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Hunt C, Patel M, Bayona Molano MDP, Patel MS, VanWagner LB. Radiological and Surgical Treatments of Portal Hypertension. Clin Liver Dis 2024; 28:437-453. [PMID: 38945636 DOI: 10.1016/j.cld.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Interventions for portal hypertension are continuously evolving and expanding beyond the realm of medical management. When complications such as varices and ascites persist despite conservative interventions, procedures including transjugular intrahepatic portosystemic shunt creation, transvenous obliteration, portal vein recanalization, splenic artery embolization, surgical shunt creation, and devascularization are all potential interventions detailed in this article. Selection of the optimal procedure to address the underlying cause, treat symptoms, and, in some cases, bridge to liver transplantation depends on the specific etiology of portal hypertension and the patient's comorbidities.
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Affiliation(s)
- Charlotte Hunt
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Mausam Patel
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Maria Del Pilar Bayona Molano
- Department of Radiology, Keck School of Medicine, University of Southern California, 1500 San Pablo Street, Health Sciences Campus, Los Angeles, CA 90033, USA
| | - Madhukar S Patel
- Division of Organ Transplantation, Department of Surgery, UT Southwestern Medical Center, 5939 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Boulevard, Suite HP4.420M, Dallas, TX 75390-8887, USA.
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Kaplan DE, Ripoll C, Thiele M, Fortune BE, Simonetto DA, Garcia-Tsao G, Bosch J. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024; 79:1180-1211. [PMID: 37870298 DOI: 10.1097/hep.0000000000000647] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA USA
| | - Cristina Ripoll
- Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Brett E Fortune
- Department of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
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Mazumder NR, Fontana RJ. MELD 3.0 in Advanced Chronic Liver Disease. Annu Rev Med 2024; 75:233-245. [PMID: 37751367 DOI: 10.1146/annurev-med-051322-122539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
The MELD (model for end-stage liver disease) 3.0 score was developed to replace the MELD-Na score that is currently used to prioritize liver allocation for cirrhotic patients awaiting liver transplantation in the United States. The MELD 3.0 calculator includes new inputs from patient sex and serum albumin levels and has new weights for serum sodium, bilirubin, international normalized ratio, and creatinine levels. It is expected that use of MELD 3.0 scores will reduce overall waitlist mortality modestly and improve access for female liver transplant candidates. The utility of MELD 3.0 and PELDcre (pediatric end-stage liver disease, creatinine) scores for risk stratification in cirrhotic patients undergoing major abdominal surgery, placement of a transjugular intrahepatic portosystemic shunt, and other interventions requires further study. This article reviews the background of the MELD score and the rationale to create MELD 3.0 as well as potential implications of using this newer risk stratification tool in clinical practice.
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Affiliation(s)
- Nikhilesh R Mazumder
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA; ,
- Gastroenterology Section, Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan, USA
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA; ,
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Mazumder NR, Jezek F, Tapper EB, Beard DA. Portal Venous Remodeling Determines the Pattern of Cirrhosis Decompensation: A Systems Analysis. Clin Transl Gastroenterol 2023; 14:e00590. [PMID: 37092902 PMCID: PMC10522110 DOI: 10.14309/ctg.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 04/25/2023] Open
Abstract
INTRODUCTION As liver disease progresses, scarring results in worsening hemodynamics ultimately culminating in portal hypertension. This process has classically been quantified through the portosystemic pressure gradient (PSG), which is clinically estimated by hepatic venous pressure gradient (HVPG); however, PSG alone does not predict a given patient's clinical trajectory regarding the Baveno stage of cirrhosis. We hypothesize that a patient's PSG sensitivity to venous remodeling could explain disparate disease trajectories. METHODS We created a computational model of the portal system in the context of worsening liver disease informed by physiologic measurements from the field of portal hypertension. We simulated progression of clinical complications, HVPG, and transjugular intrahepatic portosystemic shunt placement while only varying a patient's likelihood of portal venous remodeling. RESULTS Our results unify hemodynamics, venous remodeling, and the clinical progression of liver disease into a mathematically consistent model of portal hypertension. We find that by varying how sensitive patients are to create venous collaterals with rising PSG we can explain variation in patterns of decompensation for patients with liver disease. Specifically, we find that patients who have higher proportions of portosystemic shunting earlier in disease have an attenuated rise in HVPG, delayed onset of ascites, and less hemodynamic shifting after transjugular intrahepatic portosystemic shunt placement. DISCUSSION This article builds a computational model of portal hypertension which supports that patient-level differences in venous remodeling may explain disparate clinical trajectories of disease.
