Benefit of TIPS for patients with refractory or recidivant ascites: Serum bilirubin may make the difference

Abstract

We read with interest the editorial on the correlation between hepatitis B virus (HBV) genotypes and outcome of HBV infection by Fung and Lok. 1 This article made a succinct outline of the epidemiology of HBV genotypes and their association with hepatitis B e antigen seroconversion, activity of liver disease, and response to treatment. We believe that this article will be helpful to hepatologists when facing the explosion of knowledge regarding HBV genotypes in the literature. However, the authors inferred from our previous data 2 that genotype B may be associated with accelerated progression to hepatocellular carcinoma (HCC). This may be somewhat misleading, and we would like to address some comments to clarify this issue.In Taiwan, our first cross-sectional study indicated that more than 50% of HBV-related HCC patients were infected with genotype B. In addition, genotype C was more prevalent in patients with HCC who were older than 50 years, whereas genotype B was more common in those with HCC who were age 50 years or younger. This predominance of genotype B was more substantial in younger patients with HCC, amounting to 90% in those age 35 years or younger, and most of them did not have cirrhosis.To confirm this preliminary observation from only 80 HCC patients, a further survey of 200 surgical cases showed that the prevalence of genotype C was indeed higher in older HCC patients, while that of genotype B was higher in young HCC patients. 3 This observation also extends to HBVrelated childhood HCC. In a recent study, we demonstrated that genotype B was still the major genotype (74%) in 26 children with HCC. 4 Taken together, these lines of evidence strongly suggest that certain genotype B subtypes or strains are associated with the earlier development of HCC in Taiwan.Thus, the genotype B strains in Taiwan may be different from those in Japan and China where HCC development is less frequent and occurs at an older stage in patients with genotype B. [5][6][7] We have proposed that genotype B can be divided into three phenotypes based on the rate of liver disease progression. 8 The first is the slowly progressive phenotype that is associated with a tendency for early hepatitis B e antigen seroconversion during a carrier's lifetime or in the course of chronic hepatitis, which subsequently leads to the low death rate from HCC. The second is the intermediately progressive phenotype that runs a typical natural course of chronic HBV infection with the development of HCC, usually in the patient's 50s. The third is the rapidly progressive phenotype that is associated with the development of HCC in young HBV carriers before they reach 40 years of age, even in the absence of cirrhosis.In summary, HBV genotypes do account for the heterogeneity in clinical manifestations and treatment response among patients with chronic hepatitis B in different parts of the world; however, the paradoxical findings of genotype predominance in HCC patients between Taiwan and other countries deserve further examinations. Reply:We thank ...

Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis

“…However, since almost all studies excluded patients with a history of severe encephalopathy, serum bilirubin levels .85 mmol/l (5 mg/dl), or Child-Pugh score .12, the applicability of TIPS may be rather limited in patients with HRS who frequently show jaundice, encephalopathy and high Child-Pugh scores. 59 There has been little investigation into the mechanism through which TIPS exerts beneficial effects in patients with HRS. Nevertheless, as TIPS functions as a side-to-side portocaval shunt, it is expected to relieve portal hypertension, which plays a pivotal role in the pathogenesis of splanchnic arterial vasodilatation.…”

Management of cirrhotic ascites

“…Post-TIPS mortality is predicted by the indication for the TIPS procedure; patients with refractory ascites have decreased survival compared with the group of patients with variceal bleeding as the main indication for the TIPS procedure [Angemayr et al 2003]. In general post-TIPS mortality risk is primarily predicted by high bilirubin levels (>3 mg/ dl) [D'Amico et al 2005;Gerbes et al 2005] and high MELD score (Model of Endstage Liver Disease) [Angemayr et al 2003]. …”

Non-pharmacological Treatment of Ascites

“…High MELD score [39] and bilirubin levels >3 mg/dl [40,41] increase mortality rates in patients who had TIPS placement; therefore, good selection of candidates for TIPS is very important for good outcome. Hepatic encephalopathy is the main complication encountered in 25-30% of patients who undergo TIPS, especially older patients [41,42].…”