1
|
Gonzalez-Garay AG, Serralde-Zúñiga AE, Velasco Hidalgo L, Flores García NC, Aguirre-Salgado MI. Transjugular intrahepatic portosystemic shunts for adults with hepatorenal syndrome. Cochrane Database Syst Rev 2024; 1:CD011039. [PMID: 38235907 PMCID: PMC10795102 DOI: 10.1002/14651858.cd011039.pub2] [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] [Indexed: 01/19/2024]
Abstract
BACKGROUND Hepatorenal syndrome is a condition that occurs in people with chronic liver disease (such as alcoholic hepatitis, advanced cirrhosis, or fulminant liver failure) and portal hypertension. The prognosis is dismal, often with a survival of weeks to months. Hepatorenal syndrome is characterised by the development of intense splanchnic vasodilation favouring ascites and hypotension leading to renal vasoconstriction and acute renal failure. Therefore, treatment attempts focus on improving arterial pressure through the use of vasopressors, paracentesis, and increasing renal perfusion pressure. Several authors have reported that the placement of transjugular intrahepatic portosystemic shunts (TIPS) may be a therapeutic option because it decreases portal pressure and improves arterial and renal pressures. However, the evidence is not clearly documented and TIPS may cause adverse events. Accordingly, it is necessary to evaluate the evidence of the benefits and harms of TIPS to assess its value in people with hepatorenal syndrome. OBJECTIVES To evaluate the benefits and harms of transjugular intrahepatic portosystemic shunts (TIPS) in adults with hepatorenal syndrome compared with sham, no intervention, conventional treatment, or other treatments. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 2 June 2023. SELECTION CRITERIA We included only randomised clinical trials with a parallel-group design, which compared the TIPS placement with sham, no intervention, conventional therapy, or other therapies, in adults aged 18 years or older, regardless of sex or ethnicity, diagnosed with chronic liver disease and hepatorenal syndrome. We excluded trials of adults with kidney failure due to causes not related to hepatorenal syndrome, and we also excluded data from quasi-randomised, cross-over, and observational study designs as we did not design a separate search for such studies. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. morbidity due to any cause, and 3. serious adverse events. Our secondary outcomes were 1. health-related quality of life, 2. non-serious adverse events, 3. participants who did not receive a liver transplant, 4. participants without improvement in kidney function, and 5. length of hospitalisation. We performed fixed-effect and random-effects meta-analyses using risk ratio (RR) or Peto odds ratio (Peto OR), with 95% confidence intervals (CI) for the dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) for the continuous outcomes. We used GRADE to assess certainty of evidence. MAIN RESULTS We included two randomised clinical trials comparing TIPS placement (64 participants) versus conventional treatment (paracentesis plus albumin 8 g/L of removed ascites) (66 participants). The co-interventions used in the trials were dietary treatment (sodium less than 60 mmoL/day), spironolactone (300 mg/day to 400 mg/day), and furosemide (120 mg/day). Follow-up was up to 24 months. Both were multicentre trials from Spain and the USA, and Germany, conducted between 1993 and 2002. Most participants were men (aged 18 to 75 years). We are uncertain about the effect of TIPS placement compared with conventional treatment, during the first 24 months of follow-up, on all-cause