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Affiliation(s)
- Nikhilesh R. Mazumder
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Filip Jezek
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
- Institute of Pathological Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Daniel A. Beard
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
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Mazumder NR, Junna S, Sharma P. The Diagnosis and Non-pharmacological Management of Acute Kidney Injury in Patients with Cirrhosis. Clin Gastroenterol Hepatol 2023; 21:S11-S19. [PMID: 37625862 DOI: 10.1016/j.cgh.2023.04.033] [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: 02/07/2023] [Revised: 03/01/2023] [Accepted: 04/06/2023] [Indexed: 08/27/2023]
Abstract
Acute kidney injury in patients with cirrhosis is quite common, and is seen in up to 50% of patients hospitalized for decompensated cirrhosis. Causes of acute kidney injury include prerenal, renal, or postrenal etiologies. The diagnosis and early institution of nonpharmacologic and pharmacologic management are key to the recovery of renal function. The objective of this review is to provide a practical approach to the use of diagnostic biomarkers and highlight the nonpharmacologic management and prevention of acute kidney injury.
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Affiliation(s)
- Nikhilesh R Mazumder
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Shilpa Junna
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.
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Xiong B, Yang C, Zhu X, Zhou C, Chen S, Zhang Z, Wu X, Huang S. The Added Value of Sarcopenia on Existing Risk Scores to Predict Mortality after TIPS Placement: A Multicenter Study. Acad Radiol 2023; 30 Suppl 1:S246-S256. [PMID: 37029067 DOI: 10.1016/j.acra.2023.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 04/08/2023]
Abstract
RATIONALE AND OBJECTIVES Multiple prognostic scores have been applied for predicting survival after TIPS placement. The aim was to evaluate the added value of sarcopenia on existing risk scores and develop a sarcopenia-based scoring system for survival prediction and risk stratification. MATERIALS AND METHODS In the derivation cohort of 386 cirrhotic patients undergoing TIPS, five risk scores (Child-Pugh, MELD, MELD-Na, MELD 3.0, and FIPS) were compared for prediction of short- and long-term mortality after TIPS. Sarcopenia was diagnosed based on the L3 skeletal muscle index and was incorporated into existing scores to assess its added value. A novel sarcopenia-based score was developed and externally validated in an independent cohort of 198 patients undergoing TIPS. RESULTS Among existing scores, the FIPS score showed the highest discrimination (c-index: 0.756-0.783) and calibration (Brier score: 0.059-0.127). Besides, the FIPS score was significantly associated with the severity of baseline sarcopenia and reversal of sarcopenia after TIPS. The inclusion of sarcopenia improved discrimination of existing scores in different degrees and sarcopenia could stratify the low-risk categories deemed by these scores. A FIPS-sarcopenia score was developed, showing superior discrimination over existing scores (c-index: 0.777-0.804 in the derivation cohort, 0.738-0.788 in the validation cohort). With a determined cutoff of 0.8, this score allowed for the identification of two prognostic subgroups with distinct prognoses. CONCLUSION FIPS score was highly correlated with the severity of sarcopenia and sarcopenia reversal after TIPS, and sarcopenia could improve the prognostic ability of existing scores. A FIPS-sarcopenia score was developed and validated, showing improved survival prediction and risk stratification.
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Affiliation(s)
- Bin Xiong
- Department of Interventional Radiology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China (B.X., X.W.).
| | - Chongtu Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China (C.Y.); Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (C.Y., C.Z., S.H.)
| | - Xiaoli Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University (X.Z., Z.Z.)
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (C.Y., C.Z., S.H.)
| | - Shirui Chen
- Department of Dermatology, Chengdu Second People's Hospital, Chengdu, China (S.C.)
| | - Zichen Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University (X.Z., Z.Z.)
| | - Xiaomei Wu
- Department of Interventional Radiology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China (B.X., X.W.)
| | - Songjiang Huang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China (C.Y.); Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China (S.H.)
