Outcomes After TIPS for Ascites and Variceal Bleeding in a Contemporary Era-An ALTA Group Study

Abstract

Introduction: Advances in transjugular intrahepatic portosystemic shunt (TIPS) technology have led to expanded use. We sought to characterize contemporary outcomes of TIPS by common indications.

Methods: This was a multicenter, retrospective cohort study using data from the Advancing Liver Therapeutic Approaches study group among adults with cirrhosis who underwent TIPS for ascites/hepatic hydrothorax (ascites/HH) or variceal bleeding (2010-2015). Adjusted competing risk analysis was used to assess post-TIPS mortality or liver transplantation (LT).

Results: Among 1,129 TIPS recipients, 58% received TIPS for ascites/HH and 42% for variceal bleeding. In patients who underwent TIPS for ascites/HH, the subdistribution hazard ratio (sHR) for death was similar across all Model for End-Stage Liver Disease Sodium (MELD-Na) categories with an increasing sHR with rising MELD-Na. In patients with TIPS for variceal bleeding, MELD-Na ≥20 was associated with increased hazard for death, whereas MELD-Na ≥22 was associated with LT. In a multivariate analysis, serum creatinine was most significantly associated with death (sHR 1.2 per mg/dL, 95% confidence interval [CI] 1.04-1.4 and 1.37, 95% CI 1.08-1.73 in ascites/HH and variceal bleeding, respectively). Bilirubin and international normalized ratio were most associated with LT in ascites/HH (sHR 1.23, 95% CI 1.15-1.3; sHR 2.99, 95% CI 1.76-5.1, respectively) compared with only bilirubin in variceal bleeding (sHR 1.06, 95% CI 1.00-1.13).

Discussion: MELD-Na has differing relationships with patient outcomes dependent on TIPS indication. These data provide new insights into contemporary predictors of outcomes after TIPS.

Copyright © 2021 by The American College of Gastroenterology.

Figures

Figure 1.

Unadjusted 5-year cumulative incidence of death or liver transplant after TIPS among ascites/HH and variceal bleeding indications. Ascites/HH, ascites/hepatic hydrothorax; TIPS, transjugular intrahepatic portosystemic shunt.

Figure 2.

Unadjusted subdistribution hazard ratios for death and liver transplant among indication of ascites/HH after TIPS across all MELD-Na ranges. Ascites/HH, ascites/hepatic hydrothorax; MELD-Na, Model for End-Stage Liver Disease Sodium; TIPS, transjugular intrahepatic portosystemic shunt.

Figure 3.

Adjusted subdistribution hazard ratios for death and liver transplant among indication of ascites/HH after TIPS controlling for age, etiology of liver disease, and components of MELD-Na score. Ascites/HH, ascites/hepatic hydrothorax; ETOH, alcohol; HCV, Hepatitis C; MELD-Na, Model for End-Stage Liver Disease Sodium; NASH, nonalcoholic steatohepatitis; TIPS, transjugular intrahepatic portosystemic shunt.

Figure 4.

Unadjusted subdistribution hazard ratios for death and liver transplant among indication of variceal bleeding after TIPS across all MELD-Na ranges. MELD-Na, Model for End-Stage Liver Disease Sodium; TIPS, transjugular intrahepatic portosystemic shunt.

Figure 5.

Adjusted subdistribution hazard ratios for death and liver transplant among indication of variceal bleeding after TIPS controlling for age, etiology of liver disease, and components of MELD-Na score. ETOH, alcohol; HCV, Hepatitis C; MELD-Na, Model for End-Stage Liver Disease Sodium; NASH, nonalcoholic steatohepatitis; TIPS, transjugular intrahepatic portosystemic shunt.