Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS.
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Trebicka Jonel, Gu Wenyi, Ibáñez-Samaniego Luis, Hernández-Gea Virginia, Pitarch Carla, Garcia Elisabet, Procopet Bogdan, Giráldez Álvaro, Amitrano Lucio, Villanueva Candid, Thabut Dominique, Silva-Junior Gilberto, Martinez Javier, Genescà Joan, Bureau Cristophe, Llop Elba, Laleman Wim, Palazon Jose Maria, Castellote Jose, Rodrigues Susanag, Gluud Liselotte, Ferreira Carlos Noronha, Barcelo Rafael, Cañete Nuria, Rodríguez Manuel, Ferlitsch Arnulf, Mundi Jose Luis, Gronbaek Henning, Hernández-Guerra Manuel, Sassatelli Romano, Dell'Era Alessandra, Senzolo Marco, Abraldes Juan G, Romero-Gómez Manuel, Zipprich Alexander, Casas Meritxell, Masnou Helena, Primignani Massimo, Weiss Emmanuel, Catalina Maria-Vega, Erasmus Hans-Peter, Uschner Frank Erhard, McCoy Martin Sebastian, Brol Maximilian J, Praktiknjo Michael, Chang Johannes, Krag Aleksander, Nevens Frederik, Calleja Jose Luis, Robic Marie Angèle, Conejo Irene, Albillos Agustin, Rudler Marika, Alvarado Edilmar, Guardascione Maria Anna, Tantau Marcel, Bosch Jaime, Torres Ferran, Pavesi Marco, Garcia-Pagán Juan Carlos, Jansen Christian, Bañares Rafael, International Variceal Bleeding Observational Study Group and Baveno Cooperation
Аннотация
METHODS: A multicenter, international, observational study was conducted in 2,138 patients from 34 centers between 2011 and 2015. ACLF was defined and graded according to the EASL-CLIF consortium definition. Placement of pre-emptive TIPS (pTIPS) was based on individual center policy. Patients were followed-up for 1 year, until death or liver transplantation. Cox regression and competing risk models (Gray's test) were used to identify independent predictors of rebleeding or mortality.
RESULTS: At admission, 380/2,138 (17.8%) patients had ACLF according to EASL-CLIF criteria (grade 1: 38.7%; grade 2: 39.2%; grade 3: 22.1%). The 42-day rebleeding (19% vs. 10%; p <0.001) and mortality (47% vs. 10%; p <0.001) rates were higher in patients with ACLF and increased with ACLF grades. Of note, the presence of ACLF was independently associated with rebleeding and mortality. pTIPS placement improved survival in patients with ACLF at 42 days and 1 year. This effect was also observed in propensity score matching analysis of 66 patients with ACLF, of whom 44 received pTIPs and 22 did not.
CONCLUSIONS: This large multicenter international real-life study identified ACLF at admission as an independent predictor of rebleeding and mortality in patients with AVB. Moreover, pTIPS was associated with improved survival in patients with ACLF and AVB.
LAY SUMMARY: Acute variceal bleeding is a deadly complication of liver cirrhosis that results from severe portal hypertension. This study demonstrates that the presence of acute-on-chronic liver failure (ACLF) is the strongest predictor of mortality in patients with acute variceal bleeding. Importantly, patients with ACLF and acute variceal (re)bleeding benefit from pre-emptive (early) placement of a transjugular intrahepatic portosystemic shunt.