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Garcia-Pagan JC, Francoz C, Montagnese S, Senzolo M, Mookerjee RP. Management of the major complications of cirrhosis: Beyond guidelines. J Hepatol 2021; 75 Suppl 1:S135-S146. [PMID: 34039484 DOI: 10.1016/j.jhep.2021.01.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/17/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023]
Abstract
Along with a growing understanding of the pathophysiology of cirrhosis and its complications, new therapies and management strategies have emerged in recent years. Many of these advances have helped inform the current EASL clinical practice guidelines1 on the management of some of the key complications of cirrhosis, such as ascites, variceal bleeding and infection. However, there are still some aspects of management where the evidence base is less clear, and/or where opinions amongst practitioners remain divided. Some of these more controversial areas are explored in this section, wherein we present evidence culminating in a suggested management approach based on expert opinion and extending beyond the current guidelines.
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Affiliation(s)
- Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain
| | - Claire Francoz
- Hepatology and Liver Intensive Care Unit, Hôpital Beaujon, INSERM. Clichy; France
| | | | - Marco Senzolo
- Gastroenterology, Multi-visceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Italy
| | - Rajeshwar P Mookerjee
- Institute for Liver and Digestive Health, University College London, UK; Department of Hepatology and Gastroenterology, Aarhus University, Denmark.
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Ali B, Salim A, Alam A, Zuberi BF, Ali Z, Azam Z, Kamani L, Farooqi JI, Salih M, Nawaz AA, Chaudhry AA, Hashmi ZY, Siddique M. HEP-Net opinion on the management of ascites and its complications in the setting of decompensated cirrhosis in the resource constrained environment of Pakistan. Pak J Med Sci 2020; 36:1117-1132. [PMID: 32704299 PMCID: PMC7372671 DOI: 10.12669/pjms.36.5.2407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Approximately one half of patients develop ascites within 10 years of diagnosis of compensated cirrhosis. It is a poor prognostic indicator, with only 50% surviving beyond two years. Mortality worsens significantly to 20% to 50% at one year if the ascites becomes refractory to medical therapy. Pakistan has one of the highest prevalence of viral hepatitis in the world and patients with ascites secondary to liver cirrhosis make a major percentage of both inpatient and outpatient burden. Studies indicate that over 80% of patients admitted with ascites have liver cirrhosis as the cause. This expert opinion suggests proper assessment of patients with ascites in the presence of underlying cirrhosis. This expert opinion includes appropriate diagnosis and management of uncomplicated ascites, refractory ascites and complicated ascites (including spontaneous bacterial peritonitis (SBP) ascites, hepatorenal syndrome (HRS) and hyponatremia. The purpose behind this expert opinion is to help consultants, postgraduate trainees, medical officers and primary care physicians optimally manage their patients with cirrhosis and ascites in a resource constrained setting as is often encountered in a developing country like Pakistan.
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Affiliation(s)
- Bushra Ali
- Bushra Ali, Fatima Memorial Medical and Dental College, Lahore, Pakistan
| | - Adnan Salim
- Adnan Salim, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan
| | - Altaf Alam
- Altaf Alam, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan
| | - Bader Faiyaz Zuberi
- Bader Faiyaz Zuberi, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Zeeshan Ali
- Zeeshan Ali, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Zahid Azam
- Zahid Azam, NILGID, Dow University of Health Sciences, Karachi, Pakistan
| | - Lubna Kamani
- Lubna Kamani, Liaquat National Hospital, Karachi, Pakistan
| | | | - Muhammed Salih
- Muhammed Salih, Quaid e Azam International Hospital, Islamabad, Pakistan
| | - Arif Amir Nawaz
- Arif Amir Nawaz, Fatima Memorial Medical and Dental College, Lahore, Pakistan
| | | | | | - Masood Siddique
- Masood Siddique, Jinnah Memorial Hospital, Rawalpindi, Pakistan