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Wong RJ, Ge J, Boike J, German M, Morelli G, Spengler E, Said A, Desai A, Couri T, Paul S, Frenette C, Verna EC, Goel A, Fallon M, Thornburg B, VanWagner L, Lai JC, Kolli KP. Change in Platelet Count after Transjugular Intrahepatic Portosystemic Shunt Creation: An Advancing Liver Therapeutic Approaches (ALTA) Group Study. J Vasc Interv Radiol 2023; 34:1364-1371. [PMID: 37100199 PMCID: PMC10998695 DOI: 10.1016/j.jvir.2023.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/02/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023] Open
Abstract
PURPOSE To evaluate recovery of platelet count after transjugular intrahepatic portosystemic shunt (TIPS) creation and patient factors predicting platelet recovery after TIPS creation. MATERIALS AND METHODS Adults with cirrhosis who underwent TIPS creation at 9 U.S. hospitals from 2010 to 2015 were included in this retrospective analysis. Change in platelets from before TIPS to 4 months after TIPS creation was characterized. Logistic regression was used to assess factors associated with top quartile percentage platelet increase after TIPS. Subgroup analyses were performed among patients with a pre-TIPS platelet count of ≤50 ×109/L. RESULTS A total of 601 patients were included. The median absolute change in platelets was 1 × 109/L (-26 × 109/L to 25 × 109/L). Patients with top quartile percent platelet increase experienced ≥32% platelet increase. In multivariable analysis, pre-TIPS platelet counts (odds ratio [OR], 0.97 per 109/L; 95% CI, 0.97-0.98), age (OR, 1.24 per 5 years; 95% CI, 1.10-1.39), and pre-TIPS model for end-stage liver disease (MELD) scores (OR, 1.06 per point; 95% CI, 1.02-1.09) were associated with top quartile (≥32%) platelet increase. Ninety-four (16%) patients had a platelet count of ≤50 × 109/L before TIPS. The median absolute platelet change was 14 × 109/L (2 × 109/L to 34 × 109/L). Fifty-four percent of patients in this subgroup were in the top quartile for platelet increase. In multivariable logistic regression, age (OR, 1.50 per 5 years; 95% CI, 1.11-2.02) was the only factor associated with top quartile platelet increase in this subgroup. CONCLUSIONS TIPS creation did not result in significant platelet increase, except among patients with a platelet count of ≤50 × 109/L before TIPS. Lower pre-TIPS platelet counts, older age, and higher pre-TIPS MELD scores were associated with top quartile (≥32%) platelet increase in the entire cohort, whereas only older age was associated with this outcome in the patient subset with a pre-TIPS platelet count of ≤50 × 109/L.
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Affiliation(s)
- Randi J Wong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California San Francisco, San Francisco, California
| | - Jin Ge
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California San Francisco, San Francisco, California
| | - Justin Boike
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Margarita German
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Giuseppe Morelli
- Division of Gastroenterology, Hepatology, Department of Medicine, and Nutrition, University of Florida Health, Gainesville, Florida
| | - Erin Spengler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Adnan Said
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Archita Desai
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Thomas Couri
- Section of Gastroenterology, Hepatology & Nutrition, Department of Medicine, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Sonali Paul
- Section of Gastroenterology, Hepatology & Nutrition, Department of Medicine, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Catherine Frenette
- Department for Organ and Cell Transplantation, The Scripps Clinic, La Jolla, California
| | - Elizabeth C Verna
- Department of Medicine, Center for Liver Disease and Transplantation, Columbia University College of Physicians & Surgeons, New York, New York
| | - Aparna Goel
- Department of Internal Medicine, Banner University Medical Center, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Michael Fallon
- Department of Internal Medicine, Banner University Medical Center, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Bartley Thornburg
- Division of Vascular Interventional Radiology, Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lisa VanWagner
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California San Francisco, San Francisco, California
| | - K Pallav Kolli
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California.
