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Sánchez J, González S, Poyatos P, Escudero MD, Montón C, Carbonell JA, Casula E, Guijarro J, Lluch P, Ballester MP. Recompensation after TIPS reduces the incidence of hepatocellular carcinoma and increases survival in patients with cirrhosis. Liver Int 2024. [PMID: 39221765 DOI: 10.1111/liv.16095] [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: 06/16/2024] [Revised: 08/06/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND AIMS It has been described that recompensation can improve prognosis in patients with cirrhosis. However, recompensation after transjugular intrahepatic portosystemic shunt (TIPS) has not been studied. We evaluated the impact of recompensation after TIPS on the risk of hepatocellular carcinoma (HCC) and death, and we compared it with compensated cirrhosis patients. METHODS An observational study of consecutive patients with cirrhosis undergoing TIPS between 2008 and 2022 was performed. Baveno VII definition of recompensation was used including patients with or without diuretics/Hepatic encephalopathy prophylaxis. A prospective cohort of consecutive compensated cirrhosis patients was used for comparison. RESULTS Overall, 208 patients with cirrhosis were included, 92 compensated and 116 decompensated who underwent TIPS. After 1 year, 24% achieved recompensation. Liver function (MELD 12 ± 5 vs. 15 ± 6; p = .049), LDL-cholesterol (97 mg/dL vs. 76 mg/dL, p = .018), white cell count (7.96 × 109/dL vs. 6.24 × 109/dL, p = .039) and platelets (129 × 109/dL vs. 101 × 109/dL, p = .039) were associated with recompensation. Recompensation was associated with a reduction in the risk of HCC (p = .020). Multivariable analysis showed that this risk was significantly higher in non-recompensated patients (p = .003) but no differences were observed in recompensated compared with compensated patients (p = .816). Similarly, decompensated patients presented lower survival rates (p = .011), while no differences were observed between recompensated and compensated patients (p = .677). CONCLUSIONS Recompensation after TIPS has a clear impact on the incidence of HCC and death, with a similar prognosis than patients with compensated cirrhosis. Liver function is associated with recompensation, suggesting the importance of considering early TIPS in patients with indication.
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Affiliation(s)
- José Sánchez
- Liver Unit, Digestive Disease Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Sheila González
- Liver Unit, Digestive Disease Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Paloma Poyatos
- Liver Unit, Digestive Disease Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - María Desamparados Escudero
- Liver Unit, Digestive Disease Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Medicine Department, University of Valencia, Valencia, Spain
| | - Cristina Montón
- Liver Unit, Digestive Disease Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Elisabetta Casula
- Interventional radiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Jorge Guijarro
- Interventional radiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Paloma Lluch
- Liver Unit, Digestive Disease Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - María Pilar Ballester
- Liver Unit, Digestive Disease Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
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Mauz JB, Rieland H, Berliner D, Tiede A, Stockhoff L, Hinrichs JB, Wedemeyer H, Meyer BC, Olsson KM, Maasoumy B, Tergast TL. High Prevalence and Clinical Relevance of Intrapulmonary Vascular Dilatations in Patients Undergoing TIPS Implantation. Clin Gastroenterol Hepatol 2024; 22:1867-1877.e4. [PMID: 38729401 DOI: 10.1016/j.cgh.2024.04.027] [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: 11/16/2023] [Revised: 04/06/2024] [Accepted: 04/11/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND & AIMS Considerate patient selection is vital to ensure the best possible outcomes after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, data regarding the impact of intrapulmonary vascular dilatations (IPVDs) or hepatopulmonary syndrome (HPS) on the clinical course after TIPS implantation is lacking. Hence, this study aimed to investigate the relevance of IPVD and HPS in patients undergoing TIPS implantation. METHODS Contrast enhanced echocardiography and blood gas analysis were utilized to determine presence of IPVD and HPS. Multivariable competing risk analyses were performed to evaluate cardiac decompensation (CD), hepatic decompensation (HD), and liver transplant (LTx)-free survival within 1 year of follow-up. RESULTS Overall, 265 patients were included, of whom 136 had IPVD and 71 fulfilled the HPS criteria. Patients with IPVD had lower Freiburg index of post-TIPS survival (FIPS) scores, lower creatinine, and more often received TIPS because of variceal bleeding. Presence of IPVD was associated with a significantly higher incidence of CD (hazard ratio [HR], 1.756; 95% confidence interval [CI], 1.011-3.048; P = .046) and HD (HR, 1.841; 95% CI, 1.255-2.701; P = .002). However, LTx-free survival was comparable between patients with and without IPVD (HR, 1.081; 95% CI, 0.630-1.855; P = .780). Patients with HPS displayed a trend towards more CD (HR, 1.708; 95% CI, 0.935-3.122; P = .082) and HD (HR, 1.458; 95% CI, 0.934-2.275; P = .097) that failed to reach statistical significance. LTx-free survival did not differ in those with HPS compared with patients without HPS, respectively (HR, 1.052; 95% CI, 0.577-1.921; P = .870). CONCLUSION Screening for IPVD before TIPS implantation could help to further identify patients at higher risk of CD and HD.