mortality (RR 0.88, 95% CI 0.55 to 1.38; 2 trials, 130 participants; I2 = 58%; very low-certainty evidence) and on the development of any serious adverse event (RR 1.60, 95% CI 0.10 to 24.59; 2 trials, 130 participants; I2 = 78%; very low-certainty evidence). The use of TIPS may or may not result in a decrease in overall morbidity such as bacterial peritonitis, encephalopathy, or refractory ascites, during the first 24 months of follow-up, compared with the conventional treatment (RR 0.95, 95% CI 0.77 to 1.18; 2 trials, 130 participants; I2 = 0%; low-certainty evidence). We are uncertain about the effect of TIPS placement versus conventional treatment on the number of people who did not receive a liver transplant (RR 1.03, 95% CI 0.93 to 1.14; 2 trials, 130 participants; I2 = 0%; very low-certainty evidence) or on the length of hospitalisation (MD -20.0 days, 95% CI -39.92 to -0.08; 1 trial, 60 participants; very low-certainty evidence). Kidney function may improve in participants with TIPS placement (RR 0.53, 95% CI 0.27 to 1.02; 1 trial, 70 participants; low-certainty evidence). No trials reported health-related quality of life, non-serious adverse events, or number of participants with improvement in liver function associated with the TIPS placement. Funding No trials reported sources of commercial funding or conflicts of interest between researchers. Ongoing studies We found one ongoing trial comparing TIPS with conventional therapy (terlipressin plus albumin) and listed one study as awaiting classification as no full-text article could be found. AUTHORS' CONCLUSIONS TIPS placement was compared with conventional treatment, with a follow-up of 24 months, in adults with hepatorenal syndrome type 2. Based on two trials with insufficient sample size and trial limitations, we assessed the overall certainty of evidence as low or very low. We are unsure if TIPS may decrease all-cause mortality, serious adverse events, the number of people who did not receive a liver transplant, and the days of hospitalisation because of the very low-certainty evidence. We are unsure if TIPS, compared with conventional treatment, has better effects on overall morbidity (bacterial peritonitis, encephalopathy, or refractory ascites). TIPS may improve kidney function, but the certainty of evidence is low. The trials included no data on health-related quality of life, non-serious adverse events, and liver function associated with the TIPS placement. We identified one ongoing trial and one study awaiting classification which may contribute to the review when information becomes available.
Collapse
Affiliation(s)
| | - Aurora E Serralde-Zúñiga
- Clinical Nutrition Service, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Nayelli Cointa Flores García
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ma Isabel Aguirre-Salgado
- Medical Library, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| |
Collapse
|
2
|
Boike JR, Thornburg BG, Asrani SK, Fallon MB, Fortune BE, Izzy MJ, Verna EC, Abraldes JG, Allegretti AS, Bajaj JS, Biggins SW, Darcy MD, Farr MA, Farsad K, Garcia-Tsao G, Hall SA, Jadlowiec CC, Krowka MJ, Laberge J, Lee EW, Mulligan DC, Nadim MK, Northup PG, Salem R, Shatzel JJ, Shaw CJ, Simonetto DA, Susman J, Kolli KP, VanWagner LB. North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension. Clin Gastroenterol Hepatol 2022; 20:1636-1662.e36. [PMID: 34274511 PMCID: PMC8760361 DOI: 10.1016/j.cgh.2021.07.018] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/01/2021] [Accepted: 07/13/2021] [Indexed: 02/07/2023]
Abstract
Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.
