A novel score predicts mortality after transjugular intrahepatic portosystemic shunt: MOTS - Modified TIPS Score

Luisa Fürschuß, Florian Rainer, Maria Effenberger, Markus Niederreiter, Rupert H Portugaller, Angela Horvath, Peter Fickert, Vanessa Stadlbauer, Luisa Fürschuß, Florian Rainer, Maria Effenberger, Markus Niederreiter, Rupert H Portugaller, Angela Horvath, Peter Fickert, Vanessa Stadlbauer

Abstract

Background and aims: The high risk for severe shunting-related post-interventional complications demands a stringent selection of candidates for transjugular intrahepatic portosystemic shunt (TIPS). We aimed to develop a simple and reliable tool to accurately predict early post-TIPS mortality.

Methods: 144 cases of TIPS implantation were retrospectively analysed. Using univariate and multivariate Cox regression analysis of factors predicting mortality within 90 days after TIPS, a score integrating urea, international normalized ratio (INR) and bilirubin was developed. The Modified TIPS-Score (MOTS) ranges from 0 to 3 points: INR >1.6, urea >71 mg/dl and bilirubin >2.2 mg/dl account for one point each. Additionally, MOTS was tested in an external validation cohort (n = 187) and its performance was compared to existing models.

Results: Modified TIPS-Score achieved a significant prognostic discrimination reflected by 90-day mortality of 8% in patients with MOTS 0-1 and 60% in patients with MOTS 2-3 (p < .001). Predictive performance (area under the curve) of MOTS was accurate (c = 0.845 [0.73-0.96], p < .001), also in patients with renal insufficiency (c = 0.830 [0.64-1.00], p = .02) and in patients with refractory ascites (c = 0.949 [0.88-1.00], p < .001), which are subgroups with particular room for improvement of post-TIPS mortality prediction. The results were reproducible in the validation cohort.

Conclusions: Modified TIPS-Score is a novel, practicable tool to predict post-TIPS mortality, that can significantly simplify clinical decision making. Its practical applicability should be further investigated.

Trial registration: ClinicalTrials.gov NCT03459378.

Keywords: hepatic encephalopathy; mortality; prediction; renal insufficiency; risk; transjugular intrahepatic portosystemic shunt.

Conflict of interest statement

The authors declare that they have no relevant conflicts of interest.

© 2022 The Authors. Liver International published by John Wiley & Sons Ltd.

Figures

FIGURE 1
FIGURE 1
Flowchart of patients in the study. Three indication groups: diuretic‐refractory or recurrent ascites, portal hypertensive bleeding and refractory pleural effusion. PVT, portal venous thrombosis; TIPS, transjugular intrahepatic portosystemic shunt
FIGURE 2
FIGURE 2
Kaplan–Meier curves illustrating the probability of 90‐day survival of MOTS groups in the training cohort. p < .001; number of patients at risk (number of patients censored) at day 0, 20, 40, 60, 90. MOTS, modified transjugular intrahepatic portosystemic shunt‐score
FIGURE 3
FIGURE 3
ROC curves illustrating the predictive capability of models in the total training cohort. All scores available in n = 82; BILIPLT, model combining bilirubin and platelet count; CLIF‐C AD, CLIF‐C Acute Decompensation score; FIPS, Freiburg index of post‐TIPS survival; MELD, model for end stage liver disease; MELD‐Na, MELD sodium score; MOTS, modified TIPS score; ROC, receiver operating characteristic curve; TIPS, transjugular intrahepatic portosystemic shunt; all models were significantly predictive. For reference see Table 3 showing the related area under receiver operating characteristic, confidence intervals and p‐values
FIGURE 4
FIGURE 4
Kaplan–Meier curves illustrating the probability of 90‐day survival of MOTS groups in the validation cohort. p < .001; number of patients at risk (number of patients censored) at day 0, 20, 40, 60, 90

