Hepatic encephalopathy is not a contraindication to pre-emptive TIPS in high-risk patients with cirrhosis with variceal bleeding
Por:
Rudler, M, Hernandez-Gea, V, Procopet, BD, Giraldez, A, Amitrano, L, Villanueva, C, Ibanez, L, Silva, G, Genesca, J, Bureau, C, Trebicka, J, Banares, R, Krag, A, Llop, E, Laleman, W, Palazon, JM, Castellote, J, Rodrigues, S, Gluud, LL, Ferreira, CN, Canete, N, Rodriguez, M, Ferlitsch, A, Mundi, JL, Gronbaek, H, Hernandez-Guerra, M, Sassatelli, R, Dell'era, A, Senzolo, M, Abraldes, JG, Romero-Gomez, M, Zipprich, A, Casas, M, Masnou, H, Larrue, H, Primignani, M, Nevens, F, Calleja, JL, Schwarzer, R, Jansen, C, Robic, MA, Conejo, I, Gonzalez, JM, Catalina, MV, Albillos, A, Alvarado, E, Guardascione, MA, Mallet, M, Tripon, S, Casanovas, G, Bosch, J, Garcia-Pagan, JC, Thabut, D
Publicada:
7 mar 2023
Ahead of Print:
1 sep 2022
Resumen:
Background A pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS) reduces mortality in high-risk patients with cirrhosis (Child-Pugh C/B+active bleeding) with acute variceal bleeding (AVB). Real-life studies point out that <15% of patients eligible for pTIPS ultimately undergo transjugular intrahepatic portosystemic shunt (TIPS) due to concerns about hepatic encephalopathy (HE). The outcome of patients undergoing pTIPS with HE is unknown. We aimed to (1) assess the prevalence of HE in patients with AVB; (2) evaluate the outcome of patients presenting HE at admission after pTIPS; and (3) determine if HE at admission is a risk factor for death and post-TIPS HE.
Patients and methods This is an observational study including 2138 patients from 34 centres between October 2011 and May 2015. Placement of pTIPS was based on individual centre policy. Patients were followed up to 1 year, death or liver transplantation.
Results 671 of 2138 patients were considered at high risk, 66 received pTIPS and 605 endoscopic+drug treatment. At admission, HE was significantly more frequent in high-risk than in low-risk patients (39.2% vs 10.6%, p<0.001). In high-risk patients with HE at admission, pTIPS was associated with a lower 1-year mortality than endoscopic+drug (HR 0.374, 95% CI 0.166 to 0.845, p=0.0181). The incidence of HE was not different between patients treated with pTIPS and endoscopic+drug (38.2% vs 38.7%, p=0.9721), even in patients with HE at admission (56.4% vs 58.7%, p=0.4594). Age >56, shock, Model for End-Stage Liver Disease score >15, endoscopic+drug treatment and HE at admission were independent factors of death in high-risk patients.
Conclusion pTIPS is associated with better survival than endoscopic treatment in high-risk patients with cirrhosis with variceal bleeding displaying HE at admission.
Filiaciones:
Rudler, M:
Sorbonne Univ, Hop Pitie Salpetriere, Groupement Hosp APHP, Hepatol & gastroenterol,Unite Soins Intensifs H, Paris, France
Sorbonne Univ, INSERM, Ctr Rech Saint Antoine CRSA, Inst Cardiometabolism & Nutr ICAN, Paris, France
Sorbonne Univ, APHP, Brain Liver Pitie Salpetriere Study Grp BLIPS, Paris, France
Hernandez-Gea, V:
Hosp Clin Barcelona, IDIBAPS & CIBERehd, Liver Unit, Hepat Hemodynam Lab, Barcelona, Spain
Procopet, BD:
Octavian Fodor, Gastroenterol Reg Inst Gastroenterol & Hepatol, Cluj Napoca, Romania
Univ Med & Pharm Iuliu Hatieganu, Gastroenterol, Cluj Napoca, Romania
Giraldez, A:
Hosp Univ Virgen Rocio, Hepatol, Seville, Spain
Amitrano, L:
A Cardarelli Hosp, Gastroenterol, Naples, Italy
Villanueva, C:
Barcelona Autonomous Univ, Hosp Santa Creu Sant Pau, Dept Gastroenterol, Barcelona, Spain
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Ibanez, L:
Univ Complutense Madrid, Inst Invest Sanitaria Gregorio Maranon IiSGM, Hosp Univ Gregorio Maranon, Gastroenterol & Hepatol, Madrid, Spain
Inst Salud Carlos III, Ctr Invest Biomed Red Enfermedades Hepat & Digest, Madrid, Spain
Silva, G:
Hosp Clin Barcelona, IDIBAPS & CIBERehd, Liver Unit, Hepat Hemodynam Lab, Barcelona, Spain
Genesca, J:
Hosp Univ Vall Hebron, Internal Med Liver Unit, Barcelona, Spain
Bureau, C:
Univ Hosp, Hepato Gastroenterol, Toulouse, France
Trebicka, J:
Goethe Univ Frankfurt Main, Dept Internal Med 1, Translat Hepatol, Frankfurt, Germany
