Skip to main content

Advertisement

SpringerLink
Log in

Inpatient Mortality Benefit with Transjugular Intrahepatic Portosystemic Shunt for Hospitalized Hepatorenal Syndrome Patients

  • Original Article
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Background

It has been reported that transjugular intrahepatic portosystemic shunting (TIPS) might be utilized as a salvage option for hepatorenal syndrome (HRS), while randomized controlled trials are pending and real-world contemporary data on inpatient mortality is lacking.

Methods

We conducted an observational retrospective cohort study from the National Inpatient Sample from 2005 to 2014. We included all adult patients admitted with HRS and cirrhosis, using ICD 9-CM codes. We excluded cases with variceal bleeding, Budd–Chiari, end-stage renal disease, liver transplant and transfers to acute-care facilities. TIPS’ association with inpatient mortality was assessed using multivariable mixed-effects logistic regression, as well as exact-matching, thus mitigating for TIPS selection bias. The exact-matched analysis was repeated among TIPS-only versus dialysis-only patients.

Results

A total of 79,354 patients were included. Nine hundred eighteen (1.2%) underwent TIPS. Between TIPS and non-TIPS groups, mean age (58 years) and gender (65% males) were similar. Overall mortality was 18% in TIPS and 48% in dialysis-only cases (n = 10,379; 13.1%). Ninety six (10.5%) TIPS patients underwent dialysis. In-hospital mortality in TIPS patients was twice less likely than in non-TIPS patients (adjusted odds ratio [aOR] = 0.43, 95% CI 0.30–0.62; p < 0.001), with similar results in matched analysis [exact-matched (em) OR = 0.39, 95% CI 0.17–0.89; p < 0.024; groups = 96; unweighted n = 463]. Head-to-head comparison showed that TIPS-only patients were 3.3 times less likely to succumb inpatient versus dialysis-only patients (contrast aOR = 0.31, 95% CI 0.20–0.46; p < 0.001), with similar findings post-matching (emOR = 0.22, 95% CI 0.15–0.33; p < 0.001; groups = 54, unweighted n = 1457).

Conclusions

Contemporary, real-world data reveal that TIPS on its own, and when compared to dialysis, is associated with decreased inpatient mortality when utilized in non-bleeders-HRS patients. Further randomized studies are needed to establish the long-term benefit of TIPS in these patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Gines P, Sola E, Angeli P, Wong F, Nadim MK, Kamath PS. Hepatorenal syndrome. Nat Rev Dis Primers. 2018;4:23. https://doi.org/10.1038/s41572-018-0022-7.

    Article  PubMed  Google Scholar 

  2. de Mattos AZ, de Mattos AA, Mendez-Sanchez N. Hepatorenal syndrome: current concepts related to diagnosis and management. Ann Hepatol. 2016;15:474–481.

    PubMed  Google Scholar 

  3. Cavallin M, Fasolato S, Marenco S, Piano S, Tonon M, Angeli P. The treatment of hepatorenal syndrome. Dig Dis. 2015;33:548–554. https://doi.org/10.1159/000375346.

    Article  PubMed  Google Scholar 

  4. Piano S, Tonon M, Angeli P. Management of ascites and hepatorenal syndrome. Hepatol Int. 2018;12:122–134. https://doi.org/10.1007/s12072-017-9815-0.

    Article  PubMed  Google Scholar 

  5. Fabrizi F, Messa P. Challenges in renal failure treatment before liver transplant. Clin Liver Dis. 2017;21:303–319. https://doi.org/10.1016/j.cld.2016.12.005.

    Article  PubMed  Google Scholar 

  6. Lake JR, Ring E, LaBerge J, Gordon R, Roberts J, Ascher N. Transjugular intrahepatic portacaval stent shunts in patients with renal insufficiency. Transplant Proc. 1993;25:1766–1767.

    CAS  PubMed  Google Scholar 

  7. Ochs A, Rossle M, Haag K, et al. The transjugular intrahepatic portosystemic stent-shunt procedure for refractory ascites. N Engl J Med. 1995;332:1192–1197. https://doi.org/10.1056/NEJM199505043321803.

    Article  CAS  PubMed  Google Scholar 

  8. Anderson CL, Saad WE, Kalagher SD, et al. Effect of transjugular intrahepatic portosystemic shunt placement on renal function: a 7-year, single-center experience. J Vasc Interv Radiol. 2010;21:1370–1376. https://doi.org/10.1016/j.jvir.2010.05.009.

    Article  PubMed  Google Scholar 

  9. Guevara M, Gines P, Bandi JC, et al. Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems. Hepatology. 1998;28:416–422. https://doi.org/10.1002/hep.510280219.

