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Balcar L, Mandorfer M, Hernández-Gea V, Procopet B, Meyer EL, Giráldez Á, Amitrano L, Villanueva C, Thabut D, Samaniego LI, Silva-Junior G, Martinez J, Genescà J, Bureau C, Trebicka J, Herrera EL, Laleman W, Palazón Azorín JM, Alonso JC, Gluud LL, Ferreira CN, Cañete N, Rodríguez M, Ferlitsch A, Mundi JL, Grønbæk H, Hernandez Guerra MN, Sassatelli R, Dell'Era A, Senzolo M, Abraldes JG, Romero-Gómez M, Zipprich A, Casas M, Masnou H, Primignani M, Krag A, Nevens F, Calleja JL, Jansen C, Catalina MV, Albillos A, Rudler M, Tapias EA, Guardascione MA, Tantau M, Schwarzer R, Reiberger T, Laursen SB, Lopez-Gomez M, Cachero A, Ferrarese A, Ripoll C, La Mura V, Bosch J, García-Pagán JC. Predicting survival in patients with 'non-high-risk' acute variceal bleeding receiving β-blockers+ligation to prevent re-bleeding. J Hepatol 2024; 80:73-81. [PMID: 37852414 DOI: 10.1016/j.jhep.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/03/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND & AIMS Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for high-risk acute variceal bleeding (AVB; i.e., Child-Turcotte-Pugh [CTP] B8-9+active bleeding/C10-13). Nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation for secondary prophylaxis. We investigated prognostic factors for re-bleeding and mortality in 'non-high-risk' AVB to identify subgroups who may benefit from more potent treatments (i.e., TIPS) to prevent further decompensation and mortality. METHODS A total of 2,225 adults with cirrhosis and variceal bleeding were prospectively recruited at 34 centres between 2011-2015; for the purpose of this study, case definitions and information on prognostic indicators at index AVB and on day 5 were further refined in low-risk patients, of whom 581 (without failure to control bleeding or contraindications to TIPS) who were managed by non-selective beta-blockers/endoscopic variceal ligation, were finally included. Patients were followed for 1 year. RESULTS Overall, 90 patients (15%) re-bled and 70 (12%) patients died during follow-up. Using clinical routine data, no meaningful predictors of re-bleeding were identified. However, re-bleeding (included as a time-dependent co-variable) increased mortality, even after accounting for differences in patient characteristics (adjusted cause-specific hazard ratio: 2.57; 95% CI 1.43-4.62; p = 0.002). A nomogram including CTP, creatinine, and sodium measured at baseline accurately (concordance: 0.752) stratified the risk of death. CONCLUSION The majority of 'non-high-risk' patients with AVB have an excellent prognosis, if treated according to current recommendations. However, about one-fifth of patients, i.e. those with CTP ≥8 and/or high creatinine levels or hyponatremia, have a considerable risk of death within 1 year of the index bleed. Future clinical trials should investigate whether elective TIPS placement reduces mortality in these patients. IMPACT AND IMPLICATIONS Pre-emptive transjugular intrahepatic portosystemic shunt placement improves outcomes in high-risk acute variceal bleeding; nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation. This is the first large-scale study investigating prognostic factors for re-bleeding and mortality in 'non-high-risk' acute variceal bleeding. While no clinically meaningful predictors were identified for re-bleeding, we developed a nomogram integrating baseline Child-Turcotte-Pugh score, creatinine, and sodium to stratify mortality risk. Our study paves the way for future clinical trials evaluating whether elective transjugular intrahepatic portosystemic shunt placement improves outcomes in presumably 'non-high-risk' patients who are identified as being at increased risk of death.
