROC: 0.86 (95% CI 0.77 - 0.95). CONCLUSION MELD-Na score, and sarcopenia were significantly associated with 1-year survival in cirrhotic patients who received TIPS.
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Affiliation(s)
- Maria Gabriela Delgado
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Center for Vascular Interventions (IZI), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nando Mertineit
- Center for Vascular Interventions (IZI), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Medical Radiology, Buergerspital Solothurn, Solothurner Spitäler, Solothurn, Switzerland
| | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Center for Vascular Interventions (IZI), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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4
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Tiede A, Stockhoff L, Rieland H, Liu Z, Mauz JB, Tergast TL, Kabelitz MA, Schütte SS, Ehrenbauer AF, Meyer BC, Wedemeyer H, Hinrichs JB, Cornberg M, Falk CS, Xu CJ, Maasoumy B. No value of non-selective beta-blockers after TIPS-insertion. Aliment Pharmacol Ther 2024. [PMID: 39192553 DOI: 10.1111/apt.18204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/23/2024] [Accepted: 07/27/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND AND AIMS Non-selective beta-blockers (NSBB) are a well-established treatment in patients with clinically significant portal hypertension. However, their potential role after insertion of a transjugular intrahepatic portosystemic shunt (TIPS) still needs to be determined. Of note, recent studies suggested that favourable anti-inflammatory effects of NSBB might be independent from pressure reduction. This study aimed to evaluate whether NSBB-treatment is associated with amelioration of systemic inflammation (SI), hepatic decompensation and survival after TIPS-insertion. METHODS In a retrospective study comprising 305 consecutive patients, we investigated the impact of NSBB-intake at TIPS-placement on periinterventional cirrhosis-associated complications and continued NSBB-treatment after discharge on complications including hepatic decompensation and mortality during 1-year follow-up, employing multivariable competing-risk-analyses. In a prospective cohort including 45 patients, we performed a comprehensive analysis of SI analysing 48 soluble inflammatory markers (SIMs) at baseline plus 3 and 6 months after TIPS-insertion. RESULTS Overall, 175 (57.4%) patients received NSBB-therapy prior to TIPS-insertion; upon discharge, this decreased to 131 (22.9%), with 36 (27.5%) discontinuing NSBB within 1-year follow-up. Neither NSBB-therapy at TIPS-insertion nor treatment-continuation after discharge were associated with lower risks for hepatic decompensation, individual cirrhosis-associated complications or mortality neither in the periinterventional period nor during follow-up. Similarly, in the prospective cohort NSBB-intake was not linked to lower levels or a more prominent change of WBC, CRP or any other SIM at any of the investigated time points. CONCLUSION NSBB-therapy at the time of TIPS-insertion and its (dis-)continuation afterwards seems to have no significant impact on SI, development of hepatic decompensation and survival.
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Affiliation(s)
- Anja Tiede
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover-Braunschweig, Hannover, Germany
| | - Lena Stockhoff
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover, Germany
| | - Hannah Rieland
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover, Germany
| | - Zhaoli Liu
- Center for Individualized Infection Medicine (CIIM), c/o CRC Hannover, Hannover, Germany
- TWINCORE, Centre for Experimental and Clinical Infection Research, a joint venture between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany
| | - Jim B Mauz
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover, Germany
| | - Tammo L Tergast
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover, Germany
| | - Martin A Kabelitz
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover, Germany
| | - Sarah S Schütte
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover, Germany
| | - Alena F Ehrenbauer
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover, Germany
| | - Bernhard C Meyer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Heiner Wedemeyer
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover-Braunschweig, Hannover, Germany
| | - Jan B Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
- St. Bernward Hospital, Radiology, Hildesheim, Germany
| | - Markus Cornberg
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover-Braunschweig, Hannover, Germany
- Center for Individualized Infection Medicine (CIIM), c/o CRC Hannover, Hannover, Germany
| | - Christine S Falk
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Cheng-Jian Xu
- Center for Individualized Infection Medicine (CIIM), c/o CRC Hannover, Hannover, Germany
- TWINCORE, Centre for Experimental and Clinical Infection Research, a joint venture between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany
| | - Benjamin Maasoumy
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover-Braunschweig, Hannover, Germany
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5
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Büttner L, Pick L, Jonczyk M, Fehrenbach U, Collettini F, Auer TA, Schnapauff D, De Bucourt M, Wieners G, Gebauer B, Aigner A, Böning G. Shunt dysfunction and mortality after transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension. Insights Imaging 2024; 15:193. [PMID: 39112682 PMCID: PMC11306489 DOI: 10.1186/s13244-024-01768-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/07/2024] [Indexed: 08/10/2024] Open
Abstract
OBJECTIVES Transjugular intrahepatic portosystemic shunt (TIPS) is a catheter-based, minimally invasive procedure to reduce portal hypertension. The aim of the study was to investigate dysfunction and mortality after TIPS and to identify factors associated with these events. METHODS A retrospective analysis of 834 patients undergoing TIPS implantation in a single center from 1993-2018 was performed. Cumulative incidence curves were estimated, and frailty models were used to assess associations between potentially influential variables and time to dysfunction or death. RESULTS 1-, 2-, and 5-year mortality rates were 20.9% (confidence interval (CI) 17.7-24.1), 22.5% (CI 19.1-25.8), and 25.0% (CI: 21.1-28.8), 1-year, 2-year, and 5-year dysfunction rates were 28.4% (CI 24.6-32.3), 38.9% (CI 34.5-43.3), and 52.4% (CI 47.2-57.6). The use of covered stents is a protective factor regarding TIPS dysfunction (hazard ratio (HR) 0.47, CI 0.33-0.68) but does not play a major role in survival (HR 0.95, CI 0.58-1.56). Risk factors for mortality are rather TIPS in an emergency setting (HR 2.78, CI 1.19-6.50), a previous TIPS dysfunction (HR 2.43, CI 1.28-4.62), and an increased Freiburg score (HR 1.45, CI 0.93-2.28). CONCLUSION The use of covered stents is an important protective factor regarding TIPS dysfunction. Whereas previous TIPS dysfunction, emergency TIPS implantation, and an elevated Freiburg score are associated with increased mortality. Awareness of risk factors could contribute to a better selection of patients who may benefit from a TIPS procedure and improve clinical follow-up with regard to early detection of thrombosis/stenosis. CRITICAL RELEVANCE STATEMENT The use of covered stents reduces the risk of dysfunction after transjugular intrahepatic portosystemic shunt (TIPS). TIPS dysfunction, emergency TIPS placement, and a high Freiburg score are linked to higher mortality rates in TIPS patients. KEY POINTS The risk of dysfunction is higher for uncovered stents compared to covered stents. Transjugular intrahepatic portosystemic shunt dysfunction increases the risk of instantaneous death after the intervention. A higher Freiburg score increases the rate of death after the intervention. Transjugular intrahepatic portosystemic shunt implantations in emergency settings reduce survival rates.
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Affiliation(s)
- Laura Büttner
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany.
| | - Lisa Pick
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Jonczyk
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Uli Fehrenbach
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Federico Collettini
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Timo Alexander Auer
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Dirk Schnapauff
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Maximilian De Bucourt
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Gero Wieners
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Bernhard Gebauer
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Annette Aigner
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Georg Böning
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiology, Charitéplatz 1, 10117, Berlin, Germany
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Tang HH, Zhou LF, Wang CX, Zha Y, Fan C, Zhong BY, Zhu XL, Wang WD. The Value of Neutrophil-to-Lymphocyte Ratio in Predicting Mortality After Transjugular Intrahepatic Portosystemic Shunt Placement. J Inflamm Res 2024; 17:5211-5221. [PMID: 39104908 PMCID: PMC11299797 DOI: 10.2147/jir.s467583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 07/30/2024] [Indexed: 08/07/2024] Open
Abstract
Background and Aims The objective of this study was to investigate the effect of neutrophil-to-lymphocyte ratio (NLR) on the survival of cirrhotic patients with esophagogastric variceal bleeding (EGVB) treated with transjugular intrahepatic portosystemic shunt (TIPS). Methods A total of 293 patients treated with TIPS were included. The receiver operator characteristic curve (ROC) was used to calculate the optimal cut-off values of parameters such as NLR. The Kaplan-Meier curve and Cox proportional risk model were used to evaluate the effects of NLR and other variables on 2-year all-cause mortality. Results The area under the ROC for NLR was 0.634, with an optimal cutoff value of 4.9. Two-year mortality rates for patients with high (≥4.9) and low (<4.9) NLR were 22.1% and 9.3%, respectively (Log rank test: P = 0.002). After correcting for confounders, multivariate analysis demonstrated that NLR ≥ 4.9 (HR = 2.741, 95% CI 1.467-5.121, P = 0.002), age ≥ 63 (HR = 3.403, 95% CI 1.835-6.310, P < 0.001), and gender (male) (HR = 2.842, 95% CI 1.366-5.912, P = 0.001) were independent risk factors for the mortality outcome. Considering the stratification of early and selective TIPS treatment, high NLR still significantly increased the risk of mortality for patients (Log rank test: P = 0.007, HR = 2.317, 95% CI 1.232-4.356). Conclusion NLR can help to predict survival in EGVB patients after TIPS, and the type of TIPS should also be considered in practical applications.
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Affiliation(s)
- Hao-Huan Tang
- Department of Interventional Radiology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, People’s Republic of China
| | - Lin-Feng Zhou
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, People’s Republic of China
- Department of Radiology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430079, People’s Republic of China
| | - Chun-Xin Wang
- Department of Radiology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, People’s Republic of China
| | - Yang Zha
- Department of Radiology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, People’s Republic of China
| | - Chen Fan
- Department of Interventional Radiology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, People’s Republic of China
| | - Bin-Yan Zhong
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, People’s Republic of China
| | - Xiao-Li Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, People’s Republic of China
| | - Wei-Dong Wang
- Department of Interventional Radiology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, People’s Republic of China
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7
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Da B, Wu W, Guo W, Xiong K, Chen C, Ke Q, Zhang M, Li T, Xiao J, Wang L, Zhang M, Zhang F, Zhuge Y. External validation of the modified CTP score based on ammonia to predict survival in patients with cirrhosis after TIPS placement. Sci Rep 2024; 14:13886. [PMID: 38880817 PMCID: PMC11180650 DOI: 10.1038/s41598-024-64793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024] Open
Abstract
This study aimed to perform the first external validation of the modified Child-Turcotte-Pugh score based on plasma ammonia (aCTP) and compare it with other risk scoring systems to predict survival in patients with cirrhosis after transjugular intrahepatic portosystemic shunt (TIPS) placement. We retrospectively reviewed 473 patients from three cohorts between January 2016 and June 2022 and compared the aCTP score with the Child-Turcotte-Pugh (CTP) score, albumin-bilirubin (ALBI), model for end-stage liver disease (MELD) and sodium MELD (MELD-Na) in predicting transplant-free survival by the concordance index (C-index), area under the receiver operating characteristic curve, calibration plot, and decision curve analysis (DCA) curve. The median follow-up time was 29 months, during which a total of 62 (20.74%) patients died or underwent liver transplantation. The survival curves for the three aCTP grades differed significantly. Patients with aCTP grade C had a shorter expected lifespan than patients with aCTP grades A and B (P < 0.0001). The aCTP score showed the best discriminative performance using the C-index compared with other scores at each time point during follow-up, it also showed better calibration in the calibration plot and the lowest Brier scores, and it also showed a higher net benefit than the other scores in the DCA curve. The aCTP score outperformed the other risk scores in predicting survival after TIPS placement in patients with cirrhosis and may be useful for risk stratification and survival prediction.
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Affiliation(s)
- Binlin Da
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College, Nanjing Medical University, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Wei Wu
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wuhua Guo
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Kai Xiong
- Department of Gastroenterology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Chao Chen
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Qiao Ke
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Moran Zhang
- Department of Gastroenterology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Taishun Li
- Medical Statistical Analysis Centre, Nanjing Drum Tower Hospital, Clinical College, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jiangqiang Xiao
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College, Nanjing Medical University, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College, Nanjing Medical University, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Ming Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College, Nanjing Medical University, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China.
| | - Feng Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College, Nanjing Medical University, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China.
| | - Yuzheng Zhuge
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Clinical College, Nanjing Medical University, 321#, Zhongshan Road, Nanjing, 210008, Jiangsu, China.
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Sekandarzad A, Graf E, Prager EP, Luxenburger H, Staudacher DL, Wengenmayer T, Bettinger D, Supady A. Cytokine adsorption in patients with acute-on-chronic liver failure (CYTOHEP)-A single center, open-label, three-arm, randomized, controlled intervention pilot trial. Artif Organs 2024. [PMID: 38770971 DOI: 10.1111/aor.14774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/01/2024] [Accepted: 05/08/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND To investigate the efficacy of bilirubin reduction by hemoadsorption with CytoSorb® in patients with acute-on-chronic liver failure (ACLF) receiving continuous renal replacement therapy (CRRT). METHODS A prospective, randomized, single-center, open-label, controlled pilot trial. Patients with ACLF, acute kidney injury, and serum bilirubin ≥5 mg/dL were assigned 1:1:1 to one of three study groups (CRRT with or without hemoadsorption, no CRRT). In the hemoadsorption group, the CytoSorb adsorber was incorporated into the CRRT system, replaced after 12, 24, and 48 h, and removed after 72 h. The primary endpoint was the serum bilirubin level after 72 h. RESULTS CYTOHEP was terminated early due to difficulties in recruiting patients and ethical concerns. Three of 9 patients (33%) were treated in each group. Comparing the three groups, mean bilirubin levels after 72 h were lower by -8.0 mg/dL in the "CRRT with hemoadsorption" group compared to "CRRT without hemoadsorption" (95% CI, -21.3 to 5.3 mg/dL; p = 0.17). The corresponding mean difference between "CRRT without hemoadsorption" and "no CRRT" was -1.4 mg/dL (95% CI, -14.2 to 11.5 mg/dL; p = 0.78). Comparing "CRRT with hemoadsorption" and "no CRRT," it was -9.4 mg/dL (95% CI, -20.8 to 2.1 mg/dL; p = 0.0854). Only 1/9 patients (11%, "no CRRT" group) survived day 30 after study inclusion but died on day 89. IL-6, liver function parameters, and clinical scores were similar between the study groups. CONCLUSIONS CYTOHEP failed to demonstrate that extracorporeal hemoadsorption combined with CRRT can reduce serum bilirubin in ACLF patients with acute kidney failure.
