Clinical events after transjugular intrahepatic portosystemic shunt: Correlation with hemodynamic findings

Casado, Marta; Bosch, Jaume; García‐Pagán, Juan Carlos; Bru, C.; Bañares, Rafael; Bandi, Juan Carlos; Escorsell, Àngels; Rodríguez-laiz, J. M.; Gilabert, Rosa; Feu, Faust; Schorlemer, Carlos; Echenagusía, Antonio; Rodés, Joan

doi:10.1016/s0016-5085(98)70436-6

Cited by 428 publications

(291 citation statements)

References 26 publications

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“…Consistent with these findings, it has recently been established that recurrence of ascites after TIPS is succesfully prevented in patients in whom portosystemic gradient is maintained below 12 mm Hg. 29 Data from the current study are insufficient to establish a correlation between portosystemic gradient after TIPS and an increase in renal perfusion, but the observation that renal function did not improve in the two patients in whom portosystemic gradient did not decrease below 12 mm Hg suggests that this level is also predictive of response in patients with HRS.…”

Section: Discussioncontrasting

confidence: 59%

“…TIPS placement (Wallstent endoprothesis, Schneider Europe AG, Bü lach, Switzerland) was performed under ultrasonographic and radiological guidance as described in detail elsewhere. 29 Measurements of portal venous pressure and inferior vena cava pressure were made in baseline conditions before obtaining a portal venography. A small volume of contrast medium was used to minimize the risk of nephrotoxicity.…”

Section: Methodsmentioning

confidence: 99%

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Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: Effects on renal function and vasoactive systems

Guevara¹,

Ginès²,

Bandi³

et al. 1998

Hepatology

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Little information exists on the effects of transjugular intrahepatic portosystemic shunts (TIPS) in the management of cirrhotic patients with hepatorenal syndrome (HRS). The current study was aimed to prospectively evaluate the effects of TIPS on renal function and vasoactive systems in patients with type I HRS. Glomerular filtration rate (GFR) (inulin clearance), renal plasma flow (RPF) (para-aminohippurate clearance), plasma renin activity (PRA), aldosterone (ALDO), norepinephrine (NE), and endothelin (ET) were determined in baseline conditions and at different time intervals after TIPS in 7 patients with type I HRS. TIPS induced a marked reduction of portal pressure gradient (PPG) (20 ؎ 1 to 10 ؎ 1 mm Hg; P F .05). Renal function improved in 6 of the 7 patients. Serum creatinine and blood urea nitrogen (BUN) decreased from 5 ؎ 0.8 and 109 ؎ 7 to 1.8 ؎ 0.4 mg/dL and 56 ؎ 11 mg/dL, respectively (P F .05 for both), and GFR and RPF increased from 9 ؎ 4 and 103 ؎ 33 to 27 ؎ 7 mL/min and 233 ؎ 40 mL/min, respectively (P F .05 for both), 30 days after TIPS. These beneficial effects on renal function were associated with a significant (P F .05) reduction of PRA (18 ؎ 5 to 3 ؎ 1 ng/mL · h), ALDO (279 ؎ 58 to 99 ؎ 56 ng/dL), and NE (1,257 ؎ 187 to 612 ؎ 197 pg/mL). ET did not change significantly (28 ؎ 8 to 27 ؎ 11 pg/mL). Mean survival was 4.7 ؎ 2 months (0.3-17 months). Three patients remained alive more than 3 months after TIPS insertion. In conclusion, TIPS improves renal function and reduces the activity of the renin-angiotensin and sympathetic nervous systems in cirrhotic patients with type I HRS. Nevertheless, the efficacy of TIPS in the management of these patients should be confirmed in controlled investigations. (HEPATOLOGY 1998;28:416-422.)Hepatorenal syndrome (HRS) is a common and severe complication of patients with advanced cirrhosis and is characterized by renal failure, marked portal hypertension, abnormalities in the arterial circulation, and overactivity of endogenous vasoactive systems. [1][2][3][4][5] Up to now, the only treatment that has been shown to improve survival in patients with HRS is liver transplantation. 3-7 However, because of the short survival of patients with HRS and the limited availability of organs, only a small percentage of patients with HRS can actually reach transplantation. Therefore, it would be of great value to have a therapeutic method that could improve renal function and increase survival, especially in patients with type I HRS, which is characterized by a rapid progression of renal failure and a very short survival expectancy. 3 The transjugular intrahepatic portosystemic shunt (TIPS) has been introduced recently in clinical practice for the management of cirrhotic patients with variceal bleeding. 8,9 As with surgical portosystemic shunts, the use of TIPS is associated with a marked reduction in portal pressure but with the advantage of a very low operative morbidity and mortality. It has been shown that TIPS is useful in the management of acute variceal hemorrhage th...

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Section: Discussioncontrasting

confidence: 59%

Section: Methodsmentioning

confidence: 99%

Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: Effects on renal function and vasoactive systems

Guevara¹,

Ginès²,

Bandi³

et al. 1998

Hepatology

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386

202

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“…The normal HVPG is 3-5 mmHg. The HVPG and changes in HVPG that occur over time have predictive value for the development of esophagogastric varices, 15,16 the risk of variceal hemorrhage, [17][18][19] the development of non-variceal complications of portal hypertension, 17,20,21 and death. 19,[21][22][23] Single measurements are useful in the prognosis of both compensated and decompensated cirrhosis, while repeat measurements are useful to monitor response to pharmacological therapy and progression of liver disease.…”

Section: Evaluation Of Portal Hypertensionmentioning

confidence: 99%

“…Indeed, variceal hemorrhage does not occur when the HVPG is reduced to Ͻ12 mmHg. 17,20 It has also been shown that the risk of rebleeding decreases significantly with reductions in HVPG greater than 20% from baseline. 18 Patients whose HVPG decreases to Ͻ12 mmHg or at least 20% from baseline levels ("HVPG responders") not only have a lower probability of developing recurrent variceal hemorrhage, 36 but also have a lower risk of developing ascites, spontaneous bacterial peritonitis, and death.…”

Section: Natural History Of Varicesmentioning

confidence: 99%

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

et al. 2007

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“…1,2 It has been recently shown that pharmacological treatment with propranolol offers almost optimal protection from bleeding and rebleeding when the portal venous pressure (estimated by the hepatic venous pressure gradient [HVPG]), achieves a target reduction. 3,4 The risk of bleeding or rebleeding is virtually abolished when the HVPG decreases to 12 mm Hg or below, [3][4][5] and the actuarial risk of rebleeding at 2 years is only 9% when the HVPG is reduced by at least 20% of the baseline value. 4 This has been thereafter confirmed by other studies, 6 emphasizing the concept that pharmacological treatment represents the optimal therapy in the subgroup of patients achieving such a pronounced decrease in HVPG.…”

mentioning

confidence: 99%

Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension

et al. 2000

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Noninvasive measurements of variceal pressure adequately reflect the hemodynamic effects of propranolol on portal hypertension. However, the prognostic value of variceal pressure responses during continued propranolol therapy has not been evaluated, and it is unclear whether this may substitute invasive measurements of portal pressure response. Fifty-five portal hypertensive patients with cirrhosis were studied before and at 4 months of continued propranolol therapy. Variceal pressure was measured using an endoscopic pressure gauge. Portal pressure was evaluated as the hepatic venous pressure gradient (HVPG). Over a 28 ؎ 11 month follow-up, 16 patients experienced variceal bleeding. Baseline characteristics were similar in bleeders and nonbleeders. At 4 months, reduction in variceal pressure was less marked in bleeders than in nonbleeders (5% ؎ 20% vs. ؊15% ؎ 24%; P ‫؍‬ .03). A fall in variceal pressure 20% or greater of baseline was an independent predictor of absence of variceal bleeding; which occurred in 5% of patients with a 20% or greater fall in variceal pressure versus 42% of patients with less than a 20% reduction (P ‫؍‬ .004). The HVPG response had similar independent prognostic value (decrease H20%: 6% bleeding; decrease F20%: 45% bleeding; P ‫؍‬ .004) but identified different patients. Achieving a 20% decrease in either variceal pressure or HVPG was highly sensitive (85%) and specific ( Variceal bleeding is the most frequent and severe complication of portal hypertension in patients with cirrhosis. 1 Several treatment options are available to prevent recurrent variceal bleeding, including pharmacological therapy, endoscopic banding ligation, and surgical or transjugular intrahepatic portosystemic shunts (TIPS). 1,2 It has been recently shown that pharmacological treatment with propranolol offers almost optimal protection from bleeding and rebleeding when the portal venous pressure (estimated by the hepatic venous pressure gradient [HVPG]), achieves a target reduction. 3,4 The risk of bleeding or rebleeding is virtually abolished when the HVPG decreases to 12 mm Hg or below, 3-5 and the actuarial risk of rebleeding at 2 years is only 9% when the HVPG is reduced by at least 20% of the baseline value. 4 This has been thereafter confirmed by other studies, 6 emphasizing the concept that pharmacological treatment represents the optimal therapy in the subgroup of patients achieving such a pronounced decrease in HVPG. [1][2][3][4] Unfortunately, there is no adequate noninvasive way of assessing the HVPG response to treatment, which calls for repeated invasive hemodynamic studies.Several endoscopic findings, such as the size of the varices and the presence of red color signs (which are thought to reflect a reduced thickness of variceal wall) show a significant correlation with the risk of bleeding. 1,7,8 These are some of the main determinants of variceal wall tension, 7 which is believed to play a key role in determining variceal rupture. 7,9 According to Laplace' s law, variceal wall tension is directly re...

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Clinical events after transjugular intrahepatic portosystemic shunt: Correlation with hemodynamic findings

Cited by 428 publications

References 26 publications

Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: Effects on renal function and vasoactive systems

Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: Effects on renal function and vasoactive systems

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension

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