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Affiliation(s)
- Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria; Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain
| | - Bogdan Procopet
- Hepatology Department and 3rd Medical Clinic, Regional Institute of Gastroenterology and Hepatology 'Octavian Fodor' and 'Iuliu Hatieganu' University of Medicine and Pharmacy, Romania
| | - Elias Laurin Meyer
- Section for Medical Statistics, Center for Medical Data Science, Medical University of Vienna, Vienna, Austria; Berry Consultants, Vienna, Austria
| | - Álvaro Giráldez
- Clinical Management Unit of Digestive Diseases, University Hospital Virgen Del Rocio, Spain
| | | | - Candid Villanueva
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servei De Patologia Digestiva, Hospital De La Santa Creu I Sant Pau, Spain
| | | | - Luis Ibáñez Samaniego
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servicio De Medicina De Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Lisgm, Spain
| | - Gilberto Silva-Junior
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain
| | - Javier Martinez
- Department of Gastroenterology and Instituto Ramón y Cajal De Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal and University of Alcalá, Spain
| | - Joan Genescà
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Spain
| | - Christophe Bureau
- Department of Hepato-Gastroenterology, Purpan Hospital, University of Toulouse, France
| | - Jonel Trebicka
- Department of Internal Medicine B, University of Münster, Germany; Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Internal Medicine I, University of Bonn, Germany
| | - Elba Llop Herrera
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain
| | - Wim Laleman
- Department of Liver and Biliopancreatic Disorders, KU Leuven, Belgium
| | | | - Jose Castellote Alonso
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, Idibell, Universitat de Barcelona, Spain
| | - Lise Lotte Gluud
- Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre and Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Portugal
| | - Nuria Cañete
- Liver Section, Gastroenterology Department and Imim (Hospital del Mar Medical Research Institute), Gastroenterology Department, Spain
| | - Manuel Rodríguez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Spain
| | - Arnulf Ferlitsch
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria; Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Department of Internal Medicine I, Gastroenterology and Nephrology, St. John of God Hospital, Vienna, Austria
| | - Jose Luis Mundi
- Department of Gastroenterology, University Hospital San Cecilio, Spain
| | - Henning Grønbæk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | | | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRRCS, Italy
| | - Alessandra Dell'Era
- Gastroenterology Unit, Asst Fatebenefratelli Sacco, Department of Clinical and Biomedical Sciences, Università Degli Studi Di Milano, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Italy
| | - Juan Gonzalez Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), CEGIIR, University of Alberta, Canada
| | - Manuel Romero-Gómez
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Unidad De Hepatología, Hospital Universitario De Valme, Spain
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Germany
| | - Meritxell Casas
- Hepatology Unit, Digestive Disease Department, Hospital De Sabadell, Universitat Autónoma de Barcelona, Spain
| | - Helena Masnou
- Hospital Universitari Germans Trias I Pujol, Universitat Autònoma Barcelona, Spain
| | - Massimo Primignani
- CRC 'a.M. and a. Migliavacca' Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, Italy
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark
| | - Frederik Nevens
- Department of Liver and Biliopancreatic Disorders, KU Leuven, Belgium
| | - Jose Luis Calleja
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain
| | | | - María Vega Catalina
- Servicio De Medicina De Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Lisgm, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Instituto Ramón y Cajal De Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal and University of Alcalá, Spain
| | - Marika Rudler
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, France
| | - Edilmar Alvarado Tapias
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servei De Patologia Digestiva, Hospital De La Santa Creu I Sant Pau, Spain
| | | | - Marcel Tantau
- Hepatology Department and 3rd Medical Clinic, Regional Institute of Gastroenterology and Hepatology 'Octavian Fodor' and 'Iuliu Hatieganu' University of Medicine and Pharmacy, Romania
| | - Rémy Schwarzer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | | | - Marta Lopez-Gomez
- Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Spain
| | - Alba Cachero
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, Idibell, Universitat de Barcelona, Spain
| | - Alberto Ferrarese
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Italy
| | - Cristina Ripoll
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Germany; Internal Medicine IV, Universitätsklinikum Jena, Friedrich Schiller University, Jena, Germany
| | - Vincenzo La Mura
- Hospital Universitari Germans Trias I Pujol, Universitat Autònoma Barcelona, Spain; Uoc Medicina Generale - Emostasi e Trombosi, Fondazione IRRCS, Cà Granda, Ospedale Maggiore Policlinico, Italy
| | - Jaime Bosch
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain.
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