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Affiliation(s)
- Asieb Sekandarzad
- Interdisciplinary Medical Intensive Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Erika Graf
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Eric Peter Prager
- Department of Medicine IV, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hendrik Luxenburger
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Interdisciplinary Medical Intensive Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Supady
- Interdisciplinary Medical Intensive Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Adebayo D, Wong F. Review article: Recent advances in ascites and acute kidney injury management in cirrhosis. Aliment Pharmacol Ther 2024; 59:1196-1211. [PMID: 38526023 DOI: 10.1111/apt.17972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/08/2024] [Accepted: 03/14/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Better understanding of disease pathophysiology has led to advances in managing ascites and its associated complications including hepatorenal syndrome-acute kidney Injury (HRS-AKI), especially medicinal and interventional advances. AIM To review the latest changes in the management of ascites and HRS-AKI. METHODS A literature search was conducted in Pubmed, using the keywords cirrhosis, ascites, renal dysfunction, acute kidney injury, hepatorenal syndrome, beta-blockers, albumin, TIPS and vasoconstrictors, including only publications in English. RESULTS The medicinal advances include earlier treatment of clinically significant portal hypertension to delay the onset of ascites and the use of human albumin solution to attenuate systemic inflammation thus improving the haemodynamic changes associated with cirrhosis. Furthermore, new classes of drugs such as sodium glucose co-transporter 2 are being investigated for use in patients with cirrhosis and ascites. For HRS-AKI management, newer pharmacological agents such as vasopressin partial agonists and relaxin are being studied. Interventional advances include the refinement of TIPS technique and patient selection to improve outcomes in patients with refractory ascites. The development of the alfa pump system and the study of outcomes associated with the use of long-term palliative abdominal drain will also serve to improve the quality of life in patients with refractory ascites. CONCLUSIONS New treatment strategies emerged from better understanding of the pathophysiology of ascites and HRS-AKI have shown improved prognosis in these patients. The future will see many of these approaches confirmed in large multi-centre clinical trials with the aim to benefit the patients with ascites and HRS-AKI.
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Affiliation(s)
- Danielle Adebayo
- Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Florence Wong
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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10
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Kaplan DE, Ripoll C, Thiele M, Fortune BE, Simonetto DA, Garcia-Tsao G, Bosch J. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024; 79:1180-1211. [PMID: 37870298 DOI: 10.1097/hep.0000000000000647] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA USA
| | - Cristina Ripoll
- Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Brett E Fortune
- Department of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
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11
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Loosen SH, Benz F, Mohr R, Reuken PA, Wirtz TH, Junker L, Jansen C, Meyer C, Praktiknjo M, Wree A, Reißing J, Demir M, Gu W, Vucur M, Schierwagen R, Stallmach A, Kunstein A, Bode J, Trautwein C, Tacke F, Luedde T, Bruns T, Trebicka J, Roderburg C. Soluble urokinase plasminogen activator receptor levels predict survival in patients with portal hypertension undergoing TIPS. JHEP Rep 2024; 6:101054. [PMID: 38681861 PMCID: PMC11053213 DOI: 10.1016/j.jhepr.2024.101054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 12/10/2023] [Accepted: 01/12/2024] [Indexed: 05/01/2024] Open
Abstract
Background & Aims Transjugular intrahepatic portosystemic shunt (TIPS) is the most effective therapy for complications of portal hypertension. However, clinical outcomes following TIPS placement vary widely between patients and identifying ideal candidates remains a challenge. Soluble urokinase plasminogen activator receptor (suPAR) is a circulating marker of immune activation that has previously been associated with liver inflammation, but its prognostic value in patients receiving TIPS is unknown. In the present study, we evaluated the potential clinical relevance of suPAR levels in patients undergoing TIPS insertion. Methods suPAR concentrations were measured by ELISA in hepatic vein (HV) and portal vein (PV) blood samples from 99 patients (training cohort) as well as peripheral venous blood samples from an additional 150 patients (validation cohort) undergoing TIPS placement. The association between suPAR levels and patient outcomes was assessed using Kaplan-Meier methods and Cox-regression analyses. Results suPAR concentrations were significantly higher in HV samples compared to PV samples and correlated with PV concentration, the presence of ascites, renal injury, and consequently with the Child-Pugh and MELD scores. Patients with lower suPAR levels had significantly better short- and long-term survival after TIPS insertion, which remained robust after adjustment for confounders in multivariate Cox-regression analyses. Sensitivity analysis showed an improvement in risk prediction in patients stratified by Child-Pugh or MELD scores. In an independent validation cohort, higher levels of suPAR predicted poor transplant-free survival after TIPS, particularly in patients with Child-Pugh A/B cirrhosis. Conclusion suPAR is largely derived from the injured liver and its levels are predictive of outcome in patients undergoing TIPS. suPAR, as a surrogate of hepatic inflammation, may be used to stratify care in patients following TIPS insertion. Impact and implications Transjugular intrahepatic portosystemic shunt (TIPS) is the most effective therapy for complications of portal hypertension. However, clinical outcomes following TIPS placement vary widely between patients and identification of the ideal candidates remains challenging. We show that soluble urokinase plasminogen activator receptor (suPAR), a circulating marker of immune activation that can easily be measured in routine clinical practice, is a novel marker to identify patients who will benefit from TIPS and those who will not.
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Affiliation(s)
- Sven H. Loosen
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Fabian Benz
- Department of Gastroenterology and Hepatology, Campus Virchow Klinikum and Campus Charité Mitte, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Raphael Mohr
- Department of Gastroenterology and Hepatology, Campus Virchow Klinikum and Campus Charité Mitte, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
- Department of Internal Medicine I, University Clinic Bonn, Bonn, Germany
| | - Philipp A. Reuken
- Department of Internal Medicine IV, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Theresa H. Wirtz
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Lioba Junker
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University Clinic Bonn, Bonn, Germany
| | - Carsten Meyer
- Department of Radiology, University Clinic Bonn, Bonn, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Alexander Wree
- Department of Gastroenterology and Hepatology, Campus Virchow Klinikum and Campus Charité Mitte, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Johanna Reißing
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Münevver Demir
- Department of Gastroenterology and Hepatology, Campus Virchow Klinikum and Campus Charité Mitte, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Wenyi Gu
- Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Mihael Vucur
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Robert Schierwagen
- Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Andreas Stallmach
- Department of Internal Medicine IV, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Anselm Kunstein
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Johannes Bode
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Christian Trautwein
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Frank Tacke
- Department of Gastroenterology and Hepatology, Campus Virchow Klinikum and Campus Charité Mitte, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Tony Bruns
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Jonel Trebicka
- Department of Internal Medicine B, University of Münster, Münster, Germany
- European Foundation for the Study of Chronic Liver Failure - EF CLIF, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Christoph Roderburg
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
- Department of Gastroenterology and Hepatology, Campus Virchow Klinikum and Campus Charité Mitte, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
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12
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Reincke M, Seufert J, Laubner K, Meyer-Steenbuck M, Dammer A, Sturm L, Thimme R, Bettinger D, Schultheiss M. Reduced bone mineral density is associated to post-TIPS survival of female patients with decompensated cirrhosis. Dig Liver Dis 2024:S1590-8658(24)00710-2. [PMID: 38679509 DOI: 10.1016/j.dld.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Malnutrition is common in patients with cirrhosis, eventually leading to sarcopenia and loss of bone mass. AIMS The aims of this study was the assessment of body composition (BC) and bone mineral density (BMD) in patients with decompensated cirrhosis and the prognostic impact on survival after transjugular intrahepatic portosystemic shunt (TIPS) implantation. METHODS BMD and BC of 107 patients with cirrhosis undergoing TIPS implantation were prospectively analyzed by dual-energy X-ray absorptiometry. The prevalence and predisposing risk factors for reduced BMD and sarcopenia were assessed. Impact on 12-month survival after TIPS implantation was evaluated. RESULTS Sarcopenia was diagnosed in 48.6 % of the patients with a predominance of male patients (58.7% vs. 25.0 %, p = 0.001). 67.2 % had reduced BMD. Low BMI was independently associated with sarcopenia (OR 0.751 (95 % CI: 0.662;0.852), p < 0.001) and reduced BMD (OR 0.851 (0.773;0.937), p = 0.001). Patients with reduced BMD, but not sarcopenia, had impaired 12-month survival after TIPS-implantation (61.2% vs. 82.9 %, p = 0.030). Subgroup analysis showed that this was especially valid for female patients. CONCLUSIONS Sarcopenia and reduced BMD are frequently observed in patients with decompensated cirrhosis. Reduced BMD negatively affects post-TIPS survival. Since malnutrition is a leading cause, assessment of nutritional status and specific treatment should be included in clinical practice.
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Affiliation(s)
- Marlene Reincke
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Jochen Seufert
- Department of Medicine II, Division of Endocrinology and Diabetology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Katharina Laubner
- Department of Medicine II, Division of Endocrinology and Diabetology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Maximilian Meyer-Steenbuck
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Anna Dammer
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Lukas Sturm
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany.
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Nardelli S, Riggio O, Marra F, Gioia S, Saltini D, Bellafante D, Adotti V, Guasconi T, Ridola L, Rosi M, Caporali C, Fanelli F, Roccarina D, Bianchini M, Indulti F, Spagnoli A, Merli M, Vizzutti F, Schepis F. Episodic overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt does not increase mortality in patients with cirrhosis. J Hepatol 2024; 80:596-602. [PMID: 38097113 DOI: 10.1016/j.jhep.2023.11.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/30/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND & AIMS Overt hepatic encephalopathy (OHE) is a major complication of transjugular intrahepatic portosystemic shunt (TIPS) placement, given its high incidence and possibility of refractoriness to medical treatment. Nevertheless, the impact of post-TIPS OHE on mortality has not been investigated in a large population. METHODS We designed a multicenter, non-inferiority, observational study to evaluate the mortality rate at 30 months in patients with and without OHE after TIPS. We analyzed a database of 614 patients who underwent TIPS in three Italian centers and estimated the cumulative incidence of OHE and mortality with competitive risk analyses, setting the non-inferiority limit at 0.12. RESULTS During a median follow-up of 30 months (IQR 12-30), 293 patients developed at least one episode of OHE. Twenty-seven (9.2%) of them experienced recurrent/persistent OHE. Patients with OHE were older (64 [57-71] vs. 59 [50-67] years, p <0.001), had lower albumin (3.1 [2.8-3.5] vs. 3.25 [2.9-3.6] g/dl, p = 0.023), and had a higher prevalence of pre-TIPS OHE (15.4% vs. 9.0%, p = 0.023). Child-Pugh and MELD scores were similar. The 30-month difference in mortality between patients with and without post-TIPS OHE was 0.03 (95% CI -0.042 to 0.102). Multivariable analysis showed that age (subdistribution hazard ratio 1.04, 95% CI 1.02-1.05, p <0.001) and MELD score (subdistribution hazard ratio 1.09, 95% CI 1.05-1.13, p <0.001), but not post-TIPS OHE, were associated with a higher mortality rate. Similar results were obtained when patients undergoing TIPS for variceal re-bleeding prophylaxis (n = 356) or refractory ascites (n = 258) were analyzed separately. The proportion of patients with persistent OHE after TIPS was significantly higher in the group of patients who died. The robustness of these results was increased following propensity score matching. CONCLUSION Episodic OHE after TIPS is not associated with mortality in patients undergoing TIPS, regardless of the indication. IMPACT AND IMPLICATIONS Overt hepatic encephalopathy (OHE) is a common complication in patients with advanced liver disease and it is particularly frequent following transjugular intrahepatic portosystemic shunt (TIPS) placement. In patients with cirrhosis outside the setting of TIPS, the development of OHE negatively impacts survival, regardless of the severity of cirrhosis or the presence of acute-on-chronic liver failure. In this multicenter, non-inferiority, observational study we demonstrated that post-TIPS OHE does not increase the risk of mortality in patients undergoing TIPS, irrespective of the indication. This finding alleviates concerns regarding the weight of this complication after TIPS. Intensive research to improve patient selection and risk stratification remains crucial to enhance the quality of life of patients and caregivers and to avoid undermining the positive effects of TIPS on survival.
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Affiliation(s)
- Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy.
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Dario Saltini
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniele Bellafante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Valentina Adotti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Tomas Guasconi
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Martina Rosi
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Cristian Caporali
- Department of Radiology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Fanelli
- Interventional Radiology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Davide Roccarina
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Marcello Bianchini
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Federica Indulti
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandra Spagnoli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Filippo Schepis
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
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Kalo E, Read S, George J, Roberts SK, Majumdar A, Ahlenstiel G. Attitudes towards transjugular intrahepatic portosystemic shunt (TIPS) in Australia: a national survey of TIPS centres. BMJ Open Gastroenterol 2024; 11:e001308. [PMID: 38519047 DOI: 10.1136/bmjgast-2023-001308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/20/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive therapeutic option to treat the sequelae of portal hypertension. It is unclear whether current international recommendations are reflected in current clinical practice across Australia and the extent of variations in care. This study aimed to address this gap in knowledge and benchmark the current landscape of TIPS services in Australia against international guidelines. METHODS We designed a 42-item questionnaire according to practice-based recommendations and standards of international guidelines to investigate current landscape of TIPS service across four key domains: (1) service provision, (2) patient selection and indications, (3) best procedure practice, and (4) postoperative care. RESULTS Gastroenterologist/hepatologists from 23 major liver centres (67.6%) across Australia currently performing TIPS completed the questionnaire. Between 2017 and 2020, there were 456 elective TIPS insertions. Units offering TIPS service had a low median number of TIPS insertions (n=7 per annum). More than half of respondents (56.5%) did not have institutional clinical practice protocols. There was marked variation in practices across institutions in terms of TIPS indications and patient selection. Despite variations, the success rate of elective TIPS was high at 91.7% (79-100%), with 86.6% (29-100%) for rescue TIPS. There was significant variation in postoperative follow-up and care. CONCLUSION Current TIPS practice in Australia varies significantly across institutions. There is a need for a national consensus clinical practice guidelines to improve access and minimise unwarranted variation. A national registry for TIPS could measure, monitor, and report on quality of clinical care and patient outcomes.
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Affiliation(s)
- Eric Kalo
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Scott Read
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
| | - Jacob George
- Faculty of Medicine, Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
- Gastroenterology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Avik Majumdar
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Golo Ahlenstiel
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Blacktown Hospital, Blacktown, New South Wales, Australia
- Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
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15
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Lan T, Chen M, Tang C, Deltenre P. Recent developments in the management of ascites in cirrhosis. United European Gastroenterol J 2024; 12:261-272. [PMID: 38340308 PMCID: PMC10954428 DOI: 10.1002/ueg2.12539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/05/2023] [Indexed: 02/12/2024] Open
Abstract
In recent years, advances have been made for treating ascites in patients with cirrhosis. Recent studies have indicated that several treatments that have been used for a long time in the management of portal hypertension may have beneficial effects that were not previously identified. Long-term albumin infusion may improve survival in patients with cirrhosis and ascites while beta-blockers may reduce ascites occurrence. Transjugular intrahepatic porto-systemic shunt (TIPS) placement may also improve survival in selected patients in addition to the control with ascites. Low-flow ascites pump insertion can be another option for some patients with intractable ascites. In this review, we summarize the latest data related to the management of ascites occurring in cirrhosis. There are still unanswered questions, such as the optimal use of albumin as a long-term therapy, the place of beta-blockers, and the best timing for TIPS placement to improve the natural history of ascites, as well as the optimal stent diameter to reduce the risk of shunt-related side-effects. These issued should be addressed in future studies.
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Affiliation(s)
- Tian Lan
- Lab of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Chen
- Lab of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Chengwei Tang
- Lab of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Pierre Deltenre
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
- Department of Gastroenterology and Hepatology, Clinique St Luc, Bouge, Belgium
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16
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Lv YF, Zhu B, Meng MM, Wu YF, Dong CB, Zhang Y, Liu BW, You SL, Lv S, Yang YP, Liu FQ. Development of a new Cox model for predicting long-term survival in hepatitis cirrhosis patients underwent transjugular intrahepatic portosystemic shunts. World J Gastrointest Surg 2024; 16:491-502. [PMID: 38463355 PMCID: PMC10921221 DOI: 10.4240/wjgs.v16.i2.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/23/2023] [Accepted: 01/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) placement is a procedure that can effectively treat complications of portal hypertension, such as variceal bleeding and refractory ascites. However, there have been no specific studies on predicting long-term survival after TIPS placement. AIM To establish a model to predict long-term survival in patients with hepatitis cirrhosis after TIPS. METHODS A retrospective analysis was conducted on a cohort of 224 patients who underwent TIPS implantation. Through univariate and multivariate Cox regression analyses, various factors were examined for their ability to predict survival at 6 years after TIPS. Consequently, a composite score was formulated, encompassing the indication, shunt reasonability, portal venous pressure gradient (PPG) after TIPS, percentage decrease in portal venous pressure (PVP), indocyanine green retention rate at 15 min (ICGR15) and total bilirubin (Tbil) level. Furthermore, the performance of the newly developed Cox (NDC) model was evaluated in an internal validation cohort and compared with that of a series of existing models. RESULTS The indication (variceal bleeding or ascites), shunt reasonability (reasonable or unreasonable), ICGR15, postoperative PPG, percentage of PVP decrease and Tbil were found to be independent factors affecting long-term survival after TIPS placement. The NDC model incorporated these parameters and successfully identified patients at high risk, exhibiting a notably elevated mortality rate following the TIPS procedure, as observed in both the training and validation cohorts. Additionally, in terms of predicting the long-term survival rate, the performance of the NDC model was significantly better than that of the other four models [Child-Pugh, model for end-stage liver disease (MELD), MELD-sodium and the Freiburg index of post-TIPS survival]. CONCLUSION The NDC model can accurately predict long-term survival after the TIPS procedure in patients with hepatitis cirrhosis, help identify high-risk patients and guide follow-up management after TIPS implantation.
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Affiliation(s)
- Yi-Fan Lv
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Bing Zhu
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Ming-Ming Meng
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yi-Fan Wu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Cheng-Bin Dong
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yu Zhang
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Bo-Wen Liu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Shao-Li You
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Sa Lv
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Yong-Ping Yang
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Fu-Quan Liu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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17
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Iannone G, Pompili E, De Venuto C, Pratelli D, Tedesco G, Baldassarre M, Caraceni P, Zaccherini G. The Role of Transjugular Intrahepatic Portosystemic Shunt for the Management of Ascites in Patients with Decompensated Cirrhosis. J Clin Med 2024; 13:1349. [PMID: 38592162 PMCID: PMC10932158 DOI: 10.3390/jcm13051349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 04/10/2024] Open
Abstract
The development and progression of ascites represent a crucial event in the natural history of patients with cirrhosis, predisposing them to other complications and carrying a heavy impact on prognosis. The current standard of care for the management of ascites relies on various combinations of diuretics and large-volume paracenteses. Periodic long-term albumin infusions on top of diuretics have been recently shown to greatly facilitate the management of ascites. The insertion of a transjugular intrahepatic portosystemic shunt (TIPS), an artificial connection between the portal and caval systems, is indicated to treat patients with refractory ascites. TIPS acts to decrease portal hypertension, thus targeting an upstream event in the pathophysiological cascade of cirrhosis decompensation. Available evidence shows a significant benefit on ascites control/resolution, with less clear results on patient survival. Patient selection plays a crucial role in obtaining better clinical responses and avoiding TIPS-related adverse events, the most important of which are hepatic encephalopathy, cardiac overload and failure, and liver failure. At the same time, some recent technical evolutions of available stents appear promising but deserve further investigations. Future challenges and perspectives include (i) identifying the features for selecting the ideal candidate to TIPS; (ii) recognizing the better timing for TIPS placement; and (iii) understanding the most appropriate role of TIPS within the framework of all other available treatments for the management of patients with decompensated cirrhosis.
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Affiliation(s)
- Giulia Iannone
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Enrico Pompili
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Clara De Venuto
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Dario Pratelli
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Greta Tedesco
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
| | - Maurizio Baldassarre
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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18
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Dong X, Liu J, Bai Y, Liu X, Ma J, Zhou B, Ren Y, Zheng C. The time window for pre-emptive transjugular intrahepatic portosystemic shunt could be extended to 5 days. Heliyon 2024; 10:e25824. [PMID: 38863871 PMCID: PMC11165235 DOI: 10.1016/j.heliyon.2024.e25824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/26/2024] [Accepted: 02/02/2024] [Indexed: 06/13/2024] Open
Abstract
As recommended by Baveno VII consensus, the utilization of pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS) has been considered as standard therapeutic approach for the management of acute variceal bleeding (AVB) associated with cirrhosis., but the 72-h window for pTIPS is too narrow. This study aimed to compare the clinical outcomes between patients who received <72 h pTIPS and 72 h-5d pTIPS. In this study, a total of 63 cirrhotic patients with AVB who underwent pTIPS between October 2016 and December 2021 were included in this retrospective study. They were divided into <72 h group (n = 32) and 72 h-5d group (n = 31), based on the timing of the intervention. The Kaplan-Meier curves demonstrated that there were no significant differences in the cumulative incidence of death (22.3% ± 7.4% vs. 19.9% ± 7.3%, log-rank P = 0.849), variceal rebleeding (9.7% ± 5.3% vs. 17.8% ± 7.3%, log-rank P = 0.406), OHE (28.5% ± 8.0% vs. 23.9% ± 8.0%, log-rank P = 0.641) and shunt dysfunction (8.6% ± 6.0% vs. 17.4% ± 8.1%, log-rank P = 0.328) between <72 h and 72 h-5d groups. In the total cohort, sarcopenia was identified as an independent risk factor for mortality (HR = 11.268, 95% CI = 1.435-88.462, P = 0.021) and OHE(HR = 12.504, 95% CI = 1.598-97.814, P = 0.016). In conclusion, the clinical outcomes of cirrhotic patients with AVB who underwent pTIPS within the 72-h to 5-day window were found to be comparable to those treated within the 72-h window.
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Affiliation(s)
- Xiangjun Dong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yaowei Bai
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Xiaoming Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jinqiang Ma
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Binqian Zhou
- Department of Ultrasound, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430014, China
| | - Yanqiao Ren
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chuansheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
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19
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Zhao Y, Yang Y, Lv W, Zhu S, Chen X, Wang T, Huang M, An T, Duan C, Yu X, Li Q, Chen J, Luo J, Zhou S, Lu L, Huang M, Fu S. A modified model for predicting mortality after transjugular intrahepatic portosystemic shunt: A multicentre study. Liver Int 2024; 44:472-482. [PMID: 38010919 DOI: 10.1111/liv.15790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 10/14/2023] [Accepted: 11/05/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND AIMS The transjugular intrahepatic portosystemic shunt has controversial survival benefits; thus, patient screening should be performed preoperatively. In this study, we aimed to develop a model to predict post-transjugular intrahepatic portosystemic shunt mortality to aid clinical decision making. METHODS A total of 811 patients undergoing transjugular intrahepatic portosystemic shunt from five hospitals were divided into the training and external validation data sets. A modified prediction model of post-transjugular intrahepatic portosystemic shunt mortality (ModelMT ) was built after performing logistic regression. To verify the improved performance of ModelMT , we compared it with seven previous models, both in discrimination and calibration. Furthermore, patients were stratified into low-, medium-, high- and extremely high-risk subgroups. RESULTS ModelMT demonstrated a satisfying predictive efficiency in both discrimination and calibration, with an area under the curve of .875 in the training set and .852 in the validation set. Compared to previous models (ALBI, BILI-PLT, MELD-Na, MOTS, FIPS, MELD, CLIF-C AD), ModelMT showed superior performance in discrimination by statistical difference in the Delong test, net reclassification improvement and integrated discrimination improvement (all p < .050). Similar results were observed in calibration. Low-, medium-, high- and extremely high-risk groups were defined by scores of ≤160, 160-180, 180-200 and >200, respectively. To facilitate future clinical application, we also built an applet for ModelMT . CONCLUSIONS We successfully developed a predictive model with improved performance to assist in decision making for transjugular intrahepatic portosystemic shunt according to survival benefits.
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Affiliation(s)
- Yujie Zhao
- Zhuhai Interventional Medical Center, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People's Hospital), Zhuhai, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People's Hospital), Zhuhai, China
| | - Yang Yang
- Zhuhai Interventional Medical Center, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People's Hospital), Zhuhai, China
| | - Weifu Lv
- Division of Life Sciences and Medicine, Interventional Radiology Department, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Siyu Zhu
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Xiaoqiong Chen
- Zhuhai Interventional Medical Center, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People's Hospital), Zhuhai, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People's Hospital), Zhuhai, China
| | - Tao Wang
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
| | - Mingsheng Huang
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Taixue An
- Department of Laboratory Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chongyang Duan
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Xiangrong Yu
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People's Hospital), Zhuhai, China
- Department of Radiology, Zhuhai People's Hospital (Zhuhai hospital affiliated with Jinan University), Zhuhai, China
| | - Qiyang Li
- Department of Radiology, Shenzhen People's Hospital, Shenzhen, China
| | - Jinqiang Chen
- Zhuhai Interventional Medical Center, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People's Hospital), Zhuhai, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People's Hospital), Zhuhai, China
| | - Junyang Luo
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shuoling Zhou
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
| | - Ligong Lu
- Zhuhai Interventional Medical Center, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People's Hospital), Zhuhai, China
| | - Meiyan Huang
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, Guangzhou, China
- Guangdong Province Engineering Laboratory for Medical Imaging and Diagnostic Technology, Southern Medical University, Guangzhou, China
| | - Sirui Fu
- Zhuhai Interventional Medical Center, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People's Hospital), Zhuhai, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People's Hospital), Zhuhai, China
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20
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Wang RX, Vizzutti F, Celsa C, Schepis F, Kaplan DE, Mahmud N. Evaluating the predictive performance of the elderly patient calculator TIPS score in a North American cohort. Hepatol Commun 2024; 8:e0346. [PMID: 38251888 PMCID: PMC10805419 DOI: 10.1097/hc9.0000000000000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/07/2023] [Indexed: 01/23/2024] Open
Affiliation(s)
- Roy X. Wang
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Ciro Celsa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, Gastroenterology and Hepatology Unit, University of Palermo, Palermo, Italy
| | - Filippo Schepis
- Department of Medicine, Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - David E. Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nadim Mahmud
- Department of Medicine, Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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21
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Mazumder NR, Fontana RJ. MELD 3.0 in Advanced Chronic Liver Disease. Annu Rev Med 2024; 75:233-245. [PMID: 37751367 DOI: 10.1146/annurev-med-051322-122539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
The MELD (model for end-stage liver disease) 3.0 score was developed to replace the MELD-Na score that is currently used to prioritize liver allocation for cirrhotic patients awaiting liver transplantation in the United States. The MELD 3.0 calculator includes new inputs from patient sex and serum albumin levels and has new weights for serum sodium, bilirubin, international normalized ratio, and creatinine levels. It is expected that use of MELD 3.0 scores will reduce overall waitlist mortality modestly and improve access for female liver transplant candidates. The utility of MELD 3.0 and PELDcre (pediatric end-stage liver disease, creatinine) scores for risk stratification in cirrhotic patients undergoing major abdominal surgery, placement of a transjugular intrahepatic portosystemic shunt, and other interventions requires further study. This article reviews the background of the MELD score and the rationale to create MELD 3.0 as well as potential implications of using this newer risk stratification tool in clinical practice.
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Affiliation(s)
- Nikhilesh R Mazumder
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA; ,
- Gastroenterology Section, Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan, USA
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA; ,
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22
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Balcar L, Mandorfer M, Hernández-Gea V, Procopet B, Meyer EL, Giráldez Á, Amitrano L, Villanueva C, Thabut D, Samaniego LI, Silva-Junior G, Martinez J, Genescà J, Bureau C, Trebicka J, Herrera EL, Laleman W, Palazón Azorín JM, Alonso JC, Gluud LL, Ferreira CN, Cañete N, Rodríguez M, Ferlitsch A, Mundi JL, Grønbæk H, Hernandez Guerra MN, Sassatelli R, Dell'Era A, Senzolo M, Abraldes JG, Romero-Gómez M, Zipprich A, Casas M, Masnou H, Primignani M, Krag A, Nevens F, Calleja JL, Jansen C, Catalina MV, Albillos A, Rudler M, Tapias EA, Guardascione MA, Tantau M, Schwarzer R, Reiberger T, Laursen SB, Lopez-Gomez M, Cachero A, Ferrarese A, Ripoll C, La Mura V, Bosch J, García-Pagán JC. Predicting survival in patients with 'non-high-risk' acute variceal bleeding receiving β-blockers+ligation to prevent re-bleeding. J Hepatol 2024; 80:73-81. [PMID: 37852414 DOI: 10.1016/j.jhep.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/03/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND & AIMS Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for high-risk acute variceal bleeding (AVB; i.e., Child-Turcotte-Pugh [CTP] B8-9+active bleeding/C10-13). Nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation for secondary prophylaxis. We investigated prognostic factors for re-bleeding and mortality in 'non-high-risk' AVB to identify subgroups who may benefit from more potent treatments (i.e., TIPS) to prevent further decompensation and mortality. METHODS A total of 2,225 adults with cirrhosis and variceal bleeding were prospectively recruited at 34 centres between 2011-2015; for the purpose of this study, case definitions and information on prognostic indicators at index AVB and on day 5 were further refined in low-risk patients, of whom 581 (without failure to control bleeding or contraindications to TIPS) who were managed by non-selective beta-blockers/endoscopic variceal ligation, were finally included. Patients were followed for 1 year. RESULTS Overall, 90 patients (15%) re-bled and 70 (12%) patients died during follow-up. Using clinical routine data, no meaningful predictors of re-bleeding were identified. However, re-bleeding (included as a time-dependent co-variable) increased mortality, even after accounting for differences in patient characteristics (adjusted cause-specific hazard ratio: 2.57; 95% CI 1.43-4.62; p = 0.002). A nomogram including CTP, creatinine, and sodium measured at baseline accurately (concordance: 0.752) stratified the risk of death. CONCLUSION The majority of 'non-high-risk' patients with AVB have an excellent prognosis, if treated according to current recommendations. However, about one-fifth of patients, i.e. those with CTP ≥8 and/or high creatinine levels or hyponatremia, have a considerable risk of death within 1 year of the index bleed. Future clinical trials should investigate whether elective TIPS placement reduces mortality in these patients. IMPACT AND IMPLICATIONS Pre-emptive transjugular intrahepatic portosystemic shunt placement improves outcomes in high-risk acute variceal bleeding; nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation. This is the first large-scale study investigating prognostic factors for re-bleeding and mortality in 'non-high-risk' acute variceal bleeding. While no clinically meaningful predictors were identified for re-bleeding, we developed a nomogram integrating baseline Child-Turcotte-Pugh score, creatinine, and sodium to stratify mortality risk. Our study paves the way for future clinical trials evaluating whether elective transjugular intrahepatic portosystemic shunt placement improves outcomes in presumably 'non-high-risk' patients who are identified as being at increased risk of death.
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Affiliation(s)
- Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria; Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain
| | - Bogdan Procopet
- Hepatology Department and 3rd Medical Clinic, Regional Institute of Gastroenterology and Hepatology 'Octavian Fodor' and 'Iuliu Hatieganu' University of Medicine and Pharmacy, Romania
| | - Elias Laurin Meyer
- Section for Medical Statistics, Center for Medical Data Science, Medical University of Vienna, Vienna, Austria; Berry Consultants, Vienna, Austria
| | - Álvaro Giráldez
- Clinical Management Unit of Digestive Diseases, University Hospital Virgen Del Rocio, Spain
| | | | - Candid Villanueva
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servei De Patologia Digestiva, Hospital De La Santa Creu I Sant Pau, Spain
| | | | - Luis Ibáñez Samaniego
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servicio De Medicina De Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Lisgm, Spain
| | - Gilberto Silva-Junior
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain
| | - Javier Martinez
- Department of Gastroenterology and Instituto Ramón y Cajal De Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal and University of Alcalá, Spain
| | - Joan Genescà
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Spain
| | - Christophe Bureau
- Department of Hepato-Gastroenterology, Purpan Hospital, University of Toulouse, France
| | - Jonel Trebicka
- Department of Internal Medicine B, University of Münster, Germany; Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Internal Medicine I, University of Bonn, Germany
| | - Elba Llop Herrera
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain
| | - Wim Laleman
- Department of Liver and Biliopancreatic Disorders, KU Leuven, Belgium
| | | | - Jose Castellote Alonso
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, Idibell, Universitat de Barcelona, Spain
| | - Lise Lotte Gluud
- Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre and Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Portugal
| | - Nuria Cañete
- Liver Section, Gastroenterology Department and Imim (Hospital del Mar Medical Research Institute), Gastroenterology Department, Spain
| | - Manuel Rodríguez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Spain
| | - Arnulf Ferlitsch
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria; Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Department of Internal Medicine I, Gastroenterology and Nephrology, St. John of God Hospital, Vienna, Austria
| | - Jose Luis Mundi
- Department of Gastroenterology, University Hospital San Cecilio, Spain
| | - Henning Grønbæk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | | | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRRCS, Italy
| | - Alessandra Dell'Era
- Gastroenterology Unit, Asst Fatebenefratelli Sacco, Department of Clinical and Biomedical Sciences, Università Degli Studi Di Milano, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Italy
| | - Juan Gonzalez Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), CEGIIR, University of Alberta, Canada
| | - Manuel Romero-Gómez
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Unidad De Hepatología, Hospital Universitario De Valme, Spain
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Germany
| | - Meritxell Casas
- Hepatology Unit, Digestive Disease Department, Hospital De Sabadell, Universitat Autónoma de Barcelona, Spain
| | - Helena Masnou
- Hospital Universitari Germans Trias I Pujol, Universitat Autònoma Barcelona, Spain
| | - Massimo Primignani
- CRC 'a.M. and a. Migliavacca' Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, Italy
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark
| | - Frederik Nevens
- Department of Liver and Biliopancreatic Disorders, KU Leuven, Belgium
| | - Jose Luis Calleja
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain
| | | | - María Vega Catalina
- Servicio De Medicina De Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Lisgm, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Instituto Ramón y Cajal De Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal and University of Alcalá, Spain
| | - Marika Rudler
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, France
| | - Edilmar Alvarado Tapias
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servei De Patologia Digestiva, Hospital De La Santa Creu I Sant Pau, Spain
| | | | - Marcel Tantau
- Hepatology Department and 3rd Medical Clinic, Regional Institute of Gastroenterology and Hepatology 'Octavian Fodor' and 'Iuliu Hatieganu' University of Medicine and Pharmacy, Romania
| | - Rémy Schwarzer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | | | - Marta Lopez-Gomez
- Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Spain
| | - Alba Cachero
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, Idibell, Universitat de Barcelona, Spain
| | - Alberto Ferrarese
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Italy
| | - Cristina Ripoll
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Germany; Internal Medicine IV, Universitätsklinikum Jena, Friedrich Schiller University, Jena, Germany
| | - Vincenzo La Mura
- Hospital Universitari Germans Trias I Pujol, Universitat Autònoma Barcelona, Spain; Uoc Medicina Generale - Emostasi e Trombosi, Fondazione IRRCS, Cà Granda, Ospedale Maggiore Policlinico, Italy
| | - Jaime Bosch
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain.
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23
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Ferrarese A, Bucci M, Zanetto A, Senzolo M, Germani G, Gambato M, Russo FP, Burra P. Prognostic models in end stage liver disease. Best Pract Res Clin Gastroenterol 2023; 67:101866. [PMID: 38103926 DOI: 10.1016/j.bpg.2023.101866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/13/2023] [Accepted: 08/18/2023] [Indexed: 12/19/2023]
Abstract
Cirrhosis is a major cause of death worldwide, and is associated with significant health care costs. Even if milestones have been recently reached in understanding and managing end-stage liver disease (ESLD), the disease course remains somewhat difficult to prognosticate. These difficulties have already been acknowledged already in the past, when scores instead of single parameters have been proposed as valuable tools for short-term prognosis. These standard scores, like Child Turcotte Pugh (CTP) and model for end-stage liver disease (MELD) score, relying on biochemical and clinical parameters, are still widely used in clinical practice to predict short- and medium-term prognosis. The MELD score, which remains an accurate, easy-to-use, objective predictive score, has received significant modifications over time, in order to improve its performance especially in the liver transplant (LT) setting, where it is widely used as prioritization tool. Although many attempts to improve prognostic accuracy have failed because of lack of replicability or poor benefit with the comparator (often the MELD score or its variants), few scores have been recently proposed and validated especially for subgroups of patients with ESLD, as those with acute-on-chronic liver failure. Artificial intelligence will probably help hepatologists in the near future to fill the current gaps in predicting disease course and long-term prognosis of such patients.
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Affiliation(s)
- A Ferrarese
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Bucci
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - A Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - G Germani
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - M Gambato
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - F P Russo
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy
| | - P Burra
- Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, 2, Giustiniani Street, 35122, Padua, Italy.
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24
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Zhao Y, Wang Y, Xu J. Predictive Accuracy Comparison of Prognostic Scoring Systems for Survival in Patients Undergoing TIPS Placement: A Systematic Review and Meta-analysis. Acad Radiol 2023:S1076-6332(23)00603-7. [PMID: 38000922 DOI: 10.1016/j.acra.2023.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023]
Abstract
RATIONALE AND OBJECTIVES This meta-analysis aimed to evaluate the performance of different risk assessment models (RAMs) for survival after Transjugular Intrahepatic Portosystemic Shunt (TIPS) in patients with cirrhotic portal hypertension. MATERIALS AND METHODS A systematic search of PubMed, WOS, Embase, Cochrane, and CNKI from inception to February 2023 was conducted. We comprehensively reviewed and aggregated data from numerous studies covering prevalent RAMs such as Child-Turcotte-Pugh, the Model for End-Stage Liver Disease (MELD), MELD-Sodium (MELD-Na), the Freiburg Index of Post-TIPS Survival (FIPS), Bilirubin-platelet, Chronic Liver Failure Consortium Acute Decompensation score, and Albumin-Bilirubin grade across different timeframes. For this study, short-term is defined as outcomes within a year while long-term refers to outcomes beyond one year. The area under the receiver operating characteristic (AUC) curve or Concordance Statistics was chosen as the metric to assess predictive capacity for mortality outcomes across six predetermined time intervals. Mean effect sizes at various time points were determined using robust variance estimation. RESULTS MELD consistently stood out as a primary short-term survival predictor, particularly for 1 month (± 2 weeks) (AUC: 0.72) and 3 months of (± 1 month) survival (AUC: 0.72). MELD-Na showed the best long-term predictive ability, with an AUC of 0.70 at 3.5 years (± 1.5 years). FIPS performed well for 6 months of (± 2 months) survival (AUC: 0.68) and overall transplant-free survival (AUC: 0.75). Efficacy nuances were observed in RAMs when applied to particular subgroups. Meta-regression emphasized the potential predictor overlaps in models like MELD and FIPS. CONCLUSION This meta-analysis underscores the MELD score as the premier predictor for short-term survival following TIPS. Meanwhile, the FIPS score and MELD-Na model exhibit potential in forecasting long-term outcomes. The study accentuates the significance of RAM selection for enhancing patient outcomes and advocates for additional research to corroborate these findings and fine-tune risk assessment in TIPS.
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Affiliation(s)
- Yan Zhao
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yun Wang
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Junwang Xu
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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25
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Zhang Q, Long L, Zhu HL, Peng H, Luo XH, Zhu KS, Wang RP. Predicting disease progression in cirrhotic patients after transjugular intrahepatic portosystemic shunt implantation: A sex-stratified analysis. World J Gastroenterol 2023; 29:5768-5780. [PMID: 38075849 PMCID: PMC10701336 DOI: 10.3748/wjg.v29.i42.5768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/30/2023] [Accepted: 10/29/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) has been extensively used to treat portal hypertension-associated complications, including cirrhosis. The prediction of post-TIPS prognosis is important for cirrhotic patients, as more aggressive liver transplantation is needed when the post-TIPS prognosis is poor. AIM To construct a nutrition-based model that could predict the disease progression of cirrhotic patients after TIPS implantation in a sex-dependent manner. METHODS This study retrospectively recruited cirrhotic patients undergoing TIPS implantation for analysis. Muscle quality was assessed by measuring the skeletal muscle index (SMI) by computed tomography. Multivariate Cox proportional hazard models were utilized to determine the association between SMI and disease progression in cirrhotic patients after TIPS implantation. RESULTS This study eventually included 186 cirrhotic patients receiving TIPS who were followed up for 30.5 ± 18.8 mo. For male patients, the 30-mo survival rate was significantly lower and the probability of progressive events was higher (3.257-fold) in the low-level SMI group than in the high-level SMI group. According to the multivariate Cox analysis of male patients, SMI < 32.8 was an independent risk factor for long-term adverse outcomes after TIPS implantation. A model was constructed, which involved creatinine, plasma ammonia, SMI, and acute-on-chronic liver failure and hepatic encephalopathy occurring within half a year after surgery. This model had an area under the receiver operating characteristic curve of 0.852, sensitivity of 0.926, and specificity of 0.652. According to the results of the DeLong test, this model outperformed other models (Child-Turcotte-Pugh, Model for End-Stage Liver Disease, and Freiburg index of post-TIPS survival) (P < 0.05). CONCLUSION SMI is strongly associated with poor long-term outcomes in male patients with cirrhosis who underwent TIPS implantation.
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Affiliation(s)
- Qian Zhang
- Department of Radiology, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China
- The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, Guangdong Province, China
- Department of Infectious Diseases, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China
| | - Li Long
- Department of Infectious Diseases, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China
| | - Hong-Lin Zhu
- Department of Interventional Radiology, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China
| | - Hong Peng
- Department of Infectious Diseases, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China
| | - Xin-Hua Luo
- Department of Infectious Diseases, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China
| | - Kang-Shun Zhu
- Department of Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, Guangdong Province, China
| | - Rong-Pin Wang
- Department of Radiology, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China
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Schneider H, Berliner D, Stockhoff L, Reincke M, Mauz JB, Meyer B, Bauersachs J, Wedemeyer H, Wacker F, Bettinger D, Hinrichs JB, Maasoumy B. Diastolic dysfunction is associated with cardiac decompensation after transjugular intrahepatic portosystemic shunt in patients with liver cirrhosis. United European Gastroenterol J 2023; 11:837-851. [PMID: 37897707 PMCID: PMC10637125 DOI: 10.1002/ueg2.12471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 07/21/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND AND AIMS About 20% of patients develop cardiac decompensation within the first year after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, risk factors for cardiac decompensation remain poorly defined. We aimed to evaluate predictors of cardiac decompensation after TIPS insertion in a large, well-defined cohort of patients with liver cirrhosis. METHODS 234 cirrhotic patients who received a TIPS at Hannover Medical School were retrospectively followed up for one year to assess the incidence of cardiac decompensation. Echocardiographic parameters and established diagnostic criteria for cardiac impairment (e.g. by the American Society of Echocardiography/ European Association of Cardiovascular Imaging (ASE/EACVI)) were investigated for an association with cardiac decompensation in a competing risk analysis. Survival was analyzed using a multivariable cox regression analysis adjusting for Freiburg index of post-TIPS survival. RESULTS Predominant TIPS indication was ascites (83%). Median age was 59 years, median MELD-score 12% and 58% were male. Overall, 41 patients (18%) developed cardiac decompensation within one year after TIPS insertion. Diastolic dysfunction according to the ASE/EACVI was diagnosed in 26% of patients at baseline and was linked to a significantly higher risk for cardiac decompensation (p = 0.025) after TIPS. When investigating individual echocardiographic baseline parameters, only pathological E/A (<0.8 or >2) was identified as a risk factor for cardiac decompensation (p = 0.015). Mortality and liver transplantation (n = 50) were significantly higher among patients who developed cardiac decompensation (HR = 5.29, p < 0.001) as well as in patients with a pathological E/A (HR = 2.34, p = 0.006). Cardiac high-risk status (44% of patients) was strongly linked to cardiac decompensation (HR = 2.93, p = 0.002) and mortality (HR = 2.24, p = 0.012). CONCLUSION Cardiac decompensation after TIPS is a frequent and important complication and is associated with reduced survival. American Society of Echocardiography/EACVI criteria and E/A seem to be the best parameters to predict the cardiac risk in cirrhotic patients undergoing TIPS insertion.
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Affiliation(s)
- Hannah Schneider
- Department of Gastroenterology, Hepatology, Infectious Diseases and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Dominik Berliner
- Department of Cardiology and AngiologyHannover Medical SchoolHannoverGermany
| | - Lena Stockhoff
- Department of Gastroenterology, Hepatology, Infectious Diseases and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Marlene Reincke
- Department of Medicine IIMedical Center University of FreiburgFreiburg im BreisgauGermany
| | - Jim B. Mauz
- Department of Gastroenterology, Hepatology, Infectious Diseases and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Bernhard Meyer
- Department of Diagnostic and Interventional RadiologyHannover Medical SchoolHannoverGermany
| | - Johann Bauersachs
- Department of Cardiology and AngiologyHannover Medical SchoolHannoverGermany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, Infectious Diseases and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Frank Wacker
- Department of Diagnostic and Interventional RadiologyHannover Medical SchoolHannoverGermany
| | - Dominik Bettinger
- Department of Medicine IIMedical Center University of FreiburgFreiburg im BreisgauGermany
| | - Jan B. Hinrichs
- Department of Diagnostic and Interventional RadiologyHannover Medical SchoolHannoverGermany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology, Infectious Diseases and EndocrinologyHannover Medical SchoolHannoverGermany
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Saltini D, Indulti F, Guasconi T, Bianchini M, Cuffari B, Caporali C, Casari F, Prampolini F, Senzolo M, Colecchia A, Schepis F. Transjugular Intrahepatic Portosystemic Shunt: Devices Evolution, Technical Tips and Future Perspectives. J Clin Med 2023; 12:6758. [PMID: 37959225 PMCID: PMC10650044 DOI: 10.3390/jcm12216758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
Portal hypertension (PH) constitutes a pivotal factor in the progression of cirrhosis, giving rise to severe complications and a diminished survival rate. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has undergone significant evolution, with advancements in stent technology assuming a central role in managing PH-related complications. This review aims to outline the progression of TIPS and emphasizes the significant influence of stent advancement on its effectiveness. Initially, the use of bare metal stents (BMSs) was limited due to frequent dysfunction. However, the advent of expanding polytetrafluoroethylene-covered stent grafts (ePTFE-SGs) heralded a transformative era, greatly enhancing patency rates. Further innovation culminated in the creation of ePTFE-SGs with controlled expansion, enabling precise adjustment of TIPS diameters. Comparative analyses demonstrated the superiority of ePTFE-SGs over BMSs, resulting in improved patency, fewer complications, and higher survival rates. Additional technical findings highlight the importance of central stent placement and adequate stent length, as well as the use of smaller calibers to reduce the risk of shunt-related complications. However, improving TIPS through technical means alone is inadequate for optimizing patient outcomes. An extensive understanding of hemodynamic, cardiac, and systemic factors is required to predict outcomes and tailor a personalized approach. Looking forward, the ongoing progress in SG technology, paired with the control of clinical factors that can impact outcomes, holds the promise of reshaping the management of PH-related complications in cirrhosis.
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Affiliation(s)
- Dario Saltini
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Federica Indulti
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Tomas Guasconi
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Marcello Bianchini
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Biagio Cuffari
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Cristian Caporali
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy; (C.C.)
| | - Federico Casari
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy; (C.C.)
| | - Francesco Prampolini
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy; (C.C.)
| | - Marco Senzolo
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy;
| | - Antonio Colecchia
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Filippo Schepis
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
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March C, Thormann M, Geipel S, Sowa JP, Barajas Ordonez F, Pech M, Omari J, Lemmer P. Increase of radiologically determined muscle area in patients with liver cirrhosis after transjugular intrahepatic portosystemic shunt. Sci Rep 2023; 13:17092. [PMID: 37816875 PMCID: PMC10564886 DOI: 10.1038/s41598-023-43938-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/30/2023] [Indexed: 10/12/2023] Open
Abstract
Sarcopenia is common in patients with liver cirrhosis and related to higher mortality. Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a feasible method for reducing cirrhosis-related portal hypertension, but also possible improvement of the patient`s muscle status. We aimed to analyze changes in muscle quantity and prevalence of sarcopenia after TIPS. We retrospectively surveyed the muscle status in 52 patients (mean age 54.2 years) before and after TIPS by evaluating skeletal (SMI) and psoas muscle indices (PMI) in CT and MR images. Model for End-Stage Liver Disease (MELD), Freiburg index of post-TIPS survival (FIPS), and their underlying laboratory parameters (e.g., Albumin) were analyzed. Prevalence of sarcopenia was 84.6%. After a median follow-up of 16.5 months after TIPS, SMI (0.020) and PMI (p < 0.001) increased, and sarcopenia decreased by 14.8% (0.109). MELD and PMI after TIPS were negatively correlated (r = - 0.536, p < 0.001). Albumin levels increased in patients with increased SMI after TIPS (p = 0.022). Confirming the positive impact of TIPS implantation on muscle indices in patients with liver cirrhosis, we found indications for improved survival and possible indications for altered metabolism with increased albumin levels in patients with increased muscle quantity.
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Affiliation(s)
- Christine March
- Department of Radiology and Nuclear Medicine, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany.
- Department of Radiology and Nuclear Medicine, University of Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - Maximilian Thormann
- Department of Radiology and Nuclear Medicine, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany
| | - Sarah Geipel
- Department of Radiology and Nuclear Medicine, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany
| | - Jan-Peter Sowa
- Department of Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Ruhr University, Bochum, In der Schornau 23-25, 44892, Bochum, Germany
| | - Felix Barajas Ordonez
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Maciej Pech
- Department of Radiology and Nuclear Medicine, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany
| | - Jazan Omari
- Department of Radiology and Nuclear Medicine, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany
| | - Peter Lemmer
- Department of Gastroenterology, Hepatology, and Infectious Diseases, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany
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Gu W, Zeleke Y, Hortlik H, Schaaf L, Uschner FE, Schulz M, Tischendorf M, Peiffer KH, Brol MJ, Kimmann M, Vogl T, Köhler M, Meyer C, Gerbes A, Rössle M, Laleman W, Zipprich A, Steib C, Praktiknjo M, Trebicka J. Use and outcome of TIPS in hospitalized patients in Germany: A Nationwide study (2007-2018). Hepatol Commun 2023; 7:e0237. [PMID: 37708430 PMCID: PMC10503680 DOI: 10.1097/hc9.0000000000000237] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/14/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND The number of complications in patients admitted for cirrhosis has increased over time. Portal hypertension is the driver of many complications of cirrhosis. TIPS placement is the most effective treatment of portal hypertension. The aim of this study was to analyze the use and impact of TIPS placement in the last decade in a nationwide study in Germany. METHODS We analyzed 14,598 admissions of patients for TIPS insertions in Germany from 2007 to 2018 using the DRG system, 12,877 out of 2,000,765 total admissions of patients with cirrhosis. All diagnoses and procedures were coded according to ICD-10-CM and OPS codes. The data were analyzed, focusing on the number of admissions and in-hospital mortality. RESULTS The number of TIPS placements increased over the last decade. In-hospital mortality of cirrhotic patients with TIPS decreased when it was placed for severe bleeding (15.2% [TIPS] vs. 19.5% [endoscopy treatment]), ascites (8.7% [TIPS] vs. 14.4% [paracentesis]), and hepatorenal syndrome (HRS) (17.1% [TIPS] vs. 43.3% [no-TIPS]). In the case of bleeding, TIPS significantly decreased in-hospital mortality and also in ascites and HRS. During hospitalization, 22.6% admissions of patients with TIPS insertion showed HE. However, in-hospital mortality in patients admitted with HE grades 1 or 2 and TIPS was lower than in patients without TIPS. In the logistic regression, a higher HE grade(3 and 4), infection, and circulatory disease were found to be independently associated with in-hospital mortality in patients with TIPS insertion. CONCLUSION Our nationwide study demonstrates that TIPS insertion is increasingly used in Germany. TIPS improves outcomes, especially in patients with ascites and HRS, regardless of lower HE grades, while higher HE grades, infection, and circulatory diseases seem to be associated with risk of in-hospital mortality.
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Affiliation(s)
- Wenyi Gu
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Yasmin Zeleke
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Hannah Hortlik
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Louisa Schaaf
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Frank E. Uschner
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Martin Schulz
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Kai-Henrik Peiffer
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | | | - Markus Kimmann
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Thomas Vogl
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Köhler
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | - Carsten Meyer
- Clinic for Radiology, University Hospital Bonn, Bonn, Germany
| | - Alexander Gerbes
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Martin Rössle
- Department of Internal Medicine II, Faculty of Medicine, Medical Centre University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Wim Laleman
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Alexander Zipprich
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Christian Steib
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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Reincke M, Thimme R, Schultheiß M. [Complications of liver cirrhosis]. Dtsch Med Wochenschr 2023; 148:1371-1382. [PMID: 37820648 DOI: 10.1055/a-2001-4236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Liver cirrhosis is a chronic disease, progressing from a compensated and asymptomatic state to decompensated cirrhosis with the occurrence of multiple organ complications. This progression is accompanied by a significant increase of morbidity and mortality. Main complications include clinical manifestations of portal hypertension (ascites and varices) as well as consequences of liver insufficiency as hepatic encephalopathy. Besides, many other organ systems can be affected, as liver cirrhosis is today more and more seen as a multisystemic disease. Unfortunately, most therapy options of these complications are purely symptomatic, and the only curative treatment of advanced chronic liver disease is liver transplantation.
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Ehrenbauer AF, Schneider H, Stockhoff L, Tiede A, Lorenz C, Dirks M, Witt J, Gabriel MM, Wedemeyer H, Hinrichs JB, Weissenborn K, Maasoumy B. Predicting overt hepatic encephalopathy after TIPS: Value of three minimal hepatic encephalopathy tests. JHEP Rep 2023; 5:100829. [PMID: 37600959 PMCID: PMC10432804 DOI: 10.1016/j.jhepr.2023.100829] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/19/2023] [Accepted: 06/12/2023] [Indexed: 08/22/2023] Open
Abstract
Background & Aims Hepatic encephalopathy (HE) is a frequent and severe complication in patients after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, risk factors for post-TIPS HE remain poorly defined. Minimal HE (mHE) is a well-known risk factor for overt HE in patients with cirrhosis without TIPS. We aimed to evaluate three tools frequently used for diagnosing mHE for their dynamic changes and their predictive value for overt HE after TIPS. Methods We prospectively recruited 84 consecutive patients before TIPS insertion and monitored them for 180 days for post-TIPS HE. Before TIPS insertion, the patients underwent the portosystemic encephalopathy (PSE) syndrome test, the animal naming test (ANT), and the critical flicker frequency (CFF). Patients were retested after TIPS insertion. Results The majority of patients were male (67.9%), and the predominant indication for TIPS was refractory ascites (75%). Median age was 59 years, model for end-stage liver disease score was 12, and 66.3%, 64.6%, and 28.4% patients had evidence for mHE according to the PSE syndrome test, ANT, and CFF, respectively. Overall, 25 patients developed post-TIPS HE within 180 days after TIPS insertion. Post-TIPS incidence of overt HE was 22.2, 28.6, 45.5, and 55.6% in those with no, one, two, and three pathological tests at baseline, respectively. However, none of the three tests was significantly associated with post-TIPS HE. Of note, mean performance in all tests remained stable over time after TIPS insertion. Conclusions PSE syndrome test, ANT and CFF, which are frequently used for diagnosing mHE have limited value for predicting HE after TIPS insertion. We could not find evidence that TIPS insertion leads to a psychometric decline in the long term. Impact and implications This prospective observational study compared three diagnostic tests for mHE and showed the limited value of these tests for predicting overt HE in patients with cirrhosis undergoing TIPS insertion. In addition, the results suggest that cognitive performance generally remains stable after TIPS insertion. These results are important for physicians and researchers involved in the management of patients with cirrhosis undergoing TIPS procedures. The study's findings serve as a starting point for further investigations on the development of more effective strategies for predicting and managing post-TIPS HE. Clinical trial number ClinicalTrials.gov NCT04801290.