Collapse
Affiliation(s)
- Justin R. Boike
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bartley G. Thornburg
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Michael B. Fallon
- Department of Medicine, Division of Gastroenterology and Hepatology, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Brett E. Fortune
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Manhal J. Izzy
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth C. Verna
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Juan G. Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
| | - Andrew S. Allegretti
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Jasmohan S. Bajaj
- Department of Internal Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA, USA
| | - Scott W. Biggins
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Washington Medical Center, Seattle, WA, USA
| | - Michael D. Darcy
- Department of Radiology, Division of Interventional Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Maryjane A. Farr
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Khashayar Farsad
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Guadalupe Garcia-Tsao
- Department of Digestive Diseases, Yale University, Yale University School of Medicine, and VA-CT Healthcare System, CT, USA
| | - Shelley A. Hall
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, TX, USA
| | - Caroline C. Jadlowiec
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Michael J. Krowka
- Department of Pulmonary and Critical Care Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeanne Laberge
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Edward W. Lee
- Department of Radiology, Division of Interventional Radiology, University of California-Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - David C. Mulligan
- Department of Surgery, Division of Transplantation, Yale University School of Medicine, New Haven, CT, USA
| | - Mitra K. Nadim
- Department of Medicine, Division of Nephrology and Hypertension, University of Southern California, Los Angeles, California, USA
| | - Patrick G. Northup
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Riad Salem
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR, USA
| | - Cathryn J. Shaw
- Department of Radiology, Division of Interventional Radiology, Baylor University Medical Center, Dallas, TX, USA
| | - Douglas A. Simonetto
- Department of Physiology, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Susman
- Department of Radiology, Division of Interventional Radiology, Columbia University Irving Medical Center, New York, NY, USA
| | - K. Pallav Kolli
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Lisa B. VanWagner
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Address for correspondence: Lisa B. VanWagner MD MSc FAST FAHA, Assistant Professor of Medicine and Preventive Medicine, Divisions of Gastroenterology & Hepatology and Epidemiology, Northwestern University Feinberg School of Medicine, 676 N. St Clair St - Suite 1400, Chicago, Illinois 60611 USA, Phone: 312 695 1632, Fax: 312 695 0036,
| | | |
Collapse
|
3
|
Allegretti AS, Ortiz G, Cui J, Wenger J, Bhan I, Chung RT, Thadhani RI, Irani Z. Changes in Kidney Function After Transjugular Intrahepatic Portosystemic Shunts Versus Large-Volume Paracentesis in Cirrhosis: A Matched Cohort Analysis. Am J Kidney Dis 2016; 68:381-91. [PMID: 26994685 DOI: 10.1053/j.ajkd.2016.02.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 02/11/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with cirrhosis and refractory ascites have physiologic and hormonal dysregulation that contributes to decreased kidney function. Placement of a transjugular intrahepatic portosystemic shunt (TIPS) can reverse these changes and potentially improve kidney function. We sought to evaluate change in estimated glomerular filtration rate (eGFR) following TIPS placement. STUDY DESIGN Retrospective, matched cohort analysis. SETTINGS & PARTICIPANTS Patients who underwent first-time TIPS placement for refractory ascites in 1995 to 2014. Frequency matching was used to generate a comparator group of patients with cirrhosis and ascites treated with serial large-volume paracentesis (LVP) in a 1:1 fashion. PREDICTOR TIPS placement compared to serial LVP. OUTCOME Change in eGFR over 90 days' follow-up. MEASUREMENTS Multivariable regression stratified by baseline eGFR<60 versus ≥60mL/min/1.73m(2); analysis of effect modification between TIPS placement and baseline eGFR. RESULTS 276 participants (TIPS, n=138; serial LVP, n=138) were analyzed. After 90 days, eGFRs increased significantly after TIPS placement in participants with baseline eGFRs<60mL/min/1.73m(2) compared to treatment with serial LVP (21 [95% CI, 13-29] mL/min/1.73m(2); P<0.001) and was no different in those with eGFRs≥60mL/min/1.73m(2) (1 [95% CI, -9 to 12] mL/min/1.73m(2); P=0.8). There was significant effect modification between TIPS status and baseline eGFR (P=0.001) in a model that included all participants. LIMITATIONS Outcomes restricted by clinically recorded data; clinically important differences may still exist between the TIPS and LVP cohorts despite good statistical matching. CONCLUSIONS TIPS placement was associated with significant improvement in kidney function. This was most prominent in participants with baseline eGFRs<60mL/min/1.73m(2). Prospective studies of TIPS use in populations with eGFRs<60mL/min/1.73m(2) are needed to evaluate these findings.