References

    1. Pereira K, Baker R, Salsamendi J, Doshi M, Kably I, Bhatia S. An approach to endovascular and percutaneous Management of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction: a pictorial essay and clinical practice algorithm. Cardiovasc Intervent Radiol. 2016;39(5):639‐651.
    1. Rössle M. TIPS: 25 years later. J Hepatol. 2013;59(5):1081‐1093.
    1. Bai M, Qi X‐S, Yang Z‐P, Yang M, Fan D‐M, Han G‐H. TIPS improves liver transplantation‐free survival in cirrhotic patients with refractory ascites: an updated meta‐analysis. World J Gastroenterol. 2014;20(10):2704‐2714.
    1. Berry K, Lerrigo R, Liou IW, Ioannou GN. Association between Transjugular intrahepatic portosystemic shunt and survival in patients with cirrhosis. Clin Gastroenterol Hepatol. 2016;14(1):118‐123.
    1. Gaba RC, Parvinian A, Casadaban LC, et al. Survival benefit of TIPS versus serial paracentesis in patients with refractory ascites: a single institution case‐control propensity score analysis. Clin Radiol. 2015;70(5):e51‐e57.
    1. Bureau C, Thabut D, Oberti F, et al. Transjugular intrahepatic portosystemic shunts with covered stents increase transplant‐free survival of patients with cirrhosis and recurrent ascites. Gastroenterology. 2017;152(1):157‐163.
    1. Lv Y, Yang Z, Liu L, et al. Early TIPS with covered stents versus standard treatment for acute variceal bleeding in patients with advanced cirrhosis: a randomised controlled trial. Lancet Gastroenterol Hepatol. 2019;4(8):587‐598.
    1. Bureau C, Métivier S, D’Amico M, et al. Serum bilirubin and platelet count: a simple predictive model for survival in patients with refractory ascites treated by TIPS. J Hepatol. 2011;54(5):901‐907.
    1. Schepke M, Roth F, Fimmers R, et al. Comparison of MELD, child‐pugh, and emory model for the prediction of survival in patients undergoing transjugular intrahepatic portosystemic shunting. Am J Gastroenterol. 2003;98(5):1167‐1174.
    1. Gaba RC, Couture PM, Bui JT, Knuttinen MG, Walzer NM, Kallwitz ER, et al. Prognostic capability of different liver disease scoring systems for prediction of early mortality after transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol. 2013;24(3):411–420, 420.e1–e4; quiz 421.
    1. Jalan R, Elton RA, Redhead DN, Finlayson ND, Hayes PC. Analysis of prognostic variables in the prediction of mortality, shunt failure, variceal rebleeding and encephalopathy following the transjugular intrahepatic portosystemic stent‐shunt for variceal haemorrhage. J Hepatol. 1995;23(2):123‐128.
    1. Chalasani N, Clark WS, Martin LG, et al. Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting. Gastroenterology. 2000;118(1):138‐144.
    1. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;31(4):864‐871.
    1. Allegretti AS, Frenk NE, Li DK, et al. Evaluation of model performance to predict survival after transjugular intrahepatic portosystemic shunt placement. PLoS One. 2019;14(5):e0217442.
    1. Neuberger J, Mulligan D. Liver allocation: can we ever get it right and should we ever get it right? Hepatology. 2015;61(1):28‐31.
    1. de Mattos ÂZ, de Mattos AA. Model for end‐stage liver disease‐based allocation system: on the right path, but not there yet. Hepatology. 2016;63(1):344.
    1. Asrani SK, Kamath PS. Model for end‐stage liver disease score and MELD exceptions: 15 years later. Hepatol Int. 2015;9(3):346‐354.
    1. Busk TM, Bendtsen F, Poulsen JH, et al. Transjugular intrahepatic portosystemic shunt: impact on systemic hemodynamics and renal and cardiac function in patients with cirrhosis. Am J Physiol Gastrointest Liver Physiol. 2018;314(2):G275‐G286.
    1. Alessandria C, Gaia S, Marzano A, Venon WD, Fadda M, Rizzetto M. Application of the model for end‐stage liver disease score for transjugular intrahepatic portosystemic shunt in cirrhotic patients with refractory ascites and renal impairment. Eur J Gastroenterol Hepatol. 2004;16(6):607‐612.
    1. Allegretti AS, Ortiz G, Cui J, et al. Changes in kidney function after transjugular intrahepatic portosystemic shunts versus large‐volume paracentesis in cirrhosis: a matched cohort analysis. Am J Kidney Dis. 2016;68(3):381‐391.
    1. Anderson CL, Saad WEA, Kalagher SD, et al. Effect of transjugular intrahepatic portosystemic shunt placement on renal function: a 7‐year, single‐center experience. J Vasc Interv Radio. 2010;21(9):1370‐1376.
    1. Bettinger D, Sturm L, Pfaff L, et al. Refining prediction of survival after TIPS with the novel Freiburg index of post‐TIPS survival. J Hepatol. 2021;74(6):1362‐1372.
    1. Kraglund F, Gantzel RH, Jepsen P, Aagaard NK. External validation of the Freiburg index of post‐TIPS survival. J Hepatol. 2021;75(3):746‐747.
    1. Wang Q, Bai W, Han G. Freiburg index of post‐TIPS survival: the first score for individual prediction and a complementary tool for risk stratification. J Hepatol. 2021;75(3):747‐749.
    1. DeLong ER, DeLong DM, Clarke‐Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44(3):837‐845.