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Affiliation(s)
- Alena F. Ehrenbauer
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Hannah Schneider
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Lena Stockhoff
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Anja Tiede
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Charlotte Lorenz
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Meike Dirks
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Jennifer Witt
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Maria M. Gabriel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jan B. Hinrichs
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | | | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
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Xiong B, Yang C, Zhu X, Zhou C, Chen S, Zhang Z, Wu X, Huang S. The Added Value of Sarcopenia on Existing Risk Scores to Predict Mortality after TIPS Placement: A Multicenter Study. Acad Radiol 2023; 30 Suppl 1:S246-S256. [PMID: 37029067 DOI: 10.1016/j.acra.2023.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 04/08/2023]
Abstract
RATIONALE AND OBJECTIVES Multiple prognostic scores have been applied for predicting survival after TIPS placement. The aim was to evaluate the added value of sarcopenia on existing risk scores and develop a sarcopenia-based scoring system for survival prediction and risk stratification. MATERIALS AND METHODS In the derivation cohort of 386 cirrhotic patients undergoing TIPS, five risk scores (Child-Pugh, MELD, MELD-Na, MELD 3.0, and FIPS) were compared for prediction of short- and long-term mortality after TIPS. Sarcopenia was diagnosed based on the L3 skeletal muscle index and was incorporated into existing scores to assess its added value. A novel sarcopenia-based score was developed and externally validated in an independent cohort of 198 patients undergoing TIPS. RESULTS Among existing scores, the FIPS score showed the highest discrimination (c-index: 0.756-0.783) and calibration (Brier score: 0.059-0.127). Besides, the FIPS score was significantly associated with the severity of baseline sarcopenia and reversal of sarcopenia after TIPS. The inclusion of sarcopenia improved discrimination of existing scores in different degrees and sarcopenia could stratify the low-risk categories deemed by these scores. A FIPS-sarcopenia score was developed, showing superior discrimination over existing scores (c-index: 0.777-0.804 in the derivation cohort, 0.738-0.788 in the validation cohort). With a determined cutoff of 0.8, this score allowed for the identification of two prognostic subgroups with distinct prognoses. CONCLUSION FIPS score was highly correlated with the severity of sarcopenia and sarcopenia reversal after TIPS, and sarcopenia could improve the prognostic ability of existing scores. A FIPS-sarcopenia score was developed and validated, showing improved survival prediction and risk stratification.
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Affiliation(s)
- Bin Xiong
- Department of Interventional Radiology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China (B.X., X.W.).
| | - Chongtu Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China (C.Y.); Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (C.Y., C.Z., S.H.)
| | - Xiaoli Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University (X.Z., Z.Z.)
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (C.Y., C.Z., S.H.)
| | - Shirui Chen
- Department of Dermatology, Chengdu Second People's Hospital, Chengdu, China (S.C.)
| | - Zichen Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University (X.Z., Z.Z.)
| | - Xiaomei Wu
- Department of Interventional Radiology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China (B.X., X.W.)
| | - Songjiang Huang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China (C.Y.); Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China (S.H.)
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Nassar A, Huber JP, Stallmann D, Sharipova D, Hamad MA, Schultheiss M, Thimme R, Duerschmied D, Scharf RE, Bettinger D, Krauel K. Decreased Platelet Aggregation in Patients with Decompensated Liver Cirrhosis and TIPS Implantation. Biomedicines 2023; 11:2057. [PMID: 37509696 PMCID: PMC10508239 DOI: 10.3390/biomedicines11072057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/13/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) implantation is an effective treatment of portal hypertension in patients with decompensated liver cirrhosis. However, some patients develop TIPS thrombosis with recurrence of portal hypertension. The role of platelets in TIPS thrombosis and the necessity of antiplatelet therapy is unclear. Therefore, we aimed to study platelet function in patients with liver cirrhosis prior to and after TIPS implantation. Platelet aggregation was tested in peripheral and portal-vein blood patient samples on the day (D) of TIPS implantation (D0), D4 and D30 following the procedure (platelet count above 100 × 103/µL, aspirin starting on D5) using whole-blood impedance aggregometry (WBIA) and light transmission aggregometry (LTA). In addition, surface platelet activation markers (P-selectin, activated GPIIb/IIIa) and platelet-neutrophil complexes (PNCs) were assessed by flow cytometry. Thrombin receptor activating peptide 6 (TRAP-6), adenosine diphosphate (ADP) and arachidonic acid (AA) were used as agonists. Healthy subjects were included as controls. Agonist-induced platelet aggregation was reduced (WBIA: TRAP-6 p < 0.01, ADP p < 0.01, AA p < 0.001; LTA: TRAP-6 p = 0.13, ADP p = 0.05, AA p < 0.01) in patients (D0, n = 13) compared with healthy subjects (n = 9). While surface activation markers at baseline were negligibly low, the percentage of PNCs was higher in patients than in controls (p < 0.05). ADP-induced P-selectin expression was increased (p < 0.001), whereas TRAP-6-induced GPIIb/IIIa activation was impaired (p < 0.001) in patients versus controls. PNC formation in response to agonists was not different between groups. Results did not differ between peripheral and portal-vein blood of patients (D0, n = 11) and did not change over time (D0, D4, D30) following TIPS implantation (n = 9). In summary, patients with decompensated liver cirrhosis display in vitro platelet aggregation defects in response to various agonists. Defective aggregation persists upon TIPS implantation. Therefore, we conclude that antiplatelet treatment to prevent TIPS thrombosis is questionable.
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Affiliation(s)
- Asala Nassar
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, D-79106 Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, D-79106 Freiburg, Germany
| | - Jan Patrick Huber
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, D-79106 Freiburg, Germany
| | - Daniela Stallmann
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, D-79106 Freiburg, Germany
| | - Diana Sharipova
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, D-79106 Freiburg, Germany
| | - Muataz Ali Hamad
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, D-79106 Freiburg, Germany
- Spemann Graduate School of Biology and Medicine (SGBM), University of Freiburg, D-79104 Freiburg, Germany
- Faculty of Biology, University of Freiburg, D-79104 Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, D-79106 Freiburg, Germany
- Berta-Ottenstein-Program, Faculty of Medicine, University of Freiburg, D-79106 Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, D-79106 Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, D-79106 Freiburg, Germany
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, D-68167 Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, D-68167 Mannheim, Germany
| | - Rüdiger Eberhard Scharf
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, D-68167 Mannheim, Germany
- Program in Cellular and Molecular Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Experimental and Clinical Hemostasis, Hemotherapy, and Transfusion Medicine, Blood and Hemophilia Comprehensive Care Center, Institute of Transplantation Diagnostics and Cell Therapy, Heinrich Heine University Medical Center, D-40225 Düsseldorf, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, D-79106 Freiburg, Germany
| | - Krystin Krauel
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, D-79106 Freiburg, Germany
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, D-68167 Mannheim, Germany
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Wong F. Innovative approaches to the management of ascites in cirrhosis. JHEP Rep 2023; 5:100749. [PMID: 37250493 PMCID: PMC10220491 DOI: 10.1016/j.jhepr.2023.100749] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/20/2023] [Accepted: 03/15/2023] [Indexed: 05/31/2023] Open
Abstract
Standard of care for the treatment of ascites in cirrhosis is to administer a sodium-restricted diet and diuretic therapy. The progression of cirrhosis will eventually lead to the development of refractory ascites, at which point diuretics will no longer be able to control the ascites. Second-line therapies such as a transjugular intrahepatic portosystemic shunt (TIPS) placement or repeat large volume paracentesis are then required. There is some evidence that regular infusions of albumin may delay the onset of refractoriness and improve survival, especially if given at an early stage in the natural history of ascites and for a long enough duration. The use of TIPS can eliminate ascites, but its insertion is associated with complications, especially cardiac decompensation and worsening of hepatic encephalopathy. New information is now available regarding how to best select patients for TIPS, what type of cardiac investigations are needed and how under-dilating the TIPS at the time of insertion may help. The use of a non-absorbable antibiotics, such as rifaximin, starting in the pre-TIPS period may also reduce the likelihood of post-TIPS hepatic encephalopathy. In patients who are not suitable for TIPS, the use of an alfapump to remove the ascites via the bladder can improve quality of life without significantly altering survival. In the future it may be possible to use metabolomics to help refine the management of patients with ascites, e.g. to assess their response to non-selective beta-blockers or to predict the development of other complications such as acute kidney injury.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Division of Gastroenterology & Hepatology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Gu W, Kimmann M, Laleman W, Praktiknjo M, Trebicka J. To TIPS or Not to TIPS in High Risk of Variceal Rebleeding and Acute-on-Chronic Liver Failure. Semin Liver Dis 2023; 43:189-205. [PMID: 37286178 DOI: 10.1055/a-2107-0576] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Variceal bleeding is a consequence of severe portal hypertension in patients with liver cirrhosis. Although the rate of bleeding has decreased over time, variceal bleeding in the presence of acute-on-chronic liver failure (ACLF) carries a high risk of treatment failure and short-term mortality. Treatment and/or removal of precipitating events (mainly bacterial infection and alcoholic hepatitis) and decrease of portal pressure may improve outcome of patients with acute decompensation or ACLF. Transjugular intrahepatic portosystemic shunts (TIPSs), especially in the preemptive situation, have been found to efficiently control bleeding, prevent rebleeding, and reduce short-term mortality. Therefore, TIPS placement should be considered as an option in the management of ACLF patients with variceal bleeding.
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Affiliation(s)
- Wenyi Gu
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- Medical Department I, Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Markus Kimmann
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
| | - Wim Laleman
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Michael Praktiknjo
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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Dong J, Zhang Y, Wu YF, Yue ZD, Fan ZH, Zhang CY, Liu FQ, Wang L. Computed tomography perfusion in differentiating portal hypertension: A correlation study with hepatic venous pressure gradient. World J Gastrointest Surg 2023; 15:664-673. [PMID: 37206083 PMCID: PMC10190718 DOI: 10.4240/wjgs.v15.i4.664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/11/2023] [Accepted: 03/23/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Hepatic venous pressure gradient (HVPG) is the gold standard for diagnosis of portal hypertension (PH), invasiveness and potential risks in the process of measurement limited its widespread use.
AIM To investigate the correlation of computed tomography (CT) perfusion parameters with HVPG in PH, and quantitatively assess the blood supply changes in liver and spleen parenchyma before and after transjugular intrahepatic portosystemic shunt (TIPS).
METHODS Twenty-four PH related gastrointestinal bleeding patients were recruited in this study, and all patients were performed perfusion CT before and after TIPS surgery within 2 wk. Quantitative parameters of CT perfusion, including liver blood volume (LBV), liver blood flow (LBF), hepatic arterial fraction (HAF), spleen blood volume (SBV) and spleen blood flow (SBF), were measured and compared before and after TIPS, and the quantitative parameters between clinically significant PH (CSPH) and non-CSPH (NCSPH) group were also compared. Then the correlation of CT perfusion parameters with HVPG were analyzed, with statistical significance as P < 0.05.
RESULTS For all 24 PH patients after TIPS, CT perfusion parameters demonstrated decreased LBV, increased HAF, SBV and SBF, with no statistical difference in LBF. Compared with NCSPH, CSPH showed higher HAF, with no difference in other CT perfusion parameters. HAF before TIPS showed positive correlation with HVPG (r = 0.530, P = 0.008), while no correlation was found in other CT perfusion parameters with HVPG and Child-Pugh scores.
CONCLUSION HAF, an index of CT perfusion, was positive correlation with HVPG, and higher in CSPH than NCSPH before TIPS. While increased HAF, SBF and SBV, and decreased LBV, were found after TIPS, which accommodates a potential non-invasive imaging tool for evaluation of PH.
