New Model for End Stage Liver Disease Improves Prognostic Capability After Transjugular Intrahepatic Portosystemic Shunt

ArticleinClinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 7(11):1236-40 · June 2009with26 Reads
DOI: 10.1016/j.cgh.2009.06.009 · Source: PubMed
Cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites or recurrent variceal bleeding are at risk for decompensation and death. This study examined whether a new model for end stage liver disease (MELD), which incorporates serum sodium (MELDNa), is a better predictor of death or transplant after TIPS than the original MELD. One hundred forty-eight consecutive patients undergoing nonemergent TIPS for refractory ascites or recurrent variceal bleeding from 1997 to 2006 at a single center were evaluated retrospectively. Cox model analysis was performed with death or transplant within 6 months as the end point. The models were compared using the Harrell's C index. Recursive partitioning determined the optimal MELDNa cutoff to maximize the risk:benefit ratio of TIPS. The predictive ability of MELDNa was superior to MELD, particularly in patients with low MELD scores. The C indices (95% confidence interval [CI]) for MELDNa and MELD were 0.65 (95% CI, 0.55-0.71) and 0.58 (95% CI, 0.51-0.67) using a cut-off score of 18, and 0.72 (95% CI, 0.60-0.85) and 0.62 (95% CI, 0.49-0.74) using a cut-off score of 15. Using a MELDNa >15, 22% of patients were reclassified to a higher risk with an event rate of 44% compared with 10% when the score was <or=15. MELDNa performed better than MELD in predicting death or transplant after non-emergent TIPS, especially in patients with low MELD scores. A MELD score <or=18 can provide a false positive prognosis; a MELDNa score <or=15 provides a more accurate risk prediction.
    • "This was not unexpected, since MELD was originally designed to predict mortality after TIPS [14]. Contrarily to other studies [3,18,19], in our population sodium level and creatinine were not independently associated with mortality. This may be due to the clinical protocols applied in our Hospital, which include the routine infusion of human albumin in cirrhotic patients with refractory ascites [20] leading to a significant improvement of renal function. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: The presence of refractory ascites is a common indication for transjugular intrahepatic portosystemic shunt (TIPS). Different models have been proposed for the prediction of survival after TIPS. The aim of this study was to evaluate the predictive factors associated with patients' survival after TIPS placement for refractory ascites. Methods: Data from all consecutive patients undergoing TIPS placement in our center for refractory ascites between February 2003 and January 2008 were prospectively recorded. Results: Seventy-three patients (52M/21F; 57 ± 10 years) met the inclusion criteria; mean follow-up was 17 ± 2 months. Mean MELD value, before TIPS placement, was 15.7 ± 5.3. TIPS placement led to an effective resolution of refractory ascites in 54% of patients (n = 40) with no significant increase in severe portosystemic encephalopathy. The 1-year survival rate observed was 65.7%, while the overall mortality was 23.3% (n = 17) with a mean survival of 17 ± 14 months. MELD score (B = 0.161, p = 0.042), basal AST (B = 0.020, p = 0.090), and pre-TIPS HVPG (B = 0.016, p = 0.093) were independent predictors of overall mortality, while MELD (B = 0.419, p = 0.018) and HVPG (B = 0.223, p = 0.060) independently predicted 1-year survival. ROC curves identified MELD ≥ 19 and HVPG ≥ 25 mmHg as the best cut-off points for the prediction of 1-year mortality. Conclusions: TIPS is an effective treatment for refractory ascites in cirrhotic patients, leading to an effective ascites control in more than half patients. Improvement in patients' selection criteria could lead to better outcome and survival after this procedure. Liver function (MELD), presence of active necroinflammation (AST), and portal hypertension (HVPG) are independent predictors of patients' outcome after TIPS.
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  • [Show abstract] [Hide abstract] ABSTRACT: Transjugular intrahepatic portosystemic shunt (TIPS) is a radiological interventional procedure useful in portal hypertension-related complications. It is able to resolve variceal bleeding and refractory ascites. However, it can lead to serious side effects such as refractory encephalopathy, cardiac failure, and end-stage liver failure. Patients with refractory ascites represent the most frequent indication for TIPS. Clinicians are challenged by the necessity to select the best candidates for TIPS, so that the procedure can be successful as far as both efficacy and survival are concerned. The correct process to select TIPS for cirrhotic patients with ascites includes different steps: first, patients with absolute contraindications, such cardiopulmonary dysfunction or too severe liver failure, should be excluded, and second, criteria to predict post-TIPS survival should be considered. The most effective predictors of survival are serum creatinine, serum bilirubin, serum sodium, age and MELD or Child-Pugh scores. According to an arbitrary choice of two thresholds of different risks for each variable, we propose a simple estimation of the whole risk after TIPS placement.Copyright © 2011 S. Karger AG, Basel
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