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Gu W, Kimmann M, Laleman W, Praktiknjo M, Trebicka J. To TIPS or Not to TIPS in High Risk of Variceal Rebleeding and Acute-on-Chronic Liver Failure. Semin Liver Dis 2023; 43:189-205. [PMID: 37286178 DOI: 10.1055/a-2107-0576] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Variceal bleeding is a consequence of severe portal hypertension in patients with liver cirrhosis. Although the rate of bleeding has decreased over time, variceal bleeding in the presence of acute-on-chronic liver failure (ACLF) carries a high risk of treatment failure and short-term mortality. Treatment and/or removal of precipitating events (mainly bacterial infection and alcoholic hepatitis) and decrease of portal pressure may improve outcome of patients with acute decompensation or ACLF. Transjugular intrahepatic portosystemic shunts (TIPSs), especially in the preemptive situation, have been found to efficiently control bleeding, prevent rebleeding, and reduce short-term mortality. Therefore, TIPS placement should be considered as an option in the management of ACLF patients with variceal bleeding.
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Affiliation(s)
- Wenyi Gu
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- Medical Department I, Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Markus Kimmann
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
| | - Wim Laleman
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Michael Praktiknjo
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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Brown C, Aksan N, Muir AJ. Consider hospice in end-stage liver disease prognostic scale to open discussions regarding six-month mortality. JGH Open 2023; 7:278-285. [PMID: 37125249 PMCID: PMC10134759 DOI: 10.1002/jgh3.12889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/29/2023] [Accepted: 03/06/2023] [Indexed: 05/02/2023]
Abstract
Background and Aim Hospice is underutilized in the management of patients with end-stage liver disease and may improve the patient experience at the end of life. This study aims to create a novel prognostic scale to accurately predict 6-month mortality to more comprehensively facilitate hospice referral. Methods Sociodemographic, clinical, and laboratory variables associated with mortality from the United Network for Organ Sharing database were tested in univariate analysis followed by multivariate analyses with four predictor groups: Demographics, Diagnoses, Complexities, and Laboratory studies to develop the hospice in end-stage liver disease prognostic scale (HELP) scale (70% sample, N = 13 516) followed with replication in a 30% (N = 5792) internal validation sample. Results Only the predictor groups of Complexities and Laboratory studies met the c-statistic threshold of 0.70 for inclusion in the multivariate analyses. Backward elimination in the final logistic regression and validated weighted transformation procedure resulted in: HELP scale = (functional status × 11) + (ascites × 3) + (SBP × 3) + (HE × 4) + (dialysis × 5) + (TIPS × -3) + (albumin × -3) + (MELD-Na ≥ 21 × 20). HELP scale had a strong predictive value for six-month mortality with Area under the Receiver Operating Curve (AUROC) 0.816 and replicated in the validation sample. Conclusion HELP scale is a novel prognostic score utilizing the strength of model of end-stage liver disease-sodium (MELD-Na), along with clinical factors, for a more nuanced assessment of six-month mortality. This scale can provide an individualized approach in opening discussions of hospice referral and may be better accepted by patients and providers given its contextualization of important clinical factors.
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Affiliation(s)
- Cristal Brown
- Dell Medical SchoolUniversity of Texas at AustinAustinTexasUSA
| | - Nazan Aksan
- Dell Medical SchoolUniversity of Texas at AustinAustinTexasUSA
| | - Andrew Joseph Muir
- Duke University School of MedicineDuke Clinical Research InstituteDurhamNorth CarolinaUSA
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Identifying optimal candidates for post-TIPS patients with HCC undergoing TACE: a multicenter observational study. Eur Radiol 2023; 33:2809-2820. [PMID: 36562786 PMCID: PMC10017639 DOI: 10.1007/s00330-022-09249-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 09/19/2022] [Accepted: 10/19/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To develop a prognostic model for post-transjugular intrahepatic portosystemic shunt (TIPS) patients with hepatocellular carcinoma (HCC) beyond the Milan criteria treated by transarterial chemoembolization (TACE). DESIGN Between January 2013 and January 2020, 512 patients with HCC beyond the Milan criteria who underwent TACE after TIPS were retrospectively recruited from 15 tertiary centers. Patients were randomly sorted into a training set (n = 382) and a validation set (n = 130). Medical data and overall survival were assessed. A prediction model was developed using multivariate Cox regression analyses. Predictive performance and discrimination were evaluated and compared with other prognostic models. RESULTS Vascular invasion, log10(AFP), 1/creatinine, extrahepatic spread, and log10(ALT) were the most significant prognostic factors of survival. These five parameters were included in a new VACEA score. This score was able to stratify patients in the training set into four distinct risk grades whose median overall survival were 25.2, 15.1, 8.9, and 6.2 months, respectively. The 6-month, 1-year, 2-year, and 3-year AUROC values and C-index of the VACEA model were 0.819, 0.806, 0.779, 0.825, and 0.735, respectively, and higher than those of other seven currently available models in both the training and validation sets, as well as in different subgroups. CONCLUSION The VACEA score could stratify post-TIPS patients with HCC beyond the Milan criteria treated by TACE and help to identify candidates who benefit from this treatment. KEY POINTS • Vascular invasion, AFP, creatinine, extrahepatic spread, and ALT were independent significant prognostic factors of survival for HCC patients who underwent TACE after TIPS. • Our new model, named VACEA score, can accurately predict prognosis at the individual level and stratify patients into four distinct risk grades. • The VACEA model showed better prognostic discrimination and calibration than other current TACE-/TIPS-specific models Graphical abstract.