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Affiliation(s)
- Jim B Mauz
- 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
| | - Dominik Berliner
- Hannover Medical School, Department of Cardiology and Angiology, Hannover, Germany
| | - Anja Tiede
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany; German Center for Infection Research (DZIF), Hannover-Braunschweig, Germany
| | - Lena Stockhoff
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany
| | - Jan B Hinrichs
- St Bernward Hospital, Department of Radiology, Hildesheim, Germany
| | - Heiner Wedemeyer
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany; German Center for Infection Research (DZIF), Hannover-Braunschweig, Germany; Excellence Cluster Resist, Hannover Medical School, Hannover, Germany
| | - Bernhard C Meyer
- Hannover Medical School, Department of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Karen M Olsson
- Hannover Medical School, Department of Respiratory Medicine and Infectious Diseases, Hannover, Germany; German Center for Lung Research (DZL), 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, Germany.
| | - Tammo L Tergast
- Hannover Medical School, Department of Gastroenterology, Hepatology, Infectious Diseases, and Endocrinology, Hannover, Germany.
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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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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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Juanola A, Ma AT, Gratacós-Ginès J, Soria A, Solé C, Pose E, Ginès P. Renal Complications in Portal Hypertension. Clin Liver Dis 2024; 28:503-523. [PMID: 38945640 DOI: 10.1016/j.cld.2024.03.011] [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: 07/02/2024]
Abstract
Acute kidney injury (AKI) is a common complication among patients with decompensated cirrhosis and its development is associated with worse prognosis in terms of survival. Patients with decompensated cirrhosis may develop a unique type of AKI, known as hepatorenal syndrome (HRS-AKI), characterized by marked impairment of kidney function due to haemodynamic changes that occur in late stages of liver cirrhosis. Besides, patients with cirrhosis also may develop chronic alterations of kidney function (chronic kidney disease, CKD), the incidence of which is increasing markedly and may be associated with clinical complications. The aim of this review is to provide the reader with an update of the most relevant aspects of alterations of kidney function in patients with cirrhossi that may be useful for theri clinical practice.
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Affiliation(s)
- Adrià Juanola
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Ann Thu Ma
- Toronto Centre for Liver Disease Francis Family Liver Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jordi Gratacós-Ginès
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Anna Soria
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Cristina Solé
- Department of Gastroenterology and Hepatology, Consorci Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Elisa Pose
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; School of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain.
