Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites

Salerno, Francesco; Merli, Manuela; Riggio, Oliviero; Cazzaniga, M.; Valeriano, Valentina; Pozzi, Massimo; Nicolini, Antonio; Salvatori, Filippo Maria

doi:10.1002/hep.20364

Cited by 314 publications

(274 citation statements)

References 21 publications

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“…Survival in the setting of HCC is often limited by the patients' degree of underlying liver dysfunction rather than tumor burden. Patients with indwelling TIPS have already manifested the sequelae of portal hypertension, and median survival in these patients is clearly shorter than those without significant liver dysfunction [28,29]. Therefore, in the setting of TIPS, survival may be more limited by underlying liver disease rather than tumor.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of Locoregional Tumor Therapy for Patients with Hepatocellular Carcinoma and Transjugular Intrahepatic Portosystemic Shunts

Padia

Chewning

Kogut

et al. 2014

Cardiovasc Intervent Radiol

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Purpose Locoregional therapy for hepatocellular carcinoma (HCC) can be challenging in patients with a transjugular intrahepatic portosystemic shunt (TIPS). This study compares safety and imaging response of ablation, chemoembolization, radioembolization, and supportive care in patients with both TIPS and HCC. Methods This retrospective study included 48 patients who had both a TIPS and a diagnosis of HCC. Twenty-nine of 48 (60 %) underwent treatment for HCC, and 19/48 (40 %) received best supportive care (i.e., symptomatic management only). While etiology of cirrhosis and indication for TIPS were similar between the two groups, treated patients had better baseline liver function (34 vs. 67 % Child-Pugh class C). Tumor characteristics were similar between the two groups. A total of 39 ablations, 17 chemoembolizations, and 10 yttrium-90 radioembolizations were performed on 29 patients.Results Ablation procedures resulted in low rates of hepatotoxicity and clinical toxicity. Post-embolization/ ablation syndrome occurred more frequently in patients undergoing chemoembolization than ablation (47 vs. 15 %). Significant hepatic dysfunction occurred more frequently in the chemoembolization group than the ablation group. Follow-up imaging response showed objective response in 100 % of ablation procedures, 67 % of radioembolization procedures, and 50 % of chemoembolization procedures (p = 0.001). When censored for OLT, patients undergoing treatment survived longer than patients receiving supportive care (2273 v. 439 days, p = 0.001). Conclusions Ablation appears to be safe and efficacious for HCC in patients with TIPS. Catheter-based approaches are associated with potential increased toxicity in this patient population. Chemoembolization appears to be associated with increased toxicity compared to radioembolization.

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Section: Discussionmentioning

confidence: 99%

Outcomes of Locoregional Tumor Therapy for Patients with Hepatocellular Carcinoma and Transjugular Intrahepatic Portosystemic Shunts

Padia

Chewning

Kogut

et al. 2014

Cardiovasc Intervent Radiol

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“…Frequency of new or worsening HE ranges from 10-44% 3 , and factors associated with post-TIPS HE development include prior history of HE, increasing age, shunt caliber, high creatinine levels, low serum sodium concentration and liver dysfunction 95,115 . Previously, studies with bare metal stents found an increased risk for the development of HE after TIPS insertion for ascites 57,58,59,60,61,62 . Consequently, studies with covered stents found to have lower rates of HE after TIPS placement 113,116 .…”

Section: Portosystemic Shunting Relatedmentioning

confidence: 99%

“…A PPG less than 12 mmHg 3 should be achieved in patients with a history of bleeding esophageal varices and refractory ascites. However the optimal PPG for refractory ascites is still under much debate with some authors suggesting a PPG of less than 8mmHg 59 . In patients with pre-existing HE, a higher gradient may be appropriate to reduce post-TIPS HE 104 , more data is needed to elucidate this.…”

Section: Portal Venous Access and Tips Insertionmentioning

confidence: 99%

Transjugular Intrahepatic Portosystemic Shunt

Preedy¹,

Watson²

2010

Handbook of Disease Burdens and Quality of Life Measures

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Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylen (PTFE) covered stents, shunt patency has improved dramatically thus improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.

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“…What could be the source of this disparity? One explanation is a methodological differences between the current study and prior studies [2][3][4]8]. Other studies censored patients who underwent OLT, such that the date of transplantation was considered the last day of follow-up and not counted as an event.…”

mentioning

confidence: 92%

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mentioning

confidence: 99%

Survival in Cirrhotic Patients with High MELD Scores: The TIPping Point

Hwang

Sze

2016

Dig Dis Sci

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Although a survival benefit following transjugular intrahepatic portosystemic shunt (TIPS) creation for variceal bleeding [1] and ascites [2,3] has been reported in randomized controlled trials (RCTs) in cirrhotic patients, clinical outcomes after TIPS placement in patients with late-stage liver disease and high Model for End-Stage Liver Disease (MELD) scores remain controversial. The MELD score was originally created to predict the survival after TIPS placement in patients with cirrhosis; by intention, a high MELD score predicts poor survival after TIPS [4]. While the RCTs supported early TIPS placement for variceal bleeding and favored TIPS over repeated large-volume paracentesis in patients with Child-Pugh scores up to 11 or 13, the investigators intentionally excluded patients with severely compromised liver function and higher scores. The RCTs also did not report on outcomes relative to the MELD scores.Consequently, data regarding TIPS outcomes in patients with high MELD scores have historically been derived from non-randomized studies. Angermayr et al. [5] reported a 60% 1-year mortality rate in patients with MELD [ 18. Ferral et al. [6] reported a 90-day mortality rate of 34.8% in patients after elective TIPS with MELD scores of 18-24 and 65.5% in patients with MELD C 18, yielding a 90-day mortality of 44% for all patients with MELD C 18. Casadaban et al. [7] stated that survival rates after emergent TIPS placement for acute variceal bleeding were predicted by MELD scores and were inferior to survival rates reported in the elective TIPS placement population, with a 90-day mortality rate of 36% for MELD 19-25 and 83% for MELD C 26.The high post-TIPS mortality rates reported in patients with high MELD scores have led some to conclude that TIPS procedures should not be performed in those patients, particularly if the MELD is [25 [6]. Although such a conclusion implies that TIPS placement is harmful, or at least, not beneficial to that subset of patients, this assumption remains conjectural. The prognosis of patients with high MELD scores is generally poor, with reported 1-year mortality of approximately 30% for MELD scores between 20 and 29 and approximately 60% for MELD scores C30 [8]. Given the variability among patient cohorts in how MELD scores are stratified, and in how survival outcomes are reported, and given the similarities in the reported survival statistics for high-MELD patients with and without TIPS, it is difficult to isolate the effect of TIPS placement from the overall dismal survival typical of high-MELD patients.In this issue of Digestive Diseases and Sciences, Ascha et al. [9] have taken a step toward answering the question of whether TIPS placement increases or decreases survival in patients with high MELD scores. They retrospectively analyzed a cohort of 144 patients with MELD score C15 who underwent TIPS procedures, matched them by MELD score and age to 144 patients who had not undergone TIPS procedures, excluding patients with hepatocellular carcinoma or those who died within 48 h of ...

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Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites

Cited by 314 publications

References 21 publications

Outcomes of Locoregional Tumor Therapy for Patients with Hepatocellular Carcinoma and Transjugular Intrahepatic Portosystemic Shunts

Outcomes of Locoregional Tumor Therapy for Patients with Hepatocellular Carcinoma and Transjugular Intrahepatic Portosystemic Shunts

Transjugular Intrahepatic Portosystemic Shunt

Survival in Cirrhotic Patients with High MELD Scores: The TIPping Point

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