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11
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Yang C, Xiong B. A comprehensive review of prognostic scoring systems to predict survival after transjugular intrahepatic portosystemic shunt placement. PORTAL HYPERTENSION & CIRRHOSIS 2022; 1:133-144. [DOI: 10.1002/poh2.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/05/2022] [Indexed: 09/01/2023]
Abstract
AbstractPatient prognosis after transjugular intrahepatic portosystemic shunt (TIPS) placement is relatively poor and highly heterogeneous; therefore, a prognostic scoring system is essential for survival prediction and risk stratification. Conventional scores include the Child–Turcotte–Pugh (CTP) and model for end‐stage liver disease (MELD) scores. The CTP score was created empirically and displayed a high correlation with post‐TIPS survival. However, the inclusion of subjective parameters and the use of discrete cut‐offs limit its utility. The advantages of the MELD score include its statistical validation and objective and readily available predictors that contribute to its broad application in clinical practice to predict post‐TIPS outcomes. In addition, multiple modifications of the MELD score, by incorporating additional predictors (e.g., MELD‐Sodium and MELD‐Sarcopenia scores), adjusting coefficients (recalibrated MELD score), or combined (MELD 3.0), have been proposed to improve the prognostic ability of the standard MELD score. Despite several updates to conventional scores, a prognostic score has been proposed (based on contemporary data) specifically for outcome prediction after TIPS placement. However, this novel score (the Freiburg index of post‐TIPS survival, FIPS) exhibited inconsistent discrimination in external validation studies, and its superiority over conventional scores remains undetermined. Additionally, several tools display potential for application in specific TIPS indications (e.g., bilirubin‐platelet grade for refractory ascites), and biomarkers of systemic inflammation, nutritional status, liver disease progression, and cardiac decompensation may provide additional value, but require further validation. Future studies should consider the effect of TIPS placement when exploring predictors, as TIPS is a pathophysiological approach that substantially alters systemic hemodynamics and ameliorates bacterial translocation and malnutrition.