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Ronald J, Rao R, Choi SS, Kappus M, Martin JG, Sag AA, Pabon-Ramos WM, Suhocki PV, Smith TP, Kim CY. No Increased Mortality After TIPS Compared with Serial Large Volume Paracenteses in Patients with Higher Model for End-Stage Liver Disease Score and Refractory Ascites. Cardiovasc Intervent Radiol 2019; 42:720-728. [PMID: 30603968 DOI: 10.1007/s00270-018-02155-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/21/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE To compare survival after transjugular intrahepatic portosystemic shunt (TIPS) creation versus serial large volume paracenteses (LVP) in patients with refractory ascites and higher Model for End-Stage Liver Disease (MELD) scores. MATERIALS AND METHODS In this retrospective study, from 1/1/2013 to 10/1/2018, 478 patients (294 male; mean age 58, range 23-89) underwent serial LVP (n = 386) or TIPS (n = 92) for ascites. Propensity-matched cohorts were constructed based on age, MELD, Charlson comorbidity index, varices, and hepatic encephalopathy. Survival was analyzed using a Cox proportional hazards model in which MELD score and TIPS were treated as time-dependent covariates. An interaction term was used to assess the impact of TIPS versus serial LVP on survival as a function of increasing MELD. RESULTS In the overall patient sample, higher MELD score predicted worse survival after either serial LVP or TIPS [hazard ratio (HR) = 1.13; p < 0.001], but there was no significant interaction between TIPS and higher MELD score conferring worse survival (HR = 1.01; p = 0.55). In 92 propensity-matched serial LVP and 92 TIPS patients, higher MELD score predicted worse survival after either serial LVP or TIPS (HR = 1.19; p < 0.001), but there was no significant survival interaction between TIPS and higher MELD (HR = 0.97; p = 0.22). In 30 propensity-matched serial LVP patients and 30 TIPS patients with baseline MELD greater than 18, TIPS did not predict worse survival (HR = 0.97; p = 0.94). CONCLUSION Higher MELD predicts poorer survival after either serial LVP or TIPS, but TIPS creation is not associated with worse survival compared to serial LVP in patients with higher MELD scores LEVEL OF EVIDENCE: Level 4, case series.
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Affiliation(s)
- James Ronald
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC, 27710, USA.
| | - Rajiv Rao
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Steven S Choi
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, USA
| | - Matthew Kappus
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, USA
| | - Jonathan G Martin
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Alan A Sag
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Waleska M Pabon-Ramos
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Paul V Suhocki
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Tony P Smith
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Charles Y Kim
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC, 27710, USA
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Ascha M, Hanouneh M, S Ascha M, Zein NN, Sands M, Lopez R, Hanouneh IA. Transjugular Intrahepatic Porto-Systemic Shunt in Patients with Liver Cirrhosis and Model for End-Stage Liver Disease ≥15. Dig Dis Sci 2017; 62:534-542. [PMID: 27154510 DOI: 10.1007/s10620-016-4185-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 04/26/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND It is not known whether transjugular intrahepatic porto-systemic shunt (TIPS) is safe in patients with advanced liver cirrhosis. The aim of our study was to evaluate the impact of TIPS on transplant-free survival in patients with liver cirrhosis and MELD score ≥15. METHODS All adult patients who underwent TIPS at our institution between 2004 and 2011 were identified (N = 470). A total of 144 patients had MELD ≥15 at the time of TIPS. These patients were matched 1:1 to patients with liver cirrhosis who did not undergo TIPS based on age and MELD score using the greedy algorithm. Patients were followed up until time of death or liver transplantation. Kaplan-Meier curves and log-rank tests were used to test for differences in survival outcome between the two groups. RESULTS A total of 288 patients with liver cirrhosis were included, of whom 144 underwent TIPS and 144 did not. The two groups were matched based on age and MELD score and were comparable with regard to gender and ethnicity. Mean MELD and Child-Pugh scores in the study population were 20.9 ± 6.5 and 10.5 ± 1.8, respectively. The most common indication for TIPS was varices (49 %), followed by refractory ascites (42 %). In the first 2 months post-TIPS, there was increased mortality or liver transplantation in patients who had TIPS compared to those who did not, but this did not reach statistical significance (p = 0.07). However, after 2 months, TIPS is associated with 56 % lower risk of dying or needing liver transplantation (p < 0.01) than cirrhotic patients who did not undergo TIPS. CONCLUSION In patients with liver cirrhosis and MELD ≥15, TIPS might improve transplant-free survival for patients who live for at least 2 months after the procedure.
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Affiliation(s)
- Mona Ascha
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Mohamad Hanouneh
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mustafa S Ascha
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Nizar N Zein
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Sands
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Quantitative Health Science, Cleveland Clinic, Cleveland, OH, USA
| | - Ibrahim A Hanouneh
- Minnesota Gastroenterology, P.A., P.O. Box 14909, Minneapolis, MN, 55414, USA.
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