Predicting survival in patients with 'non-high-risk' acute variceal bleeding receiving b-blockers plus ligation to prevent re-bleeding
Por:
Balcar, L, Mandorfer, M, Hernandez-Gea, V, Procopet, B, Meyer, EL, Giráldez, A, Amitrano, L, Villanueva, C, Thabut, D, Samaniego, LI, Silva, G Jr, Martinez, J, Genescà, J, Bureau, C, Trebicka, J, Herrera, EL, Laleman, W, Azorín, JMP, Alonso, JC, Gluud, LL, Ferreira, CN, Cañete, N, Rodríguez, M, Ferlitsch, A, Mundi, JL, Gronbæk, H, Guerra, MNH, Sassatelli, R, Dell'Era, A, Senzolo, M, Abraldes, JG, Romero-Gómez, M, Zipprich, A, Casas, M, Masnou, H, Primignani, M, Krag, A, Nevens, F, Calleja, JL, Jansen, C, Catalina, MV, Albillos, A, Rudler, M, Tapias, EA, Guardascione, MA, Tantau, M, Schwarzer, R, Reiberger, T, Laursen, SB, Lopez-Gomez, M, Cachero, A, Ferrarese, A, Ripoll, C, La Mura, V, Bosch, J, Garcia-Pagán, JC
Publicada:
1 ene 2024
Ahead of Print:
1 ene 2024
Resumen:
Background & Aims: Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for high -risk acute variceal bleeding (AVB; i.e., Child-Turcotte-Pugh [CTP] B8-9+active bleeding/C10-13). Nevertheless, some 'non -highrisk' patients have poor outcomes despite the combination of non -selective beta-blockers and endoscopic variceal ligation for secondary prophylaxis. We investigated prognostic factors for re -bleeding and mortality in 'non -high -risk' AVB to identify subgroups who may benefit from more potent treatments (i.e., TIPS) to prevent further decompensation and mortality. Methods: A total of 2,225 adults with cirrhosis and variceal bleeding were prospectively recruited at 34 centres between 20112015; for the purpose of this study, case definitions and information on prognostic indicators at index AVB and on day 5 were further refined in low -risk patients, of whom 581 (without failure to control bleeding or contraindications to TIPS) who were managed by non -selective beta-blockers/endoscopic variceal ligation, were finally included. Patients were followed for 1 year. Results: Overall, 90 patients (15%) re -bled and 70 (12%) patients died during follow-up. Using clinical routine data, no meaningful predictors of re -bleeding were identified. However, re -bleeding (included as a time -dependent co -variable) increased mortality, even after accounting for differences in patient characteristics (adjusted cause -specific hazard ratio: 2.57; 95% CI 1.434.62; p = 0.002). A nomogram including CTP, creatinine, and sodium measured at baseline accurately (concordance: 0.752) stratified the risk of death. Conclusion: The majority of 'non -high -risk' patients with AVB have an excellent prognosis, if treated according to current recommendations. However, about one -fifth of patients, i.e. those with CTP >-8 and/or high creatinine levels or hyponatremia, have a considerable risk of death within 1 year of the index bleed. Future clinical trials should investigate whether elective TIPS placement reduces mortality in these patients. (c) 2023 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
Filiaciones:
Balcar, L:
Med Univ Vienna, Dept Internal Med 3, Div Gastroenterol & Hepatol, Vienna, Austria
Med Univ Vienna, Vienna Hepat Hemodynam Lab, Vienna, Austria
Mandorfer, M:
Med Univ Vienna, Dept Internal Med 3, Div Gastroenterol & Hepatol, Vienna, Austria
Med Univ Vienna, Vienna Hepat Hemodynam Lab, Vienna, Austria
Univ Barcelona, Hosp Clin, Barcelona Hepat Hemodynam Lab, Liver Unit, Barcelona, Spain
Hernandez-Gea, V:
Univ Barcelona, Hosp Clin, Barcelona Hepat Hemodynam Lab, Liver Unit, Barcelona, Spain
Inst Invest Biomed August Pi I Sunyer FCRB IDIBAPS, Fundacio Clin Recerca Biomed, Madrid, Spain
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Procopet, B:
Reg Inst Gastroenterol & Hepatol Octavian Fodor, Hepatol Dept, Cluj Napoca, Cluj, Romania
Reg Inst Gastroenterol & Hepatol Octavian Fodor, Med Clin 3, Cluj Napoca, Romania
Iuliu Hatieganu Univ Med & Pharm, Cluj Napoca, Romania
Meyer, EL:
Med Univ Vienna, Ctr Med Data Sci, Sect Med Stat, Vienna, Austria
Berry Consultants, Vienna, Austria
Giráldez, A:
Hosp Univ Virgen Del Rocio, Unit Digest Dis Clin Management, Seville, Spain
Amitrano, L:
Osped Cardarelli, Gastroenterol Unit, Naples, Italy
Villanueva, C:
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Hosp Santa Creu & Sant Pau, Serv Patol Digest, Barcelona, Spain
Thabut, D:
Grp Hosp Pitie Salpetriere Charles Foix, Unite Rech Clin Pitie Salpetriere Charles Foix, Paris, France
Samaniego, LI:
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Hosp Gen Univ Gregorio Maranon, Serv Med Aparato Digest Gregorio Maranon, Lisgm, Spain
Silva, G Jr:
Univ Barcelona, Hosp Clin, Barcelona Hepat Hemodynam Lab, Liver Unit, Barcelona, Spain
Martinez, J:
Univ Alcala, Hosp Univ Ramon & Cajal, Dept Urol, Inst Ramon & Cajal Invest Sanitaria IRYCIS, Madrid, Spain
Genescà, J:
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Univ Autonoma Barcelona, Hosp Univ Vall dHebron, Vall dHebron Inst Res VHIR, Vall dHebron Barcelona Hosp Campus, Barcelona, Spain
Bureau, C:
Univ Toulouse, Purpan Hosp, Dept Hepatogastroenterol, Toulouse, France
Trebicka, J:
Univ Munster, Dept Internal Med B, Munster, Germany
Odense Univ Hosp, Dept Gastroenterol & Hepatol, Odense, Denmark
Univ Hosp Bonn, Dept Internal Med 1, Bonn, Germany
Herrera, EL:
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Hosp Univ Puerta De Hierro Majadahonda, Liver Unit, Madrid, Spain
Laleman, W:
Katholieke Univ Leuven, Dept Liver & Biliopancreat Disorders, Leuven, Belgium
Azorín, JMP:
Hosp Gen Univ Alicante, Hepatol, Alicante, Spain
Alonso, JC:
Hosp Univ Bellvitge, Hepatol Unit, Dept Gastroenterol, Barcelona 08907, Spain
Univ Copenhagen, Fac Hlth Sci, Dept Clin Med, Copenhagen, Denmark
Gluud, LL:
Univ Copenhagen, Copenhagen Univ Hosp Hvidovre, Med Div, Gastro Unit, Copenhagen, Denmark
Ferreira, CN:
Ctr Hosp Univ Lisboa Norte, Hosp Santa Maria, Serv Gastrenterol & Hepatol, Lisbon, Portugal
Imim Hosp del Mar Med Res Inst, Gastroenterol Dept, Barcelona, Spain
Cañete, N:
Gastroenterol Dept, Liver Sect, Barcelona, Spain
Rodríguez, M:
Hosp Univ Cent Asturias, Dept Gastroenterol & Hepatol, Asturias, Spain
Ferlitsch, A:
Med Univ Vienna, Vienna Hepat Hemodynam Lab, Vienna, Austria
Univ Barcelona, Hosp Clin, Barcelona Hepat Hemodynam Lab, Liver Unit, Barcelona, Spain
St John God Hosp, Dept Internal Med Gastroenterol & Nephrol 1, Vienna, Austria
Mundi, JL:
Hosp Univ Puerta De Hierro Majadahonda, Liver Unit, Madrid, Spain
Univ Hosp San Cecilio, Dept Gastroenterol, Granada, Spain
Gronbæk, H:
Aarhus Univ Hosp, Dept Hepatol & Gastroenterol, Aarhus N, Denmark
Guerra, MNH:
Univ Hosp Canary Isl, Dept Gastroenterol, Tenerife, Spain
Sassatelli, R:
Arcispedale Santa Maria Nuova IRRCS, Unit Gastroenterol & Digest Endoscopy, Reggio Emilia, Italy
Dell'Era, A:
Univ Milan, Dept Clin & Biomed Sci, Gastroenterol Unit, Asst Fatebenefratelli Sacco, Milan, Italy
Senzolo, M:
Univ Hosp Padua, Dept Surg, Multivisceral Transplant Unit, Gastroenterol, Padua, Italy
Abraldes, JG:
Univ Alberta, Div Gastroenterol, Liver Unit, Cirrhosis Care Clin,CEGIIR, Edmonton, AB T6G 2X8, Canada
Romero-Gómez, M:
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Hosp Univ Valme, Unidad Hepatol, Seville, Spain
Zipprich, A:
Martin Luther Univ Halle Wittenberg, Dept Internal Med 1, Saale, Germany
Casas, M:
Univ Autonoma Barcelona, Hepatol Unit, Digest Dis Dept, Hosp Sabadell, Sabadell, Spain
Masnou, H:
Univ Autonoma Barcelona, Hosp Univ Germans Trias I Pujol, Barcelona, Spain
Primignani, M:
Univ Milan, Fdn IRCCS Ca Granda Osped Maggiore Policlin, CRC aM & Migliavacca Ctr Liver Dis, Div Gastroenterol & Hepatol, Milan, Italy
Krag, A:
Odense Univ Hosp, Dept Gastroenterol & Hepatol, Odense, Denmark
Nevens, F:
Katholieke Univ Leuven, Dept Liver & Biliopancreat Disorders, Leuven, Belgium
Calleja, JL:
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Jansen, C:
Univ Hosp Bonn, Dept Internal Med 1, Bonn, Germany
Catalina, MV:
Hosp Gen Univ Gregorio Maranon, Serv Med Aparato Digest Gregorio Maranon, Lisgm, Spain
Albillos, A:
Univ Alcala, Hosp Univ Ramon & Cajal, Dept Urol, Inst Ramon & Cajal Invest Sanitaria IRYCIS, Madrid, Spain
Rudler, M:
Grp Hosp Pitie Salpetriere Charles Foix, Unite Rech Clin Pitie Salpetriere Charles Foix, Paris, France
Tapias, EA:
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Hosp Santa Creu & Sant Pau, Serv Patol Digest, Barcelona, Spain
Guardascione, MA:
Osped Cardarelli, Gastroenterol Unit, Naples, Italy
Tantau, M:
Reg Inst Gastroenterol & Hepatol Octavian Fodor, Hepatol Dept, Cluj Napoca, Cluj, Romania
Reg Inst Gastroenterol & Hepatol Octavian Fodor, Med Clin 3, Cluj Napoca, Romania
Iuliu Hatieganu Univ Med & Pharm, Cluj Napoca, Romania
Schwarzer, R:
Med Univ Vienna, Dept Internal Med 3, Div Gastroenterol & Hepatol, Vienna, Austria
Med Univ Vienna, Vienna Hepat Hemodynam Lab, Vienna, Austria
Reiberger, T:
Med Univ Vienna, Dept Internal Med 3, Div Gastroenterol & Hepatol, Vienna, Austria
Med Univ Vienna, Vienna Hepat Hemodynam Lab, Vienna, Austria
Laursen, SB:
Odense Univ Hosp, Dept Gastroenterol & Hepatol, Odense, Denmark
Lopez-Gomez, M:
Hosp Univ Puerta De Hierro Majadahonda, Liver Unit, Madrid, Spain
Cachero, A:
Hosp Univ Bellvitge, Hepatol Unit, Dept Gastroenterol, Barcelona 08907, Spain
Univ Copenhagen, Fac Hlth Sci, Dept Clin Med, Copenhagen, Denmark
Ferrarese, A:
Univ Hosp Padua, Dept Surg, Multivisceral Transplant Unit, Gastroenterol, Padua, Italy
Ripoll, C:
Friedrich Schiller Univ, Internal Med 4, Univ Klinikum Jena, Jena, Germany
La Mura, V:
Univ Autonoma Barcelona, Hosp Univ Germans Trias I Pujol, Barcelona, Spain
Fdn IRCCS Ca Granda Osped Maggiore Policlin, UOC Med Gen Emostasi & Trombosi, Milan, Italy
Bosch, J:
Univ Barcelona, Hosp Clin, Barcelona Hepat Hemodynam Lab, Liver Unit, Barcelona, Spain
Inst Invest Biomed August Pi I Sunyer FCRB IDIBAPS, Fundacio Clin Recerca Biomed, Madrid, Spain
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Univ Bern, Bern Univ Hosp, Dept Visceral Surg & Med, Inselspital, Bern, Switzerland
Garcia-Pagán, JC:
Hosp Clin Barcelona, Liver Unit, Villarroel 170, Barcelona 08036, Spain
Univ Barcelona, Hosp Clin, Barcelona Hepat Hemodynam Lab, Liver Unit, Barcelona, Spain
Inst Invest Biomed August Pi I Sunyer FCRB IDIBAPS, Fundacio Clin Recerca Biomed, Madrid, Spain
Green Published
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