Short-Term Mortality is Reduced and Low-Grade Acute-on-Chronic Liver Failure Reversed by Transjugular Intrahepatic Portosystemic Shunt in Patients With Fluid Overload: A Case-Control Study.

INTRODUCTION

Portal hypertension characterizes decompensated cirrhosis and its complications. It may trigger acute-on-chronic liver failure (ACLF), which carries a high mortality. Transjugular intrahepatic portosystemic shunt (TIPS) is the most efficient therapy for most portal hypertension-related complications including fluid overload (FO) defined as refractory or recurrent ascites, hepatorenal syndrome, and/or hydrothorax. However, TIPS for FO in ACLF is questioned.

METHODS

In this case-control study, patients from the prospective cohorts CANONIC (n = 1,324) and German TIPS-Registry (n = 724) were screened for cases of FO and matched 1:1 by sex, age, Model for End-Stage Liver Disease (MELD) score, and presence and grade of ACLF. Clinical outcomes, ACLF status, and mortality were assessed.

RESULTS

The total population was 118 patients with ACLF of whom 59 received TIPS and 59 did not. The main indication for TIPS was hepatorenal syndrome (61.0%). Patients with ACLF who did not receive TIPS had a higher 28-day cumulative mortality rate (22.0% vs 5.1%, P = 0.009). At 28 days, TIPS insertion in ACLF was associated with a 78% mortality reduction (hazard ratio 0.22 [0.06-0.77]). It further led to improvement of hepatic encephalopathy and the MELD score. In addition, ACLF resolution occurred in 61% of TIPS patients with ACLF. The presence of coagulation and circulatory organ failures, and increased bilirubin, INR, MELD score, and CLIF-C OF were associated with 28-day mortality. The survival benefit of TIPS was no longer observed after 90 days.

DISCUSSION: TIPS decreased the 28-day mortality of patients with FO and ACLF. Thus, TIPS should be regarded as a bridging strategy-ideally for liver transplantation.