Collapse
Affiliation(s)
- Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA.
| | - Guillermo Ortiz
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jie Cui
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Julia Wenger
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Ishir Bhan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Raymond T Chung
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Ravi I Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Zubin Irani
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
4
|
Erly B, Carey WD, Kapoor B, McKinney JM, Tam M, Wang W. Hepatorenal Syndrome: A Review of Pathophysiology and Current Treatment Options. Semin Intervent Radiol 2015; 32:445-54. [PMID: 26622108 PMCID: PMC4640915 DOI: 10.1055/s-0035-1564794] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Brian Erly
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - William D. Carey
- Department of Gastroenterology, Cleveland Clinic, Cleveland, Ohio
| | - Baljendra Kapoor
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Mathew Tam
- Department of Radiology, Southend University Hospital, Essex, United Kingdom
| | - Weiping Wang
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
| |
Collapse
|
5
|
|
6
|
Stadlbauer V, Wright GAK, Banaji M, Mukhopadhya A, Mookerjee RP, Moore K, Jalan R, Moore K, Jalan R. Relationship between activation of the sympathetic nervous system and renal blood flow autoregulation in cirrhosis. Gastroenterology 2008; 134:111-9. [PMID: 18166350 DOI: 10.1053/j.gastro.2007.10.055] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 09/13/2007] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS It has been proposed that activation of the sympathetic nervous system causes a rightward shift in the renal autoregulatory curve such that renal blood flow is critically dependent on renal perfusion pressure and that this contributes to the development of the hepatorenal syndrome. The aims of the study were to determine the relationship of renal blood flow and renal perfusion pressure in patients with liver cirrhosis and the effect on renal hemodynamics following insertion of a transjugular intrahepatic portosystemic shunt (TIPS). METHODS Fifty-six patients were recruited into groups (1) with no ascites, (2) with diuretic-responsive ascites, (3) with intractable ascites, (4) with type II hepatorenal syndrome, and (5) requiring a TIPSs for refractory ascites. We measured cardiac hemodynamics, renal blood flow, renal perfusion pressure, and portal pressure and norepinephrine levels and mathematically modeled the renal autoregulatory curve. RESULTS Renal blood flow correlated with renal perfusion pressure (r(2) = 0.78; P < .001) and inversely with the hepatic venous pressure gradient (r(2) = 0.61; P < .0001) and plasma norepinephrine levels (r(2) = 0.78; P < .0001). Norepinephrine levels increased with increasing disease severity, and this was associated with a rightward and downward shift of the renal blood flow/renal perfusion pressure autoregulatory curve. TIPS insertion reduced portal pressure and plasma norepinephrine levels (P < .001), and the renal blood flow/renal perfusion pressure curve was shifted upward. CONCLUSIONS The relationship between renal blood flow and renal perfusion pressure involves a critical interplay between the sympathetic nervous system and the kidney. TIPS insertion decreases sympathetic activation and improves renal function through positive effects on renal blood flow autoregulation.
Collapse
Affiliation(s)
- Vanessa Stadlbauer
- Liver Failure Group, Institute of Hepatology, Division of Medicine, University College London, London, England
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Pozzi M, Ratti L, Redaelli E, Guidi C, Mancia G. Cardiovascular abnormalities in special conditions of advanced cirrhosis. The circulatory adaptative changes to specific therapeutic procedures for the management of refractory ascites. GASTROENTEROLOGIA Y HEPATOLOGIA 2006; 29:263-72. [PMID: 16584698 DOI: 10.1157/13086820] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Advanced liver disease is characterized by decreased arterial blood pressure and peripheral vascular resistances, increased cardiac output and heart rate in the setting of a hyperdynamic circulatory pattern favoured by total blood volume expansion, circulatory overload and overactivity of the endogenous vasoactive systems. Reduced heart responses to stressful conditions such as changes in loading conditions of the heart in presence of further deterioration of liver function such as refractory ascites, hepatorenal syndrome, spontaneous bacterial peritonitis and bleeding esophageal varices have been recently identified and the knowledge of the cirrhotic cardiomyopathy syndrome has gained the dignity of a new clinical entity. Facing the availability of therapeutic interventions (paracentesis, transjugular intrahepatic portosystemic shunt, peritoneovenous shunt, orthotopic liver transplantation) currently employed to manage the life-threatening complications of the most advanced phases of cirrhotic disease, the knowledge of their impact on cardiovascular function is of paramount relevance.