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Zhao CJ, Ren C, Yuan Z, Bai GH, Li JY, Gao L, Li JH, Duan ZQ, Feng DP, Zhang H. Spleen volume is associated with overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with portal hypertension. World J Gastrointest Surg 2024; 16:2054-2064. [PMID: 39087107 PMCID: PMC11287704 DOI: 10.4240/wjgs.v16.i7.2054] [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: 02/26/2024] [Revised: 05/06/2024] [Accepted: 05/27/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND Portal shunt and immune status related to the spleen are related to the occurrence of hepatic encephalopathy (HE). It is unknown whether spleen volume before transjugular intrahepatic portosystemic shunt (TIPS) is related to postoperative HE. AIM To investigate the relationship between spleen volume and the occurrence of HE. METHODS This study included 135 patients with liver cirrhosis who underwent TIPS, and liver and spleen volumes were elevated upon computed tomography imaging. The Kaplan-Meier curve was used to compare the difference in the incidence rate of HE among patients with different spleen volumes. Univariate and multivariate Cox regression analyses were performed to identify the factors affecting overt HE (OHE). Restricted cubic spline was used to examine the shapes of the dose-response association between spleen volumes and OHE risk. RESULTS The results showed that 37 (27.2%) of 135 patients experienced OHE during a 1-year follow-up period. Compared with preoperative spleen volume (901.30 ± 471.90 cm3), there was a significant decrease in spleen volume after TIPS (697.60 ± 281.0 cm3) in OHE patients. As the severity of OHE increased, the spleen volume significantly decreased (P < 0.05). Compared with patients with a spleen volume ≥ 782.4 cm3, those with a spleen volume < 782.4 cm3 had a higher incidence of HE (P < 0.05). Cox regression analysis showed that spleen volume was an independent risk factor for post-TIPS OHE (hazard ratio = 0.494, P < 0.05). Restricted cubic spline model showed that with an increasing spleen volume, OHE risk showed an initial increase and then decrease (P < 0.05). CONCLUSION Spleen volume is related to the occurrence of OHE after TIPS. Preoperative spleen volume is an independent risk factor for post-TIPS OHE.
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Affiliation(s)
- Chun-Juan Zhao
- College of Medical Imaging, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Department of Radiology, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Chao Ren
- College of Medical Imaging, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Zhen Yuan
- Department of Occupational Health, School of Public Health, Shanxi Key Laboratory of Environmental Health Impairment and Prevention, NHC Key Laboratory of Pneumoconiosis, MOE Key Laboratory of Coal Environmental Pathogenicity and Prevention, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Guo-Hui Bai
- College of Medical Imaging, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Jin-Yu Li
- Department of Oncological and Vascular Intervention, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Long Gao
- Department of Oncological and Vascular Intervention, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Jin-Hui Li
- College of Medical Imaging, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Ze-Qi Duan
- First Clinical Medical College, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Dui-Ping Feng
- Department of Oncological and Vascular Intervention, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Hui Zhang
- College of Medical Imaging, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Department of Radiology, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Shanxi Key Laboratory of Intelligent Imaging and Nanomedicine, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Intelligent Imaging Big Data and Functional Nano-imaging Engineering Research Center of Shanxi Province, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
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7
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Guixé-Muntet S, Quesada-Vázquez S, Gracia-Sancho J. Pathophysiology and therapeutic options for cirrhotic portal hypertension. Lancet Gastroenterol Hepatol 2024; 9:646-663. [PMID: 38642564 DOI: 10.1016/s2468-1253(23)00438-7] [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: 10/09/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 04/22/2024]
Abstract
Portal hypertension represents the primary non-neoplastic complication of liver cirrhosis and has life-threatening consequences, such as oesophageal variceal bleeding, ascites, and hepatic encephalopathy. Portal hypertension occurs due to increased resistance of the cirrhotic liver vasculature to portal blood flow and is further aggravated by the hyperdynamic circulatory syndrome. Existing knowledge indicates that the profibrogenic phenotype acquired by sinusoidal cells is the initial factor leading to increased hepatic vascular tone and fibrosis, which cause increased vascular resistance and portal hypertension. Data also suggest that the phenotype of hepatic cells could be further impaired due to the altered mechanical properties of the cirrhotic liver itself, creating a deleterious cycle that worsens portal hypertension in the advanced stages of liver disease. In this Review, we discuss recent discoveries in the pathophysiology and treatment of cirrhotic portal hypertension, a condition with few pharmacological treatment options.
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Affiliation(s)
- Sergi Guixé-Muntet
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sergio Quesada-Vázquez
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jordi Gracia-Sancho
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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8
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Laleman W, Peiffer KH, Tischendorf M, Ullerich HJ, Praktiknjo M, Trebicka J. Role of endoscopy in hepatology. Dig Liver Dis 2024; 56:1185-1195. [PMID: 38151452 DOI: 10.1016/j.dld.2023.11.032] [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: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany.