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Affiliation(s)
- Chongtu Yang
- Department of Radiology Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Province Key Laboratory of Molecular Imaging Wuhan China
| | - Bin Xiong
- Department of Radiology Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Province Key Laboratory of Molecular Imaging Wuhan China
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12
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Penrice DD, Thakral N, Kezer CA, Lennon R, Moreira RK, Graham RP, Kamath PS, Simonetto DA. Outcomes of idiopathic versus secondary nodular regenerative hyperplasia of the liver: A longitudinal study of 167 cases. Liver Int 2022; 42:1379-1385. [PMID: 35187783 DOI: 10.1111/liv.15202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 12/11/2021] [Accepted: 12/29/2021] [Indexed: 02/13/2023]
Abstract
BACKGROUND Nodular regenerative hyperplasia (NRH) is a rare condition characterized clinically by the development of non-cirrhotic portal hypertension. NRH is the histopathological result in the liver of various systemic disease processes including autoimmune disorders, haematological malignancies and medications. However, natural history of this condition has been limited to small case series while patient outcomes pertaining to different aetiologies of NRH are largely unknown. METHODS A retrospective cohort of consecutive patients diagnosed with pathology-confirmed NRH at Mayo Clinic between 2002 and 2017 was identified. The histological diagnosis of NRH was determined by expert liver pathologists. Patients with metastatic liver disease, history of liver transplantation or younger than 18 were excluded. Potential aetiologies of NRH were classified as haematological, rheumatological, drug-associated, miscellaneous or idiopathic. Long-term mortality was analysed using Kaplan-Meier estimation and Cox regression models. RESULTS One hundred and sixty-seven consecutive patients with pathology-confirmed NRH were analysed over a 15-year period and followed for a median time of 50 months (1-306 months). The mean age at diagnosis was 53 years. No aetiology or risk factor for NRH was identified in the majority of patients (94, 56.3%), whereas an associated, possibly causal, condition was found in 73 patients (secondary NRH). The most common presenting feature was elevated liver tests (80%), but no significant differences in laboratory tests were seen based on aetiology of NRH. Compared to idiopathic NRH, those with an identified cause had a higher rate of splenomegaly at presentation (54% vs. 27%, p = 0.002). Portal hypertension-related complications at diagnosis were common, with ascites present in one-third of patients. Overall transplant-free survival was 63% at 5 years. Median survival in idiopathic NRH was 9.4 years compared to 7.3 years in secondary NRH. Age, renal function and volume status at presentation were significantly associated with survival; however, MELD score was not. CONCLUSIONS The rates of liver-related complications and mortality in NRH are low, and only a small number of patients ultimately require liver transplantation. Most patients do not have an identified risk factor or aetiology for NRH, and liver-related outcomes do not appear to differ based on associated, possibly causal, conditions.
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Affiliation(s)
- Daniel D Penrice
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nimish Thakral
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Camille A Kezer
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan Lennon
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Roger K Moreira
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rondell P Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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FIPS Score for Prediction of Survival After TIPS Placement: External Validation and Comparison With Traditional Risk Scores in a Cohort of Chinese Patients With Cirrhosis. AJR Am J Roentgenol 2022; 219:255-267. [PMID: 35138134 DOI: 10.2214/ajr.21.27301] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Various prognostic scores for patients with chronic liver disease have been applied for predicting survival after transjugular intrahepatic portosystemic shunt (TIPS) placement. In 2021, the Freiburg index of post-TIPS survival (FIPS) score was developed specifically for predicting survival after TIPS placement. The score has exhibited variable performance in initial investigations conducted in German and U.S. cohorts. Objective: To compare utility of FIPS score and traditional scoring systems for predicting post-TIPS survival in a cohort of Chinese patients with cirrhosis. Methods: This retrospective validation study compared four prognostic scores [Model for End-Stage Liver Disease (MELD), sodium MELD (MELD-Na), CLIF Consortium Acute Decompensation (CLIF-C AD), and FIPS] in 383 patients (mean age, 54.9±11.7 years; 249 men, 134 women) with cirrhosis who underwent TIPS placement (341 for variceal bleeding, 42 for refractory ascites) at Wuhan Union Hospital between January 2016 and August 2021. Model performance was assessed in terms of discrimination (using concordance index) and calibration (using Brier score and observed-to-predicted ratios) for 6-, 12- and 24-month post-TIPS survival. Discrimination was further stratified by TIPS indication. Risk stratification was performed using previously proposed cutoffs for each score. Results: During postprocedural follow-up, 72 (18.8%) patients died. Discriminative performance for 6-month survival was highest for FIPS score (concordance index 0.784), followed by CLIF-C AD (0.743), MELD-Na (0.699), and MELD (0.694). FIPS score also showed highest calibration in terms of higher Brier scores and observed-to-predicted ratios closer to 1, as well as strongest prognostic performance for 12-month and 24-month survival and in subgroups of patients who underwent TIPS placement for either variceal bleeding or refractory ascites (except for similar performance of FIPS and CLIF-C AD in refractory ascites subgroup). When applying prior cutoffs, among patients classified as low risk by the other scores, further application of FIPS score was significantly associated with survival. Conclusion: FIPS score outperformed traditional risk scores in predicting post-TIPS survival in patients with cirrhosis. Clinical Impact: The findings support utility of FIPS score in differentiating patients who are optimal candidates for TIPS placement versus those at high risk who may instead warrant close monitoring and early liver transplantation.
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