No Increased Mortality After TIPS Compared with Serial Large Volume Paracenteses in Patients with Higher Model for End-Stage Liver Disease Score and Refractory Ascites
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To compare survival after transjugular intrahepatic portosystemic shunt (TIPS) creation versus serial large volume paracenteses (LVP) in patients with refractory ascites and higher Model for End-Stage Liver Disease (MELD) scores.
Materials and Methods
In this retrospective study, from 1/1/2013 to 10/1/2018, 478 patients (294 male; mean age 58, range 23–89) underwent serial LVP (n = 386) or TIPS (n = 92) for ascites. Propensity-matched cohorts were constructed based on age, MELD, Charlson comorbidity index, varices, and hepatic encephalopathy. Survival was analyzed using a Cox proportional hazards model in which MELD score and TIPS were treated as time-dependent covariates. An interaction term was used to assess the impact of TIPS versus serial LVP on survival as a function of increasing MELD.
In the overall patient sample, higher MELD score predicted worse survival after either serial LVP or TIPS [hazard ratio (HR) = 1.13; p < 0.001], but there was no significant interaction between TIPS and higher MELD score conferring worse survival (HR = 1.01; p = 0.55). In 92 propensity-matched serial LVP and 92 TIPS patients, higher MELD score predicted worse survival after either serial LVP or TIPS (HR = 1.19; p < 0.001), but there was no significant survival interaction between TIPS and higher MELD (HR = 0.97; p = 0.22). In 30 propensity-matched serial LVP patients and 30 TIPS patients with baseline MELD greater than 18, TIPS did not predict worse survival (HR = 0.97; p = 0.94).
Higher MELD predicts poorer survival after either serial LVP or TIPS, but TIPS creation is not associated with worse survival compared to serial LVP in patients with higher MELD scores
Level of Evidence
Level 4, case series.
KeywordsTransjugular intrahepatic portosystemic shunt Paracentesis Model for End-Stage Liver Disease Survival
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required. This article does not contain any studies with animals performed by any of the authors.
- 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 JVIR. 2013;24(3):411–20. https://doi.org/10.1016/j.jvir.2012.10.026 20.e1-4; quiz 21.CrossRefGoogle Scholar
- 2.Ronald J, Wang Q, Choi SS, Suhocki PV, Hall MD, Smith TP, et al. Albumin-bilirubin grade versus MELD score for predicting survival after transjugular intrahepatic portosystemic shunt (TIPS) creation. Diagn Interv Imaging. 2018;99(3):163–8. https://doi.org/10.1016/j.diii.2017.10.008.CrossRefGoogle Scholar
- 3.Ferral H, Gamboa P, Postoak DW, Albernaz VS, Young CR, Speeg KV, et al. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score. Radiology. 2004;231(1):231–6. https://doi.org/10.1148/radiol.2311030967.CrossRefGoogle Scholar
- 4.Ferral H, Patel NH. Selection criteria for patients undergoing transjugular intrahepatic portosystemic shunt procedures: current status. J Vasc Interv Radiol JVIR. 2005;16(4):449–55. https://doi.org/10.1097/01.rvi.0000149508.64029.02.CrossRefGoogle Scholar
- 5.Pan JJ, Chen C, Caridi JG, Geller B, Firpi R, Machicao VI, et al. Factors predicting survival after transjugular intrahepatic portosystemic shunt creation: 15 years’ experience from a single tertiary medical center. J Vasc Interv Radiol JVIR. 2008;19(11):1576–81. https://doi.org/10.1016/j.jvir.2008.07.021.CrossRefGoogle Scholar
- 10.Somsouk M, Kornfield R, Vittinghoff E, Inadomi JM, Biggins SW. Moderate ascites identifies patients with low model for end-stage liver disease scores awaiting liver transplantation who have a high mortality risk. Liver Transplant. 2011;17(2):129–36. https://doi.org/10.1002/lt.22218.CrossRefGoogle Scholar
- 11.Bureau C, Thabut D, Oberti F, Dharancy S, Carbonell N, Bouvier A, et al. Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites. Gastroenterology. 2017;152(1):157–63. https://doi.org/10.1053/j.gastro.2016.09.016.CrossRefGoogle Scholar
- 13.Narahara Y, Kanazawa H, Fukuda T, Matsushita Y, Harimoto H, Kidokoro H, et al. Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial. J Gastroenterol. 2011;46(1):78–85. https://doi.org/10.1007/s00535-010-0282-9.CrossRefGoogle Scholar
- 17.Horvath MM, Rusincovitch SA, Brinson S, Shang HC, Evans S, Ferranti JM. Modular design, application architecture, and usage of a self-service model for enterprise data delivery: the Duke Enterprise Data Unified Content Explorer (DEDUCE). J Biomed Inform. 2014;52:231–42. https://doi.org/10.1016/j.jbi.2014.07.006.CrossRefGoogle Scholar
- 18.Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173(6):676–82. https://doi.org/10.1093/aje/kwq433.CrossRefGoogle Scholar
- 19.Loffroy R, Favelier S, Pottecher P, Estivalet L, Genson PY, Gehin S, et al. Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging. 2015;96(7–8):745–55. https://doi.org/10.1016/j.diii.2015.05.005.CrossRefGoogle Scholar
- 21.R Development Core Team. R: a language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2010.Google Scholar
- 26.Pereira K, Carrion AF, Salsamendi J, Doshi M, Baker R, Kably I. Endovascular management of refractory hepatic encephalopathy complication of transjugular intrahepatic portosystemic shunt (TIPS): comprehensive review and clinical practice algorithm. Cardiovasc Interv Radiol. 2016;39(2):170–82. https://doi.org/10.1007/s00270-015-1197-x.CrossRefGoogle Scholar