| | - Kai-Henrik Peiffer
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Hans-Joerg Ullerich
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Praktiknjo
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany; European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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9
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Garbuzenko DV. Milestones to optimize of transjugular intrahepatic portosystemic shunt technique as a method for the treatment of portal hypertension complications. World J Hepatol 2024; 16:891-899. [PMID: 38948432 PMCID: PMC11212652 DOI: 10.4254/wjh.v16.i6.891] [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: 04/07/2024] [Revised: 05/10/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
This editorial describes the milestones to optimize of transjugular intrahepatic portosystemic shunt (TIPS) technique, which have made it one of the main methods for the treatment of portal hypertension complications worldwide. Innovative ideas, subsequent experimental studies and preliminary experience of use in cirrhotic patients contributed to the introduction of TIPS into clinical practice. At the moment, the main achievement in optimize of TIPS technique is progress in the qualitative characteristics of stents. The transition from bare metal stents to extended polytetrafluoroethylene-covered stent grafts made it possible to significantly prevent shunt dysfunction. However, the question of its preferred diameter, which contributes to an optimal reduction of portal pressure without the risk of developing post-TIPS hepatic encephalopathy, remains relevant. Currently, hepatic encephalopathy is one of the most common complications of TIPS, significantly affecting its effectiveness and prognosis. Careful selection of patients based on cognitive indicators, nutritional status, assessment of liver function, etc., will reduce the incidence of post-TIPS hepatic encephalopathy and improve treatment results. Optimize of TIPS technique has significantly expanded the indications for its use and made it one of the main methods for the treatment of portal hypertension complications. At the same time, there are a number of limitations and unresolved issues that require further randomized controlled trials involving a large cohort of patients.
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10
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Nardelli S, Schepis F, Vizzutti F. Reply to: "Hepatic encephalopathy and survival after transjugular intra-hepatic portosystemic shunt: Do spontaneous portosystemic shunts matter?". J Hepatol 2024; 80:e262-e263. [PMID: 38365181 DOI: 10.1016/j.jhep.2024.01.040] [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: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy.
| | - Filippo Schepis
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
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11
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Karagiannakis DS. Transjugular intrahepatic portosystemic shunt for recompensating decompensated cirrhosis? World J Gastroenterol 2024; 30:2621-2623. [PMID: 38855160 PMCID: PMC11154674 DOI: 10.3748/wjg.v30.i20.2621] [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: 02/21/2024] [Revised: 04/23/2024] [Accepted: 05/06/2024] [Indexed: 05/27/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is a medical procedure that has been used to manage variceal bleeding and ascites in patients with cirrhosis. It can prevent further decompensation and improve the survival of high-risk decompensated patients. Recent research indicates that TIPS could increase the possibility of recompensation of decompensated cirrhosis when it is combined with adequate suppression of the causative factor of liver disease. However, the results of the studies have been based on retrospective analysis, and further validation is required by conducting randomized controlled studies. In this context, we highlight the limitations of the current studies and emphasize the issues that must be addressed before TIPS can be recommended as a potential recompensating tool.
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Affiliation(s)
- Dimitrios S Karagiannakis
- Academic Department of Gastroenterology and Hepatology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens “Laiko”, Athens 11527, Greece
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12
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Trebicka J, Hernaez R, Shawcross DL, Gerbes AL. Recent advances in the prevention and treatment of decompensated cirrhosis and acute-on-chronic liver failure (ACLF) and the role of biomarkers. Gut 2024; 73:1015-1024. [PMID: 38527788 PMCID: PMC11103292 DOI: 10.1136/gutjnl-2023-330584] [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: 02/04/2024] [Accepted: 03/12/2024] [Indexed: 03/27/2024]
Abstract
The progression of cirrhosis with clinically significant portal hypertension towards decompensated cirrhosis remains clinically challenging and the evolution towards acute-on-chronic liver failure (ACLF), with one or more extrahepatic organ failures, is associated with very high mortality. In the last decade, significant progress has been made in the understanding of the mechanisms leading to decompensation and ACLF. As portal hypertension advances, bacterial translocation across an impaired gut barrier culminates in endotoxaemia, systemic inflammation and cirrhosis-associated immune dysfunction (CAID). Gut-derived systemic inflammation and CAID have become the logical targets for innovative therapies that prevent hepatic decompensation episodes and the progression to ACLF.Furthermore, classification of disease and biomarker discovery to personalise care have advanced in the field. This review discusses progress in biomarker discovery and personalisation of treatment in decompensated cirrhosis and ACLF.
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Affiliation(s)
- Jonel Trebicka
- Department of Internal Medicine B, University of Münster, Munster, Germany
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Ruben Hernaez
- Gastroenterology and Hepatology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
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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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14
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Larrue H, Bureau C, D'Amico G. Reply to: "Comment on 'TIPS prevents further decompensation and improves survival in patients with cirrhosis and portal hypertension in an individual patient data meta-analysis'": Further decompensation should now be used as a clinically relevant outcome. J Hepatol 2024; 80:e109-e110. [PMID: 37890723 DOI: 10.1016/j.jhep.2023.10.022] [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: 08/25/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Affiliation(s)
- Hélène Larrue
- Department of Hepatology, University Hospital and Toulouse III - Paul Sabatier University, France
| | - Christophe Bureau
- Department of Hepatology, University Hospital and Toulouse III - Paul Sabatier University, France.
| | - Gennaro D'Amico
- Gatroenterology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy. Gastroenterology Unit, Clinica La Maddalena, Palermo, Italy
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15
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Xu M, Chen Y, Artru F. Acute decompensation of cirrhosis versus acute-on-chronic liver failure: What are the clinical implications? United European Gastroenterol J 2024; 12:194-202. [PMID: 38376886 PMCID: PMC10954432 DOI: 10.1002/ueg2.12538] [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: 05/18/2023] [Accepted: 12/20/2023] [Indexed: 02/21/2024] Open
Abstract
It is essential to identify the subgroup of patients who experience poorer outcomes in order to adapt clinical management effectively. In the context of liver disease, the earlier the identification occurs, the greater the range of therapeutic options that can be offered to patients. In the past, patients with acute decompensation (AD) of chronic liver disease were treated as a homogeneous group, with emphasis on identifying those at the highest risk of death. In the last 15 years, a differentiation has emerged between acute-on-chronic liver failure syndrome (ACLF) and AD, primarily due to indications that the latter is linked to a less favorable short-term prognosis. Nevertheless, the definition of ACLF varies among the different knowledge societies, making it challenging to assess its true impact compared with AD. Therefore, the purpose of this review is to provide a detailed analysis emphasizing the critical importance of identifying ACLF in the field of advanced liver disease. We will discuss the differences between Eastern and Western approaches, particularly in relation to the occurrence of liver failure and disease onset. Common characteristics, such as the dynamic nature of the disease course, will be highlighted. Finally, we will focus on two key clinical implications arising from these considerations: the prevention of ACLF before its onset and the clinical management strategies once it develops, including liver transplantation and withdrawal of care.
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Affiliation(s)
- Manman Xu
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center), Beijing You'an Hospital Affiliated to Capital, Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China
| | - Yu Chen
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center), Beijing You'an Hospital Affiliated to Capital, Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China
| | - Florent Artru
- Institute of Liver Studies, King's College Hospital, London, UK
- Liver Disease Department, Rennes University Hospital, Rennes, France
- Rennes University and Inserm NuMeCan UMR 1317, Rennes, France
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16
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Tavabie OD, Salehi S, Aluvihare VR. The challenges and potential of microRNA-based therapy for patients with liver failure syndromes and hepatocellular carcinoma. Expert Opin Ther Targets 2024; 28:179-191. [PMID: 38487923 DOI: 10.1080/14728222.2024.2331598] [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] [Received: 12/21/2023] [Accepted: 03/13/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Morbidity and mortality from liver disease continues to rise worldwide. There are currently limited curative treatments for patients with liver failure syndromes, encompassing acute liver failure and decompensated cirrhosis states, outside of transplantation. Whilst there have been improvements in therapeutic options for patients with hepatocellular carcinoma (HCC), there remain challenges necessitating novel therapeutic agents. microRNA have long been seen as potential therapeutic targets but there has been limited clinical translation. AREAS COVERED We will discuss the limitations of conventional non-transplant management of patients with liver failure syndromes and HCC. We will provide an overview of microRNA and the challenges in developing and delivering microRNA-based therapeutic agents. We will finally provide an overview of microRNA-based therapeutic agents which have progressed to clinical trials. EXPERT OPINION microRNA have great potential to be developed into therapeutic agents due to their association with critical biological processes which govern health and disease. Utilizing microRNA sponges to target multiple microRNA associated with specific biological processes may improve their therapeutic efficacy. However, there needs to be significant improvements in delivery systems to ensure the safe delivery of microRNA to target sites and minimize systemic distribution. This currently significantly impacts the clinical translation of microRNA-based therapeutic agents.
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Affiliation(s)
| | - Siamak Salehi
- Institute of Liver Studies, King's College Hospital, London, UK
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17
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Villanueva C. The hidden face of preemptive TIPS. Hepatology 2024; 79:535-537. [PMID: 38085849 DOI: 10.1097/hep.0000000000000714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
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18
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Garbuzenko DV. Contemporary concepts of prevention and management of gastroesophageal variceal bleeding in liver cirrhosis patients. World J Hepatol 2024; 16:126-134. [PMID: 38495286 PMCID: PMC10941750 DOI: 10.4254/wjh.v16.i2.126] [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: 11/30/2023] [Revised: 12/31/2023] [Accepted: 01/29/2024] [Indexed: 02/27/2024] Open
Abstract
This editorial describes the contemporary concepts of prevention and management of gastroesophageal variceal bleeding in liver cirrhosis (LC) patients according to the current guidelines. Gastroesophageal variceal bleeding is the most dangerous complication of portal hypertension in LC patients. Risk stratification and determination of an individual approach to the choice of therapeutic measures aimed at their prevention and management has emerged as one of the top concerns in modern hepatology. According to the current guidelines, in the absence of clinically significant portal hypertension, etiological and non-etiological therapies of LC is advisable for the primary preventing gastroesophageal variceal bleeding, whereas its presence serves as an indication for the administration of non-selective β-blockers, among which carvedilol is the drug of choice. Non-selective β-blockers, as well as endoscopic variceal ligation and transjugular intrahepatic portosystemic shunt can be used to prevent recurrence of gastroesophageal variceal bleeding. Pharmacotherapy with vasoactive drugs (terlipressin, somatostatin, octreotide), endoscopic variceal ligation, endovascular techniques and transjugular intrahepatic portosystemic shunt are recommended for the treatment of acute gastroesophageal variceal bleeding. Objective and accurate risk stratification of gastroesophageal variceal bleeding will allow developing individual strategies for their prevention and management, avoiding the first and further decompensation in LC, which will improve the prognosis and survival of patients suffering from it.
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Kim JH, Kim S, Nam HC, Kim CW, Yoo JS, Han JW, Jang JW, Choi JY, Yoon SK, Chun HJ, Lee SE, Oh JS, Sung PS. Role of Portosystemic Shunt and Portal Vein Stent in Managing Portal Hypertension Due to Hematological Diseases. Cureus 2024; 16:e54206. [PMID: 38496121 PMCID: PMC10942847 DOI: 10.7759/cureus.54206] [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] [Accepted: 01/31/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Patients with hematological diseases experience complications related to portal hypertension, including life-threatening complications such as variceal bleeding. METHODS We analyzed the prognosis of patients with hematological diseases and portal hypertension treated with transjugular intrahepatic portosystemic shunts (TIPS) or portal vein stents. We retrospectively assessed patients with hematological diseases and portal hypertension who had variceal bleeding. We evaluated the characteristics and prognosis of the enrolled patients. A total of 11 patients with hematological diseases who underwent TIPS, or portal vein stenting, were evaluated. RESULTS The median follow-up period was 420 days. Of the 11 patients, eight showed resolution of portal hypertension and its complications following TIPS, or stent insertion. One patient experienced rebleeding due to incomplete resolution of portal hypertension, and two other patients also experienced rebleeding because they underwent TIPS closure or revision due to repetitive hepatic encephalopathy. CONCLUSION Portosystemic shunt and stent installation are effective treatment options for portal hypertension due to hematological diseases.
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Affiliation(s)
- Ji Hoon Kim
- Gastroenterology and Hepatology, Uijeongbu St. Mary's Hospital, Uijeongbu, KOR
| | - Suho Kim
- Radiology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Hee-Chul Nam
- Gastroenterology and Hepatology, Uijeongbu St. Mary's Hospital, Uijeongbu, KOR
| | - Chang Wook Kim
- The Catholic University of Korea, Internal Medicine, Uijeongbu, KOR
| | - Jae-Sung Yoo
- Gastroenterology and Hepatology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Ji Won Han
- Gastroenterology and Hepatology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Jeong Won Jang
- Gastroenterology and Hepatology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Jong Young Choi
- Gastroenterology and Hepatology, Seoul St. mary's Hospital, Seoul, KOR
| | - Seung Kew Yoon
- Gastroenterology and Hepatology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Ho-Jong Chun
- Radiology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Sung-Eun Lee
- Hematology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Jung-Suk Oh
- Radiology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Pil Soo Sung
- Gastroenterology and Hepatology, Seoul St. Mary's Hospital, Seoul, KOR
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Di Cola S, Lapenna L, Gazda J, Fonte S, Cusi G, Esposito S, Mattana M, Merli M. Role of Transjugular Intrahepatic Portosystemic Shunt in the Liver Transplant Setting. J Clin Med 2024; 13:600. [PMID: 38276106 PMCID: PMC10816519 DOI: 10.3390/jcm13020600] [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: 10/10/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation is currently the only curative therapy for patients with liver cirrhosis. Not all patients in the natural course of the disease will undergo transplantation, but the majority of them will experience portal hypertension and its complications. In addition to medical and endoscopic therapy, a key role in managing these complications is played by the placement of a transjugular intrahepatic portosystemic shunt (TIPS). Some indications for TIPS placement are well-established, and they are expanding and broadening over time. This review aims to describe the role of TIPS in managing patients with liver cirrhosis, in light of liver transplantation. As far as it is known, TIPS placement seems not to affect the surgical aspects of liver transplantation, in terms of intraoperative bleeding rates, postoperative complications, or length of stay in the Intensive Care Unit. However, the placement of a TIPS "towards transplant" can offer advantages in terms of ameliorating a patient's clinical condition at the time of transplantation and improving patient survival. Additionally, the TIPS procedure can help preserve the technical feasibility of the transplant itself. In this context, indications for TIPS placement at an earlier stage are drawing particular attention. However, TIPS insertion in decompensated patients can also lead to serious adverse events. For these reasons, further studies are needed to make reliable recommendations for TIPS in the pre-transplant setting.
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Affiliation(s)
- Simone Di Cola
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Jakub Gazda
- 2nd Department of Internal Medicine, PJ Safarik University and L. Pasteur University Hospital in Kosice, 040 11 Kosice, Slovakia;
| | - Stefano Fonte
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Giulia Cusi
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Samuele Esposito
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Marco Mattana
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
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21
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Mendizabal M, Cançado GGL, Albillos A. Evolving portal hypertension through Baveno VII recommendations. Ann Hepatol 2024; 29:101180. [PMID: 37984701 DOI: 10.1016/j.aohep.2023.101180] [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: 08/20/2023] [Accepted: 10/08/2023] [Indexed: 11/22/2023]
Abstract
The Baveno VII consensus workshop has provided several novel recommendations regarding the management of patients with clinically significant portal hypertension (CSPH). The expert panel summarized the existing data into simple clinical rules to aid clinicians in their clinical practice. The use of non-invasive tests (NITs), especially liver stiffness measurement (LSM), have gain an important role in daily practice. The use of LSM alone or in combination with platelet count can be used to rule-in and rule-out compensated advanced chronic liver disease (cACLD) and CSPH. Further decompensation events were defined as a prognostic stage associated with an even higher mortality than that associated with first decompensation. Moreover, the term hepatic recompensation was introduced in Baveno VII consensus implying a partial or complete regression of the functional and structural changes of cirrhosis after the removal of the underlying etiology. This review will summarize the reader main aspects of Baveno VII consensus regarding the use of NITs in cACLD, analyze further decompensation events, and evaluate recent recommendations for prophylaxis and management of liver decompensation events.
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Affiliation(s)
- Manuel Mendizabal
- Unidad de Hígado y Trasplante Hepático, Hospital Universitario Austral, Pilar, Provincia de Buenos Aires, Argentina.
| | | | - Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Salud Carlos III, Madrid, Spain.
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22
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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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23
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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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