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Affiliation(s)
- Jian Dong
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yu Zhang
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yi-Fan Wu
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Zhen-Dong Yue
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Zhen-Hua Fan
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Chun-Yan Zhang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Fu-Quan Liu
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Lei Wang
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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Vaz K, Little R, Majeed A, Roberts S, Kemp W. Letter to the Editor: Predicting mortality after transjugular intrahepatic portosystemic shunt in older adult patients with cirrhosis-Does novelty supplant the standard? Hepatology 2023; 77:E74-E75. [PMID: 36169940 DOI: 10.1002/hep.32811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 12/08/2022]
Affiliation(s)
- Karl Vaz
- Department of Gastroenterology and Hepatology , Alfred Health , Melbourne , Victoria , Australia
- Central Clinical School , Monash University , Melbourne , Victoria , Australia
| | - Robert Little
- Department of Gastroenterology and Hepatology , Alfred Health , Melbourne , Victoria , Australia
- Central Clinical School , Monash University , Melbourne , Victoria , Australia
| | - Ammar Majeed
- Department of Gastroenterology and Hepatology , Alfred Health , Melbourne , Victoria , Australia
- Central Clinical School , Monash University , Melbourne , Victoria , Australia
| | - Stuart Roberts
- Department of Gastroenterology and Hepatology , Alfred Health , Melbourne , Victoria , Australia
- Central Clinical School , Monash University , Melbourne , Victoria , Australia
| | - William Kemp
- Department of Gastroenterology and Hepatology , Alfred Health , Melbourne , Victoria , Australia
- Central Clinical School , Monash University , Melbourne , Victoria , Australia
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Identifying optimal candidates for post-TIPS patients with HCC undergoing TACE: a multicenter observational study. Eur Radiol 2023; 33:2809-2820. [PMID: 36562786 PMCID: PMC10017639 DOI: 10.1007/s00330-022-09249-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 09/19/2022] [Accepted: 10/19/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To develop a prognostic model for post-transjugular intrahepatic portosystemic shunt (TIPS) patients with hepatocellular carcinoma (HCC) beyond the Milan criteria treated by transarterial chemoembolization (TACE). DESIGN Between January 2013 and January 2020, 512 patients with HCC beyond the Milan criteria who underwent TACE after TIPS were retrospectively recruited from 15 tertiary centers. Patients were randomly sorted into a training set (n = 382) and a validation set (n = 130). Medical data and overall survival were assessed. A prediction model was developed using multivariate Cox regression analyses. Predictive performance and discrimination were evaluated and compared with other prognostic models. RESULTS Vascular invasion, log10(AFP), 1/creatinine, extrahepatic spread, and log10(ALT) were the most significant prognostic factors of survival. These five parameters were included in a new VACEA score. This score was able to stratify patients in the training set into four distinct risk grades whose median overall survival were 25.2, 15.1, 8.9, and 6.2 months, respectively. The 6-month, 1-year, 2-year, and 3-year AUROC values and C-index of the VACEA model were 0.819, 0.806, 0.779, 0.825, and 0.735, respectively, and higher than those of other seven currently available models in both the training and validation sets, as well as in different subgroups. CONCLUSION The VACEA score could stratify post-TIPS patients with HCC beyond the Milan criteria treated by TACE and help to identify candidates who benefit from this treatment. KEY POINTS • Vascular invasion, AFP, creatinine, extrahepatic spread, and ALT were independent significant prognostic factors of survival for HCC patients who underwent TACE after TIPS. • Our new model, named VACEA score, can accurately predict prognosis at the individual level and stratify patients into four distinct risk grades. • The VACEA model showed better prognostic discrimination and calibration than other current TACE-/TIPS-specific models Graphical abstract.
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Krige J, Jonas E, Robinson C, Beningfield S, Kotze U, Bernon M, Burmeister S, Kloppers C. Novel CABIN score outperforms other prognostic models in predicting in-hospital mortality after salvage transjugular intrahepatic portosystemic shunting. World J Gastrointest Pathophysiol 2023; 14:34-45. [PMID: 37035274 PMCID: PMC10074947 DOI: 10.4291/wjgp.v14.i2.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/23/2023] [Accepted: 03/10/2023] [Indexed: 03/21/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is now established as the salvage procedure of choice in patients who have uncontrolled or severe recurrent variceal bleeding despite optimal medical and endoscopic treatment.
AIM To analysis compared the performance of eight risk scores to predict in-hospital mortality after salvage TIPS (sTIPS) placement in patients with uncontrolled variceal bleeding after failed medical treatment and endoscopic intervention.
METHODS Baseline risk scores for the Acute Physiology and Chronic Health Evaluation (APACHE) II, Bonn TIPS early mortality (BOTEM), Child-Pugh, Emory, FIPS, model for end-stage liver disease (MELD), MELD-Na, and a novel 5 category CABIN score incorporating Creatinine, Albumin, Bilirubin, INR and Na, were calculated before sTIPS. Concordance (C) statistics for predictive accuracy of in-hospital mortality of the eight scores were compared using area under the receiver operating characteristic curve (AUROC) analysis.
RESULTS Thirty-four patients (29 men, 5 women), median age 52 years (range 31-80) received sTIPS for uncontrolled (11) or refractory (23) bleeding between August 1991 and November 2020. Salvage TIPS controlled bleeding in 32 (94%) patients with recurrence in one. Ten (29%) patients died in hospital. All scoring systems had a significant association with in-hospital mortality (P < 0.05) on multivariate analysis. Based on in-hospital survival AUROC, the CABIN (0.967), APACHE II (0.948) and Emory (0.942) scores had the best capability predicting mortality compared to FIPS (0.892), BOTEM (0.877), MELD Na (0.865), Child-Pugh (0.802) and MELD (0.792).
CONCLUSION The novel CABIN score had the best prediction capability with statistical superiority over seven other risk scores. Despite sTIPS, hospital mortality remains high and can be predicted by CABIN category B or C or CABIN scores > 10. Survival was 100% in CABIN A patients while mortality was 75% for CABIN B, 87.5% for CABIN C, and 83% for CABIN scores > 10.
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Affiliation(s)
- Jake Krige
- Department of Surgical Gastroenterology, University of Cape Town Health Sciences Faculty, Cape Town 7925, Western Cape, South Africa
| | - Eduard Jonas
- Department of Surgical Gastroenterology, University of Cape Town Health Sciences Faculty, Cape Town 7925, Western Cape, South Africa
| | - Chanel Robinson
- Department of Surgical Gastroenterology, University of Cape Town Health Sciences Faculty, Cape Town 7925, Western Cape, South Africa
| | - Steve Beningfield
- Department of Radiology, University of Cape Town Health Sciences Faculty, Cape Town 7925, Western Cape, South Africa
| | - Urda Kotze
- Department of Surgical Gastroenterology, University of Cape Town Health Sciences Faculty, Cape Town 7925, Western Cape, South Africa
| | - Marc Bernon
- Department of Surgical Gastroenterology, University of Cape Town Health Sciences Faculty, Cape Town 7925, Western Cape, South Africa
| | - Sean Burmeister
- Department of Surgical Gastroenterology, University of Cape Town Health Sciences Faculty, Cape Town 7925, Western Cape, South Africa
| | - Christo Kloppers
- Department of Surgical Gastroenterology, University of Cape Town, Faculty of Health Sciences, Cape Town 7925, Western Cape, South Africa
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Bayona Molano MDP, Barrera Gutierrez JC, Landinez G, Mejia A, Haskal ZJ. Updates on the Model for End-Stage Liver Disease Score and Impact on the Liver Transplant Waiting List: A Narrative Review. J Vasc Interv Radiol 2023; 34:337-343. [PMID: 36539154 DOI: 10.1016/j.jvir.2022.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 12/07/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
The model for end-stage liver disease (MELD) score is an established indicator of cirrhosis severity and a predictor of morbidity and mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation and for allocation in liver transplantation. Since the adoption of the score, its use has been expanded to multiple new indications requiring model modifications, including relevant clinical and demographic variables, to increase predictive accuracy. The purpose of this report is to provide an update on the modifications made to the MELD score, comparing their performance with C statistics, advantages and disadvantages, and impact on mortality at 3 months after placing a TIPS or awaiting liver transplantation.
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Affiliation(s)
| | | | - Gina Landinez
- Interventional Radiology Section, University of California San Francisco, San Francisco, California
| | - Alejandro Mejia
- Hepatobiliary and Transplant Surgery, Methodist Dallas Medical Center, Dallas, Texas
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging, University of Virginia School of Medicine, Charlottesville, Virginia
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Deltenre P, Zanetto A, Saltini D, Moreno C, Schepis F. The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions. Hepatology 2023; 77:640-658. [PMID: 35665949 DOI: 10.1002/hep.32596] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 01/28/2023]
Abstract
In selected patients with cirrhosis and ascites, transjugular intrahepatic portosystemic shunt (TIPS) placement improves control of ascites and may reduce mortality. In this review, we summarize the current knowledge concerning the use of TIPS for the treatment of ascites in patients with cirrhosis, from pathophysiology of ascites formation to hemodynamic consequences, patient selection, and technical issues of TIPS insertion. The combination of these factors is important to guide clinical decision-making and identify the best strategy for each individual patient. There is still a need to identify the best timing for TIPS placement in the natural history of ascites (recurrent vs. refractory) as well as which type and level of renal dysfunction is acceptable when TIPS is proposed for the treatment of ascites in cirrhosis. Future studies are needed to define the optimal stent diameter according to patient characteristics and individual risk of shunt-related side effects, particularly hepatic encephalopathy and insufficient cardiac response to hemodynamic consequences of TIPS insertion.
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Affiliation(s)
- Pierre Deltenre
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Department of Gastroenterology and Hepatology , CHU UCL Namur, Université Catholique de Louvain , Yvoir , Belgium.,Department of Gastroenterology and Hepatology , Clinique St Luc , Bouge , Belgium
| | - Alberto Zanetto
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy.,Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology , Padova University Hospital , Padova , Italy
| | - Dario Saltini
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Laboratory of Experimental Gastroenterology , Université Libre de Bruxelles , Brussels , Belgium
| | - Filippo Schepis
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
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Vizzutti F, Celsa C, Calvaruso V, Enea M, Battaglia S, Turco L, Senzolo M, Nardelli S, Miraglia R, Roccarina D, Campani C, Saltini D, Caporali C, Indulti F, Gitto S, Zanetto A, Di Maria G, Bianchini M, Pecchini M, Aspite S, Di Bonaventura C, Citone M, Guasconi T, Di Benedetto F, Arena U, Fanelli F, Maruzzelli L, Riggio O, Burra P, Colecchia A, Villa E, Marra F, Cammà C, Schepis F. Mortality after transjugular intrahepatic portosystemic shunt in older adult patients with cirrhosis: A validated prediction model. Hepatology 2023; 77:476-488. [PMID: 35921493 DOI: 10.1002/hep.32704] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/22/2022] [Accepted: 07/31/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) improves survival in patients with cirrhosis with refractory ascites and portal hypertensive bleeding. However, the indication for TIPS in older adult patients (greater than or equal to 70 years) is debated, and a specific prediction model developed in this particular setting is lacking. The aim of this study was to develop and validate a multivariable model for an accurate prediction of mortality in older adults. APPROACH AND RESULTS We prospectively enrolled 411 consecutive patients observed at four referral centers with de novo TIPS implantation for refractory ascites or secondary prophylaxis of variceal bleeding (derivation cohort) and an external cohort of 415 patients with similar indications for TIPS (validation cohort). Older adult patients in the two cohorts were 99 and 76, respectively. A cause-specific Cox competing risks model was used to predict liver-related mortality, with orthotopic liver transplant and death for extrahepatic causes as competing events. Age, alcoholic etiology, creatinine levels, and international normalized ratio in the overall cohort, and creatinine and sodium levels in older adults were independent risk factors for liver-related death by multivariable analysis. CONCLUSIONS After TIPS implantation, mortality is increased by aging, but TIPS placement should not be precluded in patients older than 70 years. In older adults, creatinine and sodium levels are useful predictors for decision making. Further efforts to update the prediction model with larger sample size are warranted.
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Affiliation(s)
- Francesco Vizzutti
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Ciro Celsa
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy.,Department of Surgical, Oncological, and Oral Sciences (Di.Chir.On.S.) , University of Palermo , Palermo , Italy
| | - Vincenza Calvaruso
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Marco Enea
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Salvatore Battaglia
- Department of Economics, Business, and Statistics (SEAS) , University of Palermo , Palermo , Italy
| | - Laura Turco
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy.,Internal Medicine Unit for the Treatment of Severe Organ Failure , Dipartimento medico chirurgico delle malattie digestive, epatiche ed endocrino-metaboliche , Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna , Policlinico di Sant'Orsola , Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit-Gastroenterology , Department of Surgery, Oncology, and Gastroenterology , Padua University Hospital , Padua , Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine , Sapienza University of Rome , Rome , Italy
| | - Roberto Miraglia
- Radiology Unit, Diagnostic and Therapeutic Services , IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) , Palermo , Italy
| | - Davide Roccarina
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Claudia Campani
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Dario Saltini
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Cristian Caporali
- Radiology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Federica Indulti
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit-Gastroenterology , Department of Surgery, Oncology, and Gastroenterology , Padua University Hospital , Padua , Italy
| | - Gabriele Di Maria
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Marcello Bianchini
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Maddalena Pecchini
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Chiara Di Bonaventura
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Michele Citone
- Department of Radiology, Interventional Radiology Unit , Careggi Hospital , Florence , Italy
| | - Tomas Guasconi
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit , University of Modena and Reggio Emilia , Modena , Italy
| | - Umberto Arena
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Fabrizio Fanelli
- Department of Radiology, Interventional Radiology Unit , Careggi Hospital , Florence , Italy
| | - Luigi Maruzzelli
- Radiology Unit, Diagnostic and Therapeutic Services , IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) , Palermo , Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine , Sapienza University of Rome , Rome , Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit-Gastroenterology , Department of Surgery, Oncology, and Gastroenterology , Padua University Hospital , Padua , Italy
| | - Antonio Colecchia
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Erica Villa
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy.,Center for Research, High Education and Transfer DENOThe , University of Florence , Florence , Italy
| | - Calogero Cammà
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Filippo Schepis
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
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MELD 3.0 Score for Predicting Survival in Patients with Cirrhosis After Transjugular Intrahepatic Portosystemic Shunt Creation. Dig Dis Sci 2023:10.1007/s10620-023-07834-3. [PMID: 36715817 DOI: 10.1007/s10620-023-07834-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 01/09/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIMS The selection of appropriate candidates for transjugular intrahepatic portosystemic shunt (TIPS) is important and challenging. To validate the Model for End-Stage Liver Disease (MELD) 3.0 in predicting mortality in patients with cirrhosis after TIPS creation. METHODS A total of 855 consecutive patients with cirrhosis from December 2011 to October 2019 who underwent TIPS placement were retrospectively reviewed. The prognostic value of the MELD 3.0, MELD, MELD-Na, Child-Pugh and FIPS score was assessed using Harrell's C concordance index (c-index). The Hosmer-Lemeshow test was used to test the goodness of fit of all models and the calibration plot was drawn. RESULTS The c-index of the MELD 3.0 in predicting 3-month mortality was 0.727 (0.645-0.808), which were significantly superior to the MELD (0.663 [0.565-0.761]; P = 0.015), MELD-Na (0.672 [0.577-0.768]; P = 0.008) and FIPS (0.582 [0.477-0.687]; P = 0.015). The Child-Pugh score reached c-indices of 0.754 (0.673-0.835), 0.720 (0.649-0.792), 0.705 (0.643-0.766) and 0.665 (0.614-0.716) for 3-month, 6-month, 1-year, and 2-year mortality, respectively, which seems comparable to MELD 3.0. A MELD 3.0 of 14 could be used as a cut-off point for discriminating between high- and low-risk patients. The MELD 3.0 could stratify patients with Child-Pugh grade B (log-rank P < 0.001). The Child-Pugh score could stratify patients defined as low risk by MELD 3.0 (log-rank P < 0.001). CONCLUSIONS The MELD 3.0 was significantly superior to the MELD, MELD-Na and FIPS scores in predicting mortality in patients with cirrhosis after TIPS creation.