Collapse
Affiliation(s)
- M Pozzi
- Clinica Medica, Azienda Ospedaliera San Gerardo, Università Milano-Bicocca, Monza, Italy.
| | | | | | | | | |
Collapse
|
8
|
Deltenre P, Mathurin P, Dharancy S, Moreau R, Bulois P, Henrion J, Pruvot FR, Ernst O, Paris JC, Lebrec D. Transjugular intrahepatic portosystemic shunt in refractory ascites: a meta-analysis. Liver Int 2005; 25:349-56. [PMID: 15780061 DOI: 10.1111/j.1478-3231.2005.01095.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
UNLABELLED Transjugular intrahepatic portosystemic shunt (TIPS) is a more effective treatment for refractory ascites than large volume paracentesis (LVP), but the magnitude of its effect in terms of control of ascites, encephalopathy and survival has not been established. AIM This meta-analysis compare TIPS to LVP in terms of control of ascites at 4 and 12 months, encephalopathy and survival at 1 and 2 years. RESULTS Five randomized controlled trials involving 330 patients were included. In the TIPS group, control of ascites was more frequently achieved at 4 months (66% vs 23.8%, mean difference: 41.4%, 95% confidence interval (CI): 29.5-53.2%, P < 0.001) and 12 months (54.8% vs 18.9%, mean difference: 35%, 95% CI: 24.9-45.1%, P < 0.001), whereas encephalopathy was higher (54.9% vs 38.1%, mean difference: 17%, 95% CI: 7.3-26.6%, P < 0.001). Survival at 1 year (61.7% vs 56.5%, mean difference: 3.2%, 95% CI: -14.7 to 21.9%) and 2 years (50% vs 42.8%, mean difference: 6.8%, 95% CI: -10 to 23.6%) were not significantly different. CONCLUSIONS TIPS is a more effective treatment for refractory ascites than LVP. However, TIPS increase encephalopathy and does not improve survival.
Collapse
Affiliation(s)
- P Deltenre
- Services d'Hépato-Gastroentérologie, Hôpital Huriez, CHRU Lille, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side portosystemic anastomosis. Since its introduction 16 years ago, more than 1,000 publications have appeared demonstrating broad acceptance and increasing clinical use. This review summarizes our present knowledge about technical aspects and complications, follow-up of patients and indications. A technical success rate near 100% and a low occurrence of complications clearly depend on the skills of the operator. The follow-up of the TIPS patient has to assess shunt patency, liver function, hepatic encephalopathy and the possible development of hepatocellular carcinoma. Shunt patency can best be monitored by duplex sonography and can avoid routine radiological revision. Short-term patency may be improved by anticoagulation, while such a treatment does not influence long-term patency. Stent grafts covered with expanded polytetrafluoroethylene show promising long-term patency comparable with that of surgical shunts. With respect to the indications of TIPS, much is known about treatment of variceal bleeding and refractory ascites. The thirteen randomized studies that are available to date show that survival is comparable in patients receiving TIPS or endoscopic treatment for acute or recurrent variceal bleeding. Another group comprises patients with refractory ascites and related complications, such as hepatorenal syndrome and hepatic hydrothorax. It has been demonstrated that TIPS improves these complications. Five randomized studies comparing TIPS with paracentesis and one study comparing TIPS with the peritoneo-venous shunt showed good response of ascites but controversial results on survival. In addition, TIPS has been successfully applied to patients with Budd-Chiari syndrome, portal vein thrombosis, before liver transplantation, and for the treatment of ectopic variceal bleeding.
