Nonalcoholic Fatty Liver Disease and Diabetes Mellitus Are Associated With Post–Transjugular Intrahepatic Portosystemic Shunt Renal Dysfunction: An Advancing Liver Therapeutic Approaches Group Study

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for portal hypertensive complications, but its effect on renal function is not well characterized. Here we describe renal function and characteristics associated with renal dysfunction at 30 days post‐TIPS. Adults with cirrhosis who underwent TIPS at 9 hospitals in the United States from 2010 to 2015 were included. We defined “post‐TIPS renal dysfunction” as a change in estimated glomerular filtration rate (ΔeGFR) ≤−15 and eGFR ≤ 60 mL/min/1.73 m2 or new renal replacement therapy (RRT) at day 30. We identified the characteristics associated with post‐TIPS renal dysfunction by logistic regression and evaluated survival using adjusted competing risk regressions. Of the 673 patients, the median age was 57 years, 38% of the patients were female, 26% had diabetes mellitus, and the median MELD‐Na was 17. After 30 days post‐TIPS, 66 (10%) had renal dysfunction, of which 23 (35%) required new RRT. Patients with post‐TIPS renal dysfunction, compared with those with stable renal function, were more likely to have nonalcoholic fatty liver disease (NAFLD; 33% versus 17%; P = 0.01) and comorbid diabetes mellitus (42% versus 24%; P = 0.001). Multivariate logistic regressions showed NAFLD (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.00‐4.17; P = 0.05), serum sodium (Na; OR, 1.06 per mEq/L; 95% CI, 1.01‐1.12; P = 0.03), and diabetes mellitus (OR, 2.04; 95% CI, 1.16‐3.61; P = 0.01) were associated with post‐TIPS renal dysfunction. Competing risk regressions showed that those with post‐TIPS renal dysfunction were at a higher subhazard of death (subhazard ratio, 1.74; 95% CI, 1.18‐2.56; P = 0.01). In this large, multicenter cohort, we found NAFLD, diabetes mellitus, and baseline Na associated with post‐TIPS renal dysfunction. This study suggests that patients with NAFLD and diabetes mellitus undergoing TIPS evaluation may require additional attention to cardiac and renal comorbidities before proceeding with the procedure.

The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: Advantages and pitfalls

“…78,79 TIPS implementation for LC patients with refractory ascites and an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m 2 at baseline significantly improved the eGFR to 21 mL/min/1.73 m 2 at 90 days after TIPS compared to that in patients treated with LVP, while there was no change in the eGFR level in patients with an eGFR of 60 mL/min/1.73 m 2 or greater 80 Other studies have also demonstrated an improvement in renal function after TIPS. 81,82 However, TIPS might not be beneficial in patients who already have intrinsic renal disease. 83 A high creatinine level was significantly associated with post-TIPS HE.…”

“…Patients with nonalcoholic fatty liver disease and diabetes susceptible to having intrinsic renal disease were at increased risk of post-TIPS renal impairment. 82 A recent guideline does not recommend performing TIPS in patients with intrinsic renal disease of stage 4 or 5. 9 Collectively, although renal dysfunction caused by portal hypertension usually improves after TIPS, performing TIPS should be carefully decided in patients with intrinsic renal disease.…”

“…A recent study that enrolled 673 patients who underwent TIPS showed that 10% of the patients experienced deterioration in renal function at 30 days after TIPS. Patients with nonalcoholic fatty liver disease and diabetes who were susceptible to having intrinsic renal disease were at high risk of post-TIPS renal impairment [ 81 ]. A recent guideline does not recommend performing TIPS in patients with intrinsic renal disease of stage 4 or 5 [ 8 ].…”

Current considerations for clinical management and care of non-alcoholic fatty liver disease: Insights from the 1st International Workshop of the Canadian NASH Network (CanNASH)

“…Portal vein thrombosis occurs more frequently in NASH compared to HCV-related cirrhosis ( 49 ). Moreover, renal dysfunction is usually more severe in NASH cirrhosis and requires more often renal replacement therapy, while NASH cirrhosis is an independent risk factor for renal replacement therapy after transjugular intrahepatic portosystemic shunt ( 50 , 51 ). Sarcopenia and myosteatosis are common in patients with NASH cirrhosis and are independently associated with higher mortality ( 52 ).…”

Pre-emptive TIPSS in Acute Variceal Bleeding: Current Status, Controversies, and Future Directions

“…28 In summary, TIPSS can be associated with an increased risk of HE and renal dysfunction in NASH-related cirrhosis. 29 Therefore insertion of p-TIPSS in NASH cirrhosis patients must consider co-existing cardiac and renal comorbidities to minimize potential TIPSS-related complications in those patients.…”