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Ntandja Wandji LC, Ningarhari M, Lassailly G, Dharancy S, Boleslawski E, Mathurin P, Louvet A. Liver Transplantation in Alcohol-related Liver Disease and Alcohol-related Hepatitis. J Clin Exp Hepatol 2023; 13:127-138. [PMID: 36647412 PMCID: PMC9840078 DOI: 10.1016/j.jceh.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/25/2022] [Indexed: 02/07/2023] Open
Abstract
Alcohol-related liver disease (ARLD) remains one of the leading causes of chronic liver disease and the prevalence of alcohol-related cirrhosis is still increasing worldwide. Thus, ARLD is one of the leading indications for liver transplantation (LT) worldwide especially after the arrival of direct-acting antivirals for chronic hepatitis C infection. Despite the risk of alcohol relapse, the outcomes of LT for ARLD are as good as for other indications such as hepatocellular carcinoma (HCC), with 1-, 5-, and 10- year survival rates of 85%, 74%, and 59%, respectively. Despite these good results, certain questions concerning LT for ARLD remain unanswered, in particular because of persistent organ shortages. As a result, too many transplantation centers continue to require 6 months of abstinence from alcohol for patients with ARLD before LT to reduce the risk of alcohol relapse even though compelling data show the poor prognostic value of this criterion. A recent pilot study even observed a lower alcohol relapse rate in patients receiving LT after less than 6 months of abstinence as long as addictological follow-up is reinforced. Thus, the question should not be whether LT should be offered to patients with ARLD but how to select patients who will benefit from this treatment.
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Key Words
- AH, alcohol-related hepatitis
- ARLD, Alcohol-related liver disease
- AUDIT, Alcohol Use Disorders Identification Test
- CLD, chronic liver disease
- ELTR, European Liver Transplant Registry
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- LT, liver transplantation
- NASH, non-alcoholic steatohepatitis
- NIAAA, National Institute on Alcohol Abuse and Alcoholism
- UNOS, United Network for Organ Sharing
- alcohol
- alcohol-related hepatitis
- alcohol-related liver disease
- liver transplantation
- survival
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Affiliation(s)
- Line Carolle Ntandja Wandji
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Massih Ningarhari
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Guillaume Lassailly
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Sébastien Dharancy
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Emmanuel Boleslawski
- University of Lille, Inserm, CHU Lille, U1189 - ONCO-THAI - Image Assisted Laser Therapy for Oncology, Lille, F-59000 France
| | - Philippe Mathurin
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Alexandre Louvet
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
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Abstract
The development of refractory ascites in approximately 10% of patients with decompensated cirrhosis heralds the progression to a more advanced stage of cirrhosis. Its pathogenesis is related to significant hemodynamic changes, initiated by portal hypertension, but ultimately leading to renal hypoperfusion and avid sodium retention. Inflammation can also contribute to the pathogenesis of refractory ascites by causing portal microthrombi, perpetuating the portal hypertension. Many complications accompany the development of refractory ascites, but renal dysfunction is most common. Management starts with continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesisinduced circulatory dysfunction. Albumin infusions independent of paracentesis may have a role in the management of these patients. The insertion of a covered, smaller diameter, transjugular intrahepatic porto-systemic stent shunt (TIPS) in the appropriate patients with reasonable liver reserve can bring about improvement in quality of life and improved survival after ascites clearance. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites should be referred for liver transplant, as their prognosis is poor. In patients with refractory ascites and concomitant chronic kidney disease of more than stage 3b, assessment should be referred for dual liver-kidney transplants. In patients with very advanced cirrhosis not suitable for any definitive treatment for ascites control, palliative care should be involved to improve the quality of life of these patients.
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Affiliation(s)
- Florence Wong
- Division of Gastroenterology and Hepatology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada,Corresponding author : Florence Wong Division of Gastroenterology and Hepatology, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto Ontario M5G2C4, Canada Tel: +1-416-3403834, Fax: +1-416-3405019, E-mail:
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Luxenburger H, Schmidt K, Biever P, Supady A, Sekandarzad A, Roehlen N, Reincke M, Neumann-Haefelin C, Schultheiss M, Wengenmayer T, Thimme R, Bettinger D. Survival prediction using the Freiburg index of post-TIPS survival (FIPS) in critically ill patients with acute- on chronic liver failure: A retrospective observational study. Front Med (Lausanne) 2022; 9:1042674. [PMID: 36619640 PMCID: PMC9812953 DOI: 10.3389/fmed.2022.1042674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Background and aim Liver cirrhosis in patients treated in the intensive care unit (ICU) is associated with high mortality. Well established scores are useful to allow for assessment of prognosis and support ICU treatment guidance. However, currently used scoring systems often do not reflect the complexity of critically ill patients. Therefore, we tested the newly developed Freiburg index-of post-TIPS survival (FIPS) score in order to assess its potential role for prognostication of cirrhotic patients in the ICU. Methods A total of 310 patients with liver cirrhosis treated in the ICU between 2010 and 2021 were enrolled in this retrospective observational study. Prognostic factors for mortality and 28-day mortality were assessed. Moreover, using c indices the prognostic discrimination of different prognostic scores was analyzed. Results The FIPS score allowed to discriminate patients with high ICU mortality and within 28-days after ICU treatment (ICU mortality: 42.2 vs. 59.9%, p = 0.008 and 28-day mortality: 43.3 vs. 74.1%, p < 0.001). However, the FIPS score in its current composition showed no superior prognostic discrimination compared to other established scores. Multivariable analyses identified the FIPS score (HR 1.25 [1.04-1.49], p = 0.015) and lactate at admission (HR 1.07 [1.04-1.09], p < 0.001) as significant predictors of ICU mortality. Lactate at admission substantially improved patient risk stratification within each FIPS risk groups. Conclusion Similar to other commonly used scores, the FIPS score in its current composition does not allow a sufficiently reliable prognostication of critically ill patients treated in the ICU. However, adding lactate as additional factor to the FIPS score may improve its prognostic ability.
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Affiliation(s)
- Hendrik Luxenburger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,IMM-PACT, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg im Breisgau, Germany
| | - Katharina Schmidt
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Paul Biever
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Alexander Supady
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Asieb Sekandarzad
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Natascha Roehlen
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Marlene Reincke
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christoph Neumann-Haefelin
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,*Correspondence: Dominik Bettinger,
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Zimmermann HW, Trautwein C, Bruns T. [Current diagnostics and treatment of portal hypertension]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2022; 63:1257-1267. [PMID: 36374293 DOI: 10.1007/s00108-022-01427-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
In industrial nations portal hypertension is mostly a consequence of liver cirrhosis and is a prerequisite for complications, such as esophageal varices and ascites. The pathophysiology of portal hypertension is complex. It is defined as an increase in the hepatovenous pressure gradient to > 5 mm Hg, with complications to be expected at ≥ 10 mm Hg. Measurement of the pressure of the hepatic vein occlusion is the gold standard for estimating portal pressure but this is not very practical. Liver elastography, in particular, has proven to be an effective noninvasive tool to identify patients with clinically significant portal hypertension (CSPH). Current treatment concepts address the CSPH even before the onset of complications to reduce the likelihood of decompensation. In addition to beta blockers, a transjugular intrahepatic portosystemic shunt is the most important procedure to lower portal vein pressure and enables an improvement in the prognosis of selected patients.
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Affiliation(s)
- Henning W Zimmermann
- Medizinische Klinik III, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - Christian Trautwein
- Medizinische Klinik III, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland.
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Validating the prognostic value of Freiburg index of posttransjugular intrahepatic portosystemic shunt survival score and classic scores in Chinese patients with implantation of transjugular intrahepatic portosystemic shunt. Eur J Gastroenterol Hepatol 2022; 34:1074-1080. [PMID: 36062497 DOI: 10.1097/meg.0000000000002427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS It is important and challenging to evaluate the survival of cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). We aimed to validate the Freiburg index of post-TIPS survival (FIPS) score and classic scores for predicting mortality in Chinese patients after TIPS creation. METHODS A total of 709 consecutive patients with cirrhosis from December 2011 to July 2018 who underwent TIPS placement were retrospectively reviewed. The prognostic value of the FIPS score, the model for end-stage liver disease (MELD) score, Child-Pugh score and Chronic Liver Failure Consortium Acute Decompensation score was validated with the receiver operating characteristic (ROC) curve and DeLong et al. test. RESULTS The MELD-Na score was superior to the FIPS score in predicting 1-month mortality [AUROC, 0.727 (0.692-0.759) vs. 0.588 (0.551-0.625); P = 0.048]. The MELD and MELD-Na scores were significant superior to the FIPS score in predicting 3-month mortality [AUROC, 0.730 (0.696-0.762) vs. 0.598 (0.561-0.634); P = 0.044 and 0.740 (0.706-0.772) vs. 0.598 (0.561-0.634); P = 0.028]. Subgroup analyses revealed that Child-Pugh score was better than FIPS score in predicting 3-month mortality [AUROC, 0.797 (0.745-0.843) vs. 0.578 (0.517-0.637); P = 0.049] in nonviral cirrhosis group. CONCLUSION Classic scores still had good risk stratification and predictive ability of post-TIPS mortality. The FIPS score was not superior to the classic scores in the current Chinese cohort. The MELD and MELD-Na scores were significantly superior to the FIPS score in predicting 3-month mortality.
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Bai YW, Liu JC, Yang CT, Wang YL, Wang CY, Ju SG, Zhou C, Huang SJ, Li TQ, Chen Y, Yao W, Xiong B. Inclusion of sarcopenia improves the prognostic value of MELD score in patients after transjugular intrahepatic portosystemic shunt. Eur J Gastroenterol Hepatol 2022; 34:948-955. [PMID: 35594511 PMCID: PMC9345516 DOI: 10.1097/meg.0000000000002391] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To explore the predictive value of model for end-stage liver disease (MELD)-Sarcopenia score for survival of cirrhotic patients after transjugular intrahepatic portosystemic shunt (TIPS) placement. METHODS 289 patients who underwent TIPS between February 2016 and December 2020 were included, they were divided into the sarcopenia group ( n = 138) and non-sarcopenia group ( n = 151) according to whether they were complicated with sarcopenia. Kaplan-Meier curve was used to analyze and compare the prognosis of the above two groups and multivariate Cox regression analysis was used to identify the independent prognostic factors. The performance of different predictive models was compared using C-index. RESULTS During the follow-up, Kaplan-Meier analyses indicated that cumulative survival was significantly lower in sarcopenia group than that in non-sarcopenia group [74.6% vs. 92.7%, HR, 0.24 (95% confidence interval (CI), 0.12-0.46), Log-rank P < 0.001]. After multivariate Cox analysis, age [HR, 1.040 (95% CI, 1.015-1.065), P = 0.002], sarcopenia [HR, 3.948 (95% CI, 1.989-7.838), P < 0.001], albumin [HR, 0.945 (95% CI, 0.897-0.997), P = 0.037], and MELD score [HR, 1.156 (95% CI, 1.097-1.217), P < 0.001] were identified as the independent risk factors for mortality after TIPS. The C-indexes of MELD-Sarcopenia, Child-Pugh, MELD, MELD-Na, and the Freiburg index of post-TIPS survival (FIPS) scores were 0.782, 0.688, 0.719, 0.734, and 0.770, respectively. CONCLUSION Sarcopenia is independently correlated with post-TIPS mortality, and MELD-Sarcopenia score showed the best performance in predicting post-TIPS mortality than the traditional predictive models.
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Affiliation(s)
- Yao-wei Bai
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jia-cheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chong-tu Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Ying-liang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chao-yang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Shu-guang Ju
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Song-jiang Huang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Tong-qiang Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yang Chen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Wei Yao
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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50
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Chapin SE, Goldberg DS, Kaplan DE, Mahmud N. External Validation of the FIPS Score for Post-TIPS Mortality in a National Veterans Affairs Cohort. Dig Dis Sci 2022; 67:4581-4589. [PMID: 34797445 PMCID: PMC9117561 DOI: 10.1007/s10620-021-07307-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Freiburg index of post-TIPS survival (FIPS) score was recently demonstrated to improve prediction of post-TIPS mortality relative to existing standards. As this score was derived from a German cohort over an extended time period, it is unclear if performance will translate well to other settings. This study aimed to externally validate the FIPS score in a large Veterans Affairs (VA) cohort over two separate eras of TIPS-related care. METHODS This was a retrospective cohort study of patients with cirrhosis who underwent TIPS placement in the VA from 2008 to 2020. Cox regression models for post-TIPS survival were constructed using FIPS, MELD, MELD-Na, or CTP scores as predictors. Discrimination (Harrell's C) and calibration (joint tests of calibration curve slope and intercept) were evaluated for each score. A stratified analysis was performed for time periods between 2008-2013 and 2014-2020. RESULTS The cohort of 1,274 patients was 97.3% male with mean age 60.9 years and mean MELD-Na 14. The FIPS score demonstrated the highest overall discrimination versus MELD, MELD-Na, and CTP (0.634 vs. 0.585, 0.626, 0.612, respectively). However, in the modern treatment era (2014-2020), the FIPS score performed similarly to MELD-Na. Additionally, the FIPS score demonstrated poor calibration at one-month and six-month post-TIPS timepoints (joint p = 0.04 and 0.004, respectively). MELD, MELD-Na, and CTP were well-calibrated at each timepoint (each joint p > 0.05). CONCLUSION The FIPS score performed similarly to MELD-Na in the modern TIPS treatment era and demonstrated regions of poor calibration. Future models derived with contemporary data may improve prediction of post-TIPS mortality.
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Affiliation(s)
- Sara E Chapin
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA.
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