Changes in Kidney Function After Transjugular Intrahepatic Portosystemic Shunts Versus Large-Volume Paracentesis in Cirrhosis: A Matched Cohort Analysis

Abstract

Background Patients with cirrhosis and refractory ascites have physiologic and hormonal dysregulation that contributes to decreased kidney function. Placement of a transjugular intrahepatic portosystemic shunt (TIPS) can reverse these changes and potentially improve kidney function. We sought to evaluate change in estimated glomerular filtration rate (eGFR) following TIPS. Study Design Retrospective, matched cohort analysis. Settings & Participants Patients who underwent first-time TIPS placement for refractory ascites in 1995–2014. Frequency matching was used to generate a comparator group of patients with cirrhosis and ascites treated with serial large-volume paracentesis (LVP) in a 1:1 fashion. Predictor TIPS placement compared to serial LVP. Outcome Change in eGFR over 90 days’ follow-up. Measurements Multivariable regression stratified by baseline eGFR <60 vs. ≥60 mL/min/1.73 m2; analysis of effect modification between TIPS placement and baseline eGFR. Results 276 subjects (TIPS, n=138; serial LVP, n=138) were analyzed. After 90 days, eGFR increased significantly after TIPS placement in subjects with baseline eGFR <60 mL/min/1.73 m2 compared to treatment with serial LVP (21 [95% CI, 13–29] mL/min/1.73 m2; p <0.001) and was no different in those with eGFR ≥60 mL/min/1.73 m2 (1 [−9 to 12] mL/min/1.73 m2; p = 0.8). There was significant effect modification between TIPS status and baseline eGFR (p = 0.001) in a model that included all subjects. Limitations Outcomes restricted by clinically recorded data; clinically important differences may still exist between TIPS and LVP cohorts despite good statistical matching. Conclusions TIPS placement was associated with a significant improvement in kidney function. This was most prominent in subjects with baseline eGFR <60 mL/min/1.73 m2. Prospective studies of TIPS in populations with eGFR <60 mL/min/1.73 m2 are needed to evaluate these findings.

Does Transjugular Intrahepatic Portosystemic Shunt Stent Differentially Improve Survival in a Subset of Cirrhotic Patients?

“…14,[48][49][50] This has been shown in different situations and in older studies even with HRS patients, as well as in recent studies. 14,[48][49][50] One particular study clearly showed that TIPS not only improved renal function, but also, compared with LVP, was more successful in bridging over patients to liver transplantation. 50 In this regard, one issue requires specific attention.…”

“…14,[48][49][50] One particular study clearly showed that TIPS not only improved renal function, but also, compared with LVP, was more successful in bridging over patients to liver transplantation. 50 In this regard, one issue requires specific attention. Especially in the transplant setting, several physicians seem to be reluctant to employ TIPS and frequently argue that, technically, it could render transplantation difficult.…”

Emergency TIPS in a Child-Pugh B patient: When does the window of opportunity open and close?

“…While the effects on systemic and local vasoactive systems were observed six months after TIPS insertion, the improvement of kidney function, the decrease in bacterial translocation and systemic inflammation were observed a mere two weeks after placement [8,9,[27][28][29][30]. The immediate increase in effective blood volume by TIPS improves renal perfusion and sodium excretion, controls ascites and reverses hepatorenal syndromes, confirmed recently using expanded polytetrafluoroethylene (ePTFE) covered stents [27,28,31] still astonishing to observe that only two weeks after TIPS, endotoxin, soluble tumor necrosis factor receptor (TNFR), C-X-C motif chemokine (CXCL)11 and CXCL9 levels decrease in the patients receiving TIPS. These data show a direct pathophysiological relationship between the hemodynamic and immunological changes [8,9,29,30].…”

“…Patients with refractory ascites usually present with low serum sodium and low sodium excretion, and are prone to develop AKI and hepatorenal syndrome (HRS) [28]. These patients might benefit from TIPS [27].…”

Transjugular Intrahepatic Portosystemic Shunts in High-Risk Patients

“…When TIPS was compared with large-volume paracentesis in patients with refractory ascites, patients treated with TIPS had greater improvement in renal function and this effect was most pronounced in patients with an estimated GFR < 60 -mL/min. 46 There are also several studies that have shown TIPS to be effective even in the most severe form of renal dysfunction in cirrhosis-the dreaded hepatorenal syndrome (HRS). HRS carries an extremely high mortality and has been thought to be mostly related to a decrease in renal perfusion in liver disease 47 but there is now evolving evidence that it may also be caused by systemic inflammatory changes, microvascular dysfunction, and direct tubular damage.…”