Transjugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: Effect on clinical, renal, humoral, and hemodynamic parameters

Quiroga, Jorge; Sangro, Bruno; Núñez, Marina; Bilbao, I.; Longo, Jesús M.; García-Villarreal, Luis; Zozaya, José Manuel; Betés, Maite; Herrero, J.I.; Prìeto, Jesús

doi:10.1002/hep.1840210416

Cited by 104 publications

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“…[1][2][3][4] The influence of TIPS on renal function, however, has been investigated only in patients with refractory or recurrent ascites. [6][7][8][9][10][11][12][13] Compared with a practical clinical setting, most of these studies lack important information: they investigated renal function the day after TIPS, when it might be influenced by the procedure itself (e.g., contrast medium, analgesics, or anesthesia) and at 1 month, when it might be influenced by other factors (e.g., influence of TIPS on the nutritional status). So far, there has been little information on the renal function at 1 week after TIPS, the interval when most patients will be considered for release of hospital care.…”

Section: Discussionmentioning

confidence: 99%

“…One of the studies 8 completely withheld diuretic treatment for all patients during 1 month after TIPS and placed patients on a severely sodium-restricted diet, which is clearly not a practical approach (comment by Siuta 11 ). In other studies, 6,7,12 diuretic treatment was changed following TIPS. While this may be advisable in many patients several weeks after TIPS, it precludes an analysis of the effects of TIPS per se on renal sodium handling.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, information about the early influence of TIPS on renal function is limited. [6][7][8][9][10][11][12][13] Most of the previous studies were performed without diuretics or with the dose of diuretics decreasing throughout the observation period. While withholding diuretic treatment from those patients does not represent a practical clinical approach, the change of dosage of diuretics could disguise the effects of TIPS per se.…”

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confidence: 99%

“…Therefore, patients with refractory or recurrent ascites were treated with TIPS, most of them with remarkable success. [5][6][7][8][9] These observations prompted studies on the effects of TIPS on sodium handling in patients with refractory ascites. Little is known, however, about the effects of TIPS on renal function in patients without ascites or with ascites not refractory to diuretic treatment.…”

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Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: Comparison of patients with ascites, with refractory ascites, or without ascites

et al. 1998

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Renal effects of the transjugular intrahepatic portosystemic shunt (TIPS) were compared in 6 patients without ascites (group 1), 11 patients with ascites responding to diuretic treatment (group 2), and 6 patients with refractory ascites (group 3). Seven days after insertion of TIPS, 24-hour urinary sodium excretion had increased in patients with ascites: 113 ؎ 16 mmol to 170 ؎ 30 mmol (P ‫؍‬ .012) in group 2, and 22 ؎ 8 mmol to 77 ؎ 27 mmol (P ‫؍‬ .050) in group 3. In group 3, fractional sodium excretion tended to increase from 0.26% ؎ 0.14% to 0.62% ؎ 18% (P ‫؍‬ .081). The relative increase of urinary sodium excretion (to 444% ؎ 122%) and fractional sodium excretion (to 413% ؎ 127%) in group 3 was significantly (P F .05) higher than in group 1 and group 2, respectively. Creatinine clearance and 24-hour urinary volume were not significantly changed in either group. Patients with Child-Pugh class C had a more pronounced effect of TIPS on urinary sodium excretion (increase to 396% ؎ 115% vs. 139% ؎ 15%; P ‫؍‬ .066) and on fractional sodium excretion (increase to 415% ؎ 103% vs. 94% ؎ 15%; P ‫؍‬ .020) than patients with less-severe liver disease. Fractional sodium excretion of less than 0.35% before TIPS was found to be an indicator of renal response to TIPS. The effect of TIPS on urinary sodium excretion and on fractional sodium excretion was related to the patients' Child-Pugh score (r ‫؍‬ .55; P ‫؍‬ .007 and r ‫؍‬ .68; P ‫؍‬ .001, respectively) and inversely to their fractional sodium excretion (r ‫؍‬ Ϫ.44; P ‫؍‬ .047 and r ‫؍‬ Ϫ.54; P ‫؍‬ .012, respectively) before TIPS. These data demonstrate that TIPS affects renal sodium handling in patients with ascites, particularly in patients with refractory ascites. Severity of liver disease and fractional sodium excretion before TIPS are parameters to predict the extent of the renal response. (HEPATOLOGY 1998;28:683-688.)The transjugular intrahepatic portosystemic shunt (TIPS), a nonsurgical side-to-side shunt, has been introduced to prevent variceal rebleeding or to control refractory variceal bleeding by reducing the portal pressure gradient. 1-4 A considerable portion of these patients who had ascites at the time of TIPS insertion reduced the degree of ascites following TIPS. Therefore, patients with refractory or recurrent ascites were treated with TIPS, most of them with remarkable success. [5][6][7][8][9] These observations prompted studies on the effects of TIPS on sodium handling in patients with refractory ascites. Little is known, however, about the effects of TIPS on renal function in patients without ascites or with ascites not refractory to diuretic treatment. Moreover, predictors of renal response to TIPS have not yet been identified. Furthermore, information about the early influence of TIPS on renal function is limited. [6][7][8][9][10][11][12][13] Most of the previous studies were performed without diuretics or with the dose of diuretics decreasing throughout the observation period. While withholding diuretic treatment from those patients does not repr...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: Comparison of patients with ascites, with refractory ascites, or without ascites

et al. 1998

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“…Over the next 10 days, in its control of portal hypertension 2,3 and bleeding var-the serum bilirubin level increased and the hemoglobin ices 4 and semimagical in its treatment of refractory concentration decreased, in the absence of further bleedascites. 5,6 However, it is not free of problems. It has ing.…”

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Hemolysis after transjugular intrahepatic portosystemic shunting: The naked stent syndrome

Conn¹

1996

Hepatology

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SEE ARTICLE ON PAGE 32. venous pressure and the severity of PSE after TIPS are inversely related. 12 In 1992, Sanyal et al reported a post-TIPS patient with Naked we came into the world, and naked we shall depart hemolytic anemia and progressive hepatic encephalopathy from it.(HE), which they attributed to the stent, 13 although the Aesop, Fables relationship between the encephalopathy and the hemolyTransjugular intrahepatic portosystemic shunts sis was not clear. The patient, a Korean man with post-(TIPS) is an exciting new technique for the treatment HCV cirrhosis, received a Wallstent implant (Schneider, of portal hypertension. In the 8 years since it was first Inc., Minneapolis, MN) following an episode of hemordescribed, 1 it has been reported to be almost magical rhage from esophageal varices. Over the next 10 days, in its control of portal hypertension 2,3 and bleeding var-the serum bilirubin level increased and the hemoglobin ices 4 and semimagical in its treatment of refractory concentration decreased, in the absence of further bleedascites. 5,6 However, it is not free of problems. It has ing. Intravascular hemolysis was diagnosed, based on caused a broad spectrum of complications 7 and has these findings and the appearance of schistocytes in the been plagued by a variety of malfunctions. 8,9 The most peripheral blood smear, reticulocytosis, hypohaptoglobincommon of the complications are procedural, primarily emia, hemosiderinuria, and a negative Coomb's test. Worsperforations of the capsule of the liver or of abdominal ening HE required a liver transplantation, after which the organs that are associated with intra-abdominal hem-hemolysis promptly subsided. At the time of liver transorrhage. Infection, arrhythmias, thrombosis, misplaced plantation, they observed in the explanted liver that the or migrating stents, and nephrotoxicity are common Wallstent protruded into the portal and hepatic veins. The occurrences.intrahepatic portion of the stent was completely endotheliBased on the similarity of TIPS to portosystemic alized, but the extrahepatic, intravenous ends of the stent, anastomoses (PSA) it was predicted that portosystemic which consisted of bare wires, protruded into the portal encephalopathy (PSE) would be a common metabolic and hepatic veins (Fig. 1). They postulated that the hemocomplication. Indeed, 25% to 35% of patients who have lysis resulted from traumatic injury to erythrocytes flowundergone TIPS implantation have promptly devel-ing through the naked steel wires of the stent that prooped new or worsened PSE. 10 The frequency and sever-truded into the veins. In the absence of a positive Coomb's ity of PSE after PSA, whether spontaneous, surgical, test, which excludes antibodies to gamma globulins, macor interventional are proportional to the size of the roglobulins and complement, of spur cells, of sepsis, of shunt. 11 Most descriptions of post-TIPS PSE mention hepatocellular carcinoma or of disseminated intravascular that it tends to be mild, easily treatable, and of short hemo...

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Surgical treatment for hepatocellular carcinoma and concomitant esophagogastric varices

Harada

Nonami

Nakao

et al. 1996

Semin. Surg. Oncol.

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Preventing a rupture of esophagogastric varices (EGV) is very important in aggressively treating hepatocellular carcinoma (HCC) in cirrhotic patients. We therefore performed simultaneous partial hepatic resection and direct interruption procedure on nine patients with HCC and concomitant EGV. Patients were selected on the basis of their stages of HCC and hepatic functional reserve. Postoperative hospital courses of all patients were uneventful. Six patients had recurrence of HCC and received non‐surgical anti‐tumor treatments. Only one patient had upper gastrointestinal bleeding at 18 months after operation, and the other eight patients have had no episodes of upper gastrointestinal bleeding during the follow‐up period. The 5‐year survival rate of these patients was 48%. This operative procedure is quite effective and is one of the treatments of choice for patients with less advanced HCC and concomitant risk of EGV. © 1996 Wiley‐Liss, Inc.

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Transjugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: Effect on clinical, renal, humoral, and hemodynamic parameters

Cited by 104 publications

References 23 publications

Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: Comparison of patients with ascites, with refractory ascites, or without ascites

Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: Comparison of patients with ascites, with refractory ascites, or without ascites

Hemolysis after transjugular intrahepatic portosystemic shunting: The naked stent syndrome

Surgical treatment for hepatocellular carcinoma and concomitant esophagogastric varices

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