Transjugular intrahepatic portosystemic shunt in refractory ascites: A meta-analysis

University of Lille Nord de France, Lille, Nord-Pas-de-Calais, France
Liver international: official journal of the International Association for the Study of the Liver (Impact Factor: 4.85). 04/2005; 25(2):349-56. DOI: 10.1111/j.1478-3231.2005.01095.x
Source: PubMed


Transjugular intrahepatic portosystemic shunt (TIPS) is a more effective treatment for refractory ascites than large volume paracentesis (LVP), but the magnitude of its effect in terms of control of ascites, encephalopathy and survival has not been established.
This meta-analysis compare TIPS to LVP in terms of control of ascites at 4 and 12 months, encephalopathy and survival at 1 and 2 years.
Five randomized controlled trials involving 330 patients were included. In the TIPS group, control of ascites was more frequently achieved at 4 months (66% vs 23.8%, mean difference: 41.4%, 95% confidence interval (CI): 29.5-53.2%, P < 0.001) and 12 months (54.8% vs 18.9%, mean difference: 35%, 95% CI: 24.9-45.1%, P < 0.001), whereas encephalopathy was higher (54.9% vs 38.1%, mean difference: 17%, 95% CI: 7.3-26.6%, P < 0.001). Survival at 1 year (61.7% vs 56.5%, mean difference: 3.2%, 95% CI: -14.7 to 21.9%) and 2 years (50% vs 42.8%, mean difference: 6.8%, 95% CI: -10 to 23.6%) were not significantly different.
TIPS is a more effective treatment for refractory ascites than LVP. However, TIPS increase encephalopathy and does not improve survival.

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Available from: Pierre Deltenre
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    • "TIPS-induced decrease in portal pressure leads to a good control of ascites in a majority of cases and more often than repeated large volume paracentesis. However, hepatic encephalopathy is observed more frequently, and survival is not improved in a majority of trials [96, 107, 108] (Table 6). However, a recent meta-analysis showed different results after analysing individual data [109]. "
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    ABSTRACT: The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.
    Full-text · Article · Jul 2012
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    • "Deltenre et al. [29], Albillos et al. [30], D'Amico et al. [31] and Saab et al. [32], examines the role of TIPS versus paracentesis for refractory ascites by meta-analyses. They concluded that TIPS was more effective than paracentesis in clearing ascites but with equivocal effect on survival and increased incidence of encephalopathy. "
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    ABSTRACT: Mortality in cirrhosis is consequent of decompensation, only treatment being timely liver transplantation. Organ allocation is prioritized for the sickest patients based on Model for End Stage Liver Disease (MELD) score. In order to improve survival in patients with high MELD score it is imperative to preserve them in suitable condition till transplantation. Here we examine means to prolong life in high MELD score patients till a suitable liver is available. We specially emphasize protection of airways by avoidance of sedatives, avoidance of Bilevel Positive Airway Pressure, elective intubation in grade III or higher encephalopathy, maintaining a low threshold for intubation with lesser grades of encephalopathy when undergoing upper endoscopy or colonoscopy as pre transplant evaluation or transferring patient to a transplant center. Consider post-pyloric tube feeding in encephalopathy to maintain muscle mass and minimize risk of aspiration. In non intubated and well controlled encephalopathy, frequent physical mobility by active and passive exercises are recommended. When renal replacement therapy is needed, night-time Continuous Veno-Venous Hemodialysis may be useful in keeping the daytime free for mobility. Sparing and judicious use of steroids needs to be borne in mind in treatment of ARDS and acute hepatitis from alcohol or autoimmune process.
    Full-text · Article · Jul 2012
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    • "19.9 ± [5-52] 0.04 ND PPG before TIPS (mmHg) 18 ± 5 [7-36] 17 ± 5 [10-33] NS 20 ± 5 [12-32] PPG after TIPS (mmHg) 6 ± 3 [0-15] 6 ± 6 [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] NS 10 ± 3 [4-18] ⁄p <0.05 between the external cohort ant the first internal cohort. "
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    ABSTRACT: Refractory ascites in patients with cirrhosis is associated with poor survival. TIPS is more effective than paracentesis for the prevention of recurrence of ascites but increases the risk of encephalopathy while survival remains unchanged. A more accurate selection of the patients might improve these results. The aim of the present study was to identify parameters of prognostic value for survival in patients with refractory ascites treated with TIPS. One hundred and five consecutive French patients with cirrhosis and refractory ascites treated with TIPS were used to assess parameters associated with 1-year survival. The model was then tested in two different cohorts: a local and prospective one including 40 patients from Toulouse, France, and an external one including 48 patients from Barcelona, Spain. The actuarial rate of survival in the first 105 patients was 60% at 1 year. Using multivariate analysis, only lower bilirubin levels and higher platelet counts were independently associated with survival. The actuarial 1-year survival rate in patients with both a platelet count above 75×10(9)/L and a bilirubin level lower than 50 μmol/L [3mg/dl] was 73.1% as compared to 31.2%, in patients with a platelet count below 75×10(9)/L or a bilirubin level higher than 50 μmol/L. These results were confirmed in the two different validation cohorts. The combination of a bilirubin level below 50 μmol/L and a platelet count above 75×10(9)/L is predictive of survival in patients with refractory ascites treated with TIPS. This simple score could be used at bedside to help choose the best therapeutic options.
    Full-text · Article · Feb 2011 · Journal of Hepatology
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