    1. Yang D, Dalton JE. A unified approach to measuring the effect size between two groups using SAS®. SAS Glob Forum. 2012;335:1‐6.
    1. Goykhman Y, Ben‐Haim M, Rosen G, et al. Transjugular intrahepatic portosystemic shunt: current indications, patient selection and results. Isr Med Assoc J. 2010;12(11):687‐691.
    1. Schindler P, Seifert L, Masthoff M, et al. TIPS modification in the management of shunt‐induced hepatic encephalopathy: analysis of predictive factors and outcome with shunt modification. J Clin Med. 2020;9(2):567.
    1. Angermayr B, Cejna M, Karnel F, et al. Child‐Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt. Gut. 2003;52(6):879‐885.
    1. Reiberger T, Püspök A, Schoder M, et al. Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr. 2017;129(suppl 3):135‐158.
    1. European Association for the Study of the Liver . EASL clinical practice guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018;69(2):406‐460.
    1. Ronald J, Wang Q, Choi SS, et al. Albumin‐bilirubin grade versus MELD score for predicting survival after transjugular intrahepatic portosystemic shunt (TIPS) creation. Diagn Interv Radiol. 2018;99(3):163‐168.
    1. Sturm L, Praktiknjo M, Bettinger D, et al. Prognostic value of the CLIF‐C AD score in patients with implantation of transjugular intrahepatic portosystemic shunt. Hepatol Commun. 2021;5(4):650‐660.
    1. Francoz C, Prié D, Abdelrazek W, et al. Inaccuracies of creatinine and creatinine‐based equations in candidates for liver transplantation with low creatinine: impact on the model for end‐stage liver disease score. Liver Transplant. 2010;16(10):1169‐1177.
    1. Sherman DS, Fish DN, Teitelbaum I. Assessing renal function in cirrhotic patients: problems and pitfalls. Am J Kidney Dis. 2003;41(2):269‐278.
    1. Francoz C, Sola E. Assessment of renal function in cirrhosis: sarcopenia, gender and ethnicity matter. J Hepatol. 2019;70(5):828‐830.
    1. Chopra D, Rosenberg M, Moayyedi P, Narula N. Is blood urea concentration an independent predictor of positive endoscopic findings in presumed upper gastrointestinal bleeding? Dig Dis Basel Switz. 2020;38(1):77‐84.
    1. Srygley FD, Gerardo CJ, Tran T, Fisher DA. Does this patient have a severe upper gastrointestinal bleed? JAMA. 2012;307(10):1072‐1079.
    1. Tomizawa M, Shinozaki F, Hasegawa R, et al. Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding. World J Gastroenterol. 2015;21(24):7500‐7505.
    1. Kumar NL, Claggett BL, Cohen AJ, Nayor J, Saltzman JR. Association between an increase in blood urea nitrogen at 24 hours and worse outcomes in acute nonvariceal upper GI bleeding. Gastrointest Endosc 2017;86(6):1022‐1027.e1.
    1. Wu BU, Johannes RS, Sun X, Conwell DL, Banks PA. Early changes in blood urea nitrogen predict mortality in acute pancreatitis. Gastroenterology. 2009;137(1):129‐135.
    1. Ferenci P. Hepatic encephalopathy. Gastroenterol Rep. 2017;5(2):138‐147.
    1. Ahuja NK, Ally WA, Caldwell SH. Direct acting inhibitors of ammoniagenesis: a role in post‐TIPS encephalopathy? Ann Hepatol. 2014;13(2):179‐186.
    1. Olde Damink SWM, Jalan R, Redhead DN, Hayes PC, Deutz NEP, Soeters PB. Interorgan ammonia and amino acid metabolism in metabolically stable patients with cirrhosis and a TIPSS. Hepatology. 2002;36(5):1163‐1171.
    1. Romero‐Gomez M, Jover M, Diaz‐Gomez D, et al. Phosphate‐activated glutaminase activity is enhanced in brain, intestine and kidneys of rats following portacaval anastomosis. World J Gastroenterol. 2006;12(15):2406‐2411.
    1. Ong JP, Aggarwal A, Krieger D, et al. Correlation between ammonia levels and the severity of hepatic encephalopathy. Am J Med. 2003;114(3):188‐193.
    1. Ninan J, Feldman L. Ammonia levels and hepatic encephalopathy in patients with known chronic liver disease. J Hosp Med. 2017;12(8):659‐661.
    1. Stahl J. Studies of the blood ammonia in liver disease. Its diagnostic, prognostic, and therapeutic significance. Ann Intern Med. 1963;58:1‐24.
    1. da Fonseca‐Wollheim F. Preanalytical increase of ammonia in blood specimens from healthy subjects. Clin Chem. 1990;36(8 pt 1):1483‐1487.
    1. Howanitz JH, Howanitz PJ, Skrodzki CA, Iwanski JA. Influences of specimen processing and storage conditions on results for plasma ammonia. Clin Chem. 1984;30(6):906‐908.
    1. Austin PC, Lee DS, D’Agostino RB, Fine JP. Developing points‐based risk‐scoring systems in the presence of competing risks. Stat Med. 2016;35(22):4056‐4072.
    1. Child CG, Turcotte JG. Surgery and portal hypertension. Major Probl Clin Surg. 1964;1:1‐85.
    1. Vincent JL, Moreno R, Takala J, et al. The SOFA (sepsis‐related organ failure assessment) score to describe organ dysfunction/failure. On behalf of the working group on sepsis‐related problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22(7):707‐710.
    1. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d‐dimer. Ann Intern Med. 2001;135(2):98‐107.
    1. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of atrial fibrillation. JAMA. 2001;285(22):2864‐2870.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir