Mortality after transjugular intrahepatic portosystemic shunt in older adult patients with cirrhosis: A validated prediction model

Abstract

Background and Aims: Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) improves survival in patients with cirrhosis with refractory ascites and portal hypertensive bleeding. However, the indication for TIPS in older adult patients (greater than or equal to 70 years) is debated, and a specific prediction model developed in this particular setting is lacking. The aim of this study was to develop and validate a multivariable model for an accurate prediction of mortality in older adults. Approach and Results: We prospectively enrolled 411 consecutive patients observed at four referral centers with de novo TIPS implantation for refractory ascites or secondary prophylaxis of variceal bleeding (derivation cohort) and an external cohort of 415 patients with similar indications for TIPS (validation cohort). Older adult patients in the two cohorts were 99 and 76, respectively. A cause‐specific Cox competing risks model was used to predict liver‐related mortality, with orthotopic liver transplant and death for extrahepatic causes as competing events. Age, alcoholic etiology, creatinine levels, and international normalized ratio in the overall cohort, and creatinine and sodium levels in older adults were independent risk factors for liver‐related death by multivariable analysis. Conclusions: After TIPS implantation, mortality is increased by aging, but TIPS placement should not be precluded in patients older than 70 years. In older adults, creatinine and sodium levels are useful predictors for decision making. Further efforts to update the prediction model with larger sample size are warranted.

Transjugular intrahepatic portosystemic shunt in portal hypertension: How to go further while staying on track?

“…The invasiveness of TIPS has prompted the search for prognostic indicators to limit their use to patients with a low risk of shunting complications. However, in the present issue, the study by Vizzutti et al proposes a predictive model of mortality after TIPS in patients with cirrhosis who are over 70 years of age, when these patients are at high risk of HE and cardiac decompensation 9. Another relevant contribution in this issue by Queck et al reminds us of a key feature: the hemodynamic objective “portal hepatic systemic pressure gradient” (PPG) remains the main target for evaluating the result of the shunt at a time when everything is done to limit the risks of overshunting (smallest possible diameter, per‐procedure embolization) 10…”

“…However, in the present issue, the study by Vizzutti et al proposes a predictive model of mortality after TIPS in patients with cirrhosis who are over 70 years of age, when these patients are at high risk of HE and cardiac decompensation. [9] Another relevant contribution in this issue by Queck et al reminds us of a key feature: the hemodynamic objective "portal hepatic systemic pressure gradient" (PPG) remains the main target for evaluating the result of the shunt at a time when everything is done to limit the risks of overshunting (smallest possible diameter, per-procedure embolization). [10] The aim of the first paper was to develop and validate a model for the prediction of mortality in older adults with cirrhosis treated with elective TIPS.…”

Survival prediction using the Freiburg index of post-TIPS survival (FIPS) in critically ill patients with acute- on chronic liver failure: A retrospective observational study

“…different cohorts (7)(8)(9)(10)(11). The use of the FIPS outside the TIPS setting, especially in patients with more advanced liver disease and particularly ACLF remains unclear.…”

Reply

“…We read with interest the letter from Vaz and colleagues and the comments on our recent study 1. As acknowledged in the letter, a major message of our paper is that transjugular intrahepatic shunt (TIPS) should be considered in carefully selected patients with cirrhosis older than 70 years.…”