Banares, R:
Hosp Gen Univ Gregorio Maranon, IRYCIS, Gastroenterol, Madrid, Spain
Krag, A:
Univ Southern Denmark, Odense Univ Hosp, Dept Gastroenterol, Odense, Denmark
Llop, E:
Univ Barcelona, IDIBAPS, Hosp Clin, Hepat Hemodynam Lab Liver Unit, Barcelona, Spain
CIBEREHD, Barcelona, Spain
Laleman, W:
Katholieke Univ Leuven, Univ Leuven, Div Liver & Biliopancreat Disorders, Leuven, Belgium
Palazon, JM:
Hosp Gen Univ Alicante, Alicante, Spain
Castellote, J:
Hosp Univ Bellvitge, Digest Dis, Lhospitalet De Llobregat, Spain
Rodrigues, S:
Ctr Hosp Sao Joao, Fac Med, Dept Gastroenterol, Porto, Portugal
Gluud, LL:
Univ Copenhagen, Fac Hlth & Med Sci, Hvidovre Univ Hosp, Gastrounit,Med Div, Copenhagen, Denmark
Ferreira, CN:
Hosp Santa Maria, Gastroenterol, Lisbon, Portugal
Canete, N:
Univ Autonoma Barcelona, Hosp Mar, Dept Gastroenterol, Liver Sect, Barcelona, Spain
Rodriguez, M:
Hosp Cent Asturias, Dept Gastroenterol, Oviedo, Spain
Ferlitsch, A:
Med Univ Vienna, Div Gastroenterol & Hepatol, Internal Med 3, Vienna, Austria
Mundi, JL:
Univ Hosp San Cecilio, Dept Gastroenterol, Granada, Spain
Gronbaek, H:
Aarhus Univ Hosp, Dept Hepatol & Gastroenterol, Aarhus, Denmark
Hernandez-Guerra, M:
Univ Hosp Canary Islands, Liver Unit, Santa Cruz De Tenerife, Spain
Sassatelli, R:
IRCCS Santa Maria Nuova, Endoscopy Unit, Reggio Emilia, Italy
Dell'era, A:
Univ Milan, Dipartimento Sci Biomed & Clin, Milan, Italy
UOC Gastroenterol Endoscopia, Aziende Socio Sanitarie Territoriale Fatebenefrat, Milan, Italy
Senzolo, M:
Univ Padua, Dept Surg & Gastroenterol Sci, Multivisceral Transplant Unit, Padua, Italy
Abraldes, JG:
Univ Alberta, Cirrhosis Care Clin, Edmonton, AB, Canada
Romero-Gomez, M:
Hosp Univ Valme, Unit Clin Management Digest Dis & CIBERehd, Seville, Spain
Zipprich, A:
Martin Luther Univ Halle Wittenberg, Dept Internal Med 1, Halle, Germany
Casas, M:
Corporac Sanitaria Parc Tauli, Dept Gastroenterol, Liver Unit, Sabadell, Spain
Masnou, H:
Univ Autonoma Barcelona, Hosp Univ Germans Trias & Pujol, Barcelona, Spain
Larrue, H:
CHU Purpan, Serv D'Hepatogastro Enterol, Toulouse, France
Primignani, M:
Univ Milan, Fdn IRCCS Ca Granda Osped Maggiore Policli, Div Gastroenterol & Hepatol, Milan, Italy
Nevens, F:
UZ Leuven, Hepatol, Leuven, Belgium
Calleja, JL:
Hosp Univ Puerta Hierro Majadahonda, Gastroenterol & Hepatol, IDIPHISA, Majadahonda, Spain
Ctr Invest Biomed Red Enfermedades Hepat & Digest, CIBERehd, Inst Salud Carlos III, Madrid, Spain
Schwarzer, R:
Med Univ Vienna, Div Gastroenterol & Hepatol, Internal Med 3, Vienna, Austria
Jansen, C:
Univ Bonn, Internal Med, Bonn, Germany
Robic, MA:
CHU Purpan, Serv D'Hepatogastro Enterol, Toulouse, France
Conejo, I:
CIBEREHD, Barcelona, Spain
Univ Autonoma Barcelona, Vall Hebron Inst Res VHIR, Hosp Univ Vall Hebron, Liver Unit, Barcelona, Spain
Gonzalez, JM:
Univ Alcala, IRYCIS, Hosp Univ Ramon & Cajal, Dept Gastroenterol, Madrid, Spain
Catalina, MV:
Hosp Gen Univ Gregorio Maranon, CIBERehd, Serv Med Aparato Digestivo Gregorio Maranon, Madrid, Spain
Albillos, A:
Hepatol Hosp Ramon & Cajal, Madrid, Spain
Univ Alcala Henares, Madrid, Spain
Alvarado, E:
Hosp Santa Creu Sant Pau Inst Recerca, Gastroenterol, Barcelona, Spain
Guardascione, MA:
Gastroenterol Unit, Osped Cardarelli, Naples, Italy
Mallet, M:
Sorbonne Univ, Hop Pitie Salpetriere, Groupement Hosp APHP, Hepatol & gastroenterol,Unite Soins Intensifs H, Paris, France
Tripon, S:
Sorbonne Univ, Hop Pitie Salpetriere, Groupement Hosp APHP, Hepatol & gastroenterol,Unite Soins Intensifs H, Paris, France
Casanovas, G:
Univ Autonoma Barcelona, Biostat Unit, Fac Med, Barcelona, Spain
Bosch, J:
Univ Bern, Dept Biomed Res, Hepatol, Inselspital, Bern, Switzerland
Garcia-Pagan, JC:
Hosp Clin Barcelona, IDIBAPS & CIBERehd, Liver Unit, Hepat Hemodynam Lab, Barcelona, Spain
Thabut, D:
Sorbonne Univ, Hop Pitie Salpetriere, Groupement Hosp APHP, Hepatol & gastroenterol,Unite Soins Intensifs H, Paris, France
Sorbonne Univ, INSERM, Ctr Rech Saint Antoine CRSA, Inst Cardiometabolism & Nutr ICAN, Paris, France
Sorbonne Univ, APHP, Brain Liver Pitie Salpetriere Study Grp BLIPS, Paris, France
|