Collapse
Affiliation(s)
- Andreas Ochs
- Department of Internal Medicine, Evangelisches Diakonie Krankenhaus, Teaching Hospital of the Medical Faculty, University of Freiburg, Freiburg, Germany.
| |
Collapse
|
10
|
Stanley AJ, Redhead DN, Bouchier IA, Hayes PC. Acute effects of transjugular intrahepatic portosystemic stent-shunt (TIPSS) procedure on renal blood flow and cardiopulmonary hemodynamics in cirrhosis. Am J Gastroenterol 1998; 93:2463-8. [PMID: 9860410 DOI: 10.1111/j.1572-0241.1998.00705.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE An acute increase in portal pressure is associated with an immediate reduction in renal blood flow. It has been suggested that this supports the presence of an hepatorenal reflex. In this study, we used TIPSS placement as a model to investigate the effect of an acute reduction in portal pressure on renal blood flow and cardiopulmonary hemodynamic parameters. METHODS Eleven cirrhotic patients were studied during elective TIPSS placement for variceal hemorrhage (n = 9) or refractory ascites (n = 2). Unilateral renal blood flow (RBF) was measured before and at 5, 15, 30, 45, and 60 min after shunt insertion. Heart rate (HR), mean arterial pressure (MAP), right atrial pressure (RAP), mean pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), cardiac output (CO), and systemic vascular resistance (SVR) were also measured before and 30 min after TIPSS placement. RESULTS Despite significant increases in CO (p = 0.001), RAP (p < 0.001), PAP (p < 0.001), and PCWP (p = 0.001), and a fall in SVR (p = 0.003), no change was observed in RBF, HR, or MAP after TIPSS placement. The fall in the portoatrial pressure gradient correlated only with the rise in CO (p < 0.05) and the drop in SVR (p < 0.05). CONCLUSION Despite the fall in portal pressure and the systemic hemodynamic changes caused by TIPSS placement, there is no immediate effect on RBF. Any improvement in renal function after TIPSS procedure does not appear to be due to an acute increase in RBF.
Collapse
Affiliation(s)
- A J Stanley
- Department of Medicine, Royal Infirmary of Edinburgh, United Kingdom
| | | | | | | |
Collapse
|
11
|
Rössle M, Siegerstetter V, Huber M, Ochs A. The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art. LIVER 1998; 18:73-89. [PMID: 9588766 DOI: 10.1111/j.1600-0676.1998.tb00132.x] [Citation(s) in RCA: 165] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side portosystemic anastomosis. Since its introduction 10 years ago, more than 500 publications have appeared demonstrating rapid acceptance and increasing clinical use. This review summarizes the present knowledge of technical aspects and complications, follow-up of patients, and indications. With respect to the technique, the TIPS procedure is probably one of the most difficult interventions and, therefore, technical success and complications clearly depend on the skills of the operator. Thus, the number and kind of complications reported in this review do not necessarily relate to the procedural complications of an experienced center. The follow-up of the TIPS patient has to assess shunt patency, liver function and hepatic encephalopathy. Shunt patency can best be monitored by duplex-sonography. Routine radiological revision seems not to be helpful and does not improve results, i.e., rebleeding and survival. Short term patency may be improved by anticoagulation, while such a treatment does not influence long-term patency. With respect to the indications of TIPS, much is known about treatment of variceal bleeding. The nine randomized studies that are available to date show that survival is comparable between patients receiving TIPS or endoscopic treatment. The second group of patients is the group with refractory ascites and related complications, such as hepatorenal syndrome and hepatic hydrothorax. It has been demonstrated that TIPS improves these complications, but randomized studies are still lacking. In addition, TIPS has been applied successfully to patients with Budd-Chiari syndrome, portal vein thrombosis, before liver transplantation, and for the treatment of ectopic portal hypertensive bleeding.
Collapse
Affiliation(s)
- M Rössle
- School of Medicine, Department of Gastroenterology and Hepatology, Freiburg, Germany
| | | | | | | |
Collapse
|