    Article  CAS  PubMed  Google Scholar 

  10. Brensing KA, Textor J, Perz J, et al. Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study. Gut. 2000;47:288–295.

    Article  CAS  Google Scholar 

  11. Wong F, Pantea L, Sniderman K. Midodrine, octreotide, albumin, and TIPS in selected patients with cirrhosis and type 1 hepatorenal syndrome. Hepatology. 2004;40:55–64. https://doi.org/10.1002/hep.20262.

    Article  CAS  PubMed  Google Scholar 

  12. Testino G, Leone S, Ferro C, Borro P. Severe acute alcoholic hepatitis and hepatorenal syndrome: role of transjugular intrahepatic portosystemic stent shunt. J Med Life. 2012;5:203–205.

    CAS  PubMed  PubMed Central  Google Scholar 

  13. Arroyo V, Fernandez J. Management of hepatorenal syndrome in patients with cirrhosis. Nat Rev Nephrol. 2011;7:517–526. https://doi.org/10.1038/nrneph.2011.96.

    Article  CAS  PubMed  Google Scholar 

  14. Egerod Israelsen M, Gluud LL, Krag A. Acute kidney injury and hepatorenal syndrome in cirrhosis. J Gastroenterol Hepatol. 2015;30:236–243. https://doi.org/10.1111/jgh.12709.

    Article  CAS  PubMed  Google Scholar 

  15. HCUP Databases. Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD. 2016. https://www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed June 26, 2016.

  16. HCUP NIS Database Documentation. Agency for Healthcare Research and Quality, Rockville, MD. 2016. http://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp. Accessed June 26, 2016.

  17. HCUP Methods Series 2012 HCUP National Inpatient Sample (NIS) Comparison Report. Agency for Healthcare Research and Quality. Rockville, MD. 2016. Available at: https://www.hcup-us.ahrq.gov/db/nation/nis/reports/2012niscomparisonrpt.jsp.

  18. Kramer JR, Davila JA, Miller ED, Richardson P, Giordano TP, El-Serag HB. The validity of viral hepatitis and chronic liver disease diagnoses in Veterans Affairs administrative databases. Aliment Pharmacol Ther. 2008;27:274–282. https://doi.org/10.1111/j.1365-2036.2007.03572.x.

    Article  CAS  PubMed  Google Scholar 

  19. Nehra MS, Ma Y, Clark C, Amarasingham R, Rockey DC, Singal AG. Use of administrative claims data for identifying patients with cirrhosis. J Clin Gastroenterol. 2013;47:e50–e54. https://doi.org/10.1097/MCG.0b013e3182688d2f.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Brown JR, Rezaee ME, Nichols EL, Marshall EJ, Siew ED, Matheny ME. Incidence and in-hospital mortality of Acute Kidney Injury (AKI) and dialysis-requiring AKI (AKI-D) after cardiac catheterization in the national inpatient sample. J Am Heart Assoc. 2016;5:e002739. https://doi.org/10.1161/JAHA.115.002739.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Dombrovskiy VY, Martin AA, Sunderram J, Paz HL. Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003. Crit Care Med. 2007;35:1244–1250. https://doi.org/10.1097/01.CCM.0000261890.41311.E9.

    Article  PubMed  Google Scholar 

  22. Hsu RK, McCulloch CE, Dudley RA, Lo LJ, Hsu CY. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol. 2013;24:37–42. https://doi.org/10.1681/ASN.2012080800.

    Article  PubMed  Google Scholar 

  23. Lenihan CR, Montez-Rath ME, Mora Mangano CT, Chertow GM, Winkelmayer WC. Trends in acute kidney injury, associated use of dialysis, and mortality after cardiac surgery, 1999–2008. Ann Thorac Surg. 2013;95:20–28. https://doi.org/10.1016/j.athoracsur.2012.05.131.

    Article  PubMed  Google Scholar 

  24. Gordon M. Calculates Comorbidity Indices Based on ICD-9/10 (comorbidities.icd10). 0.6.1 ed. https://github.com/gforge/comorbidities.icd10. 2016.

  25. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43:1130–1139.

    Article  Google Scholar 

  26. Paul P, Pennell ML, Lemeshow S. Standardizing the power of the Hosmer–Lemeshow goodness of fit test in large data sets. Stat Med. 2013;32:67–80. https://doi.org/10.1002/sim.5525.

    Article  PubMed  Google Scholar 

  27. Blackwell MIS, King G, Porro G. cem: Coarsened Exact Matching in Stata. 2010. http://gking.harvard.edu/files/gking/files/cem-stata.pdf. Accessed December 12, 2016.

  28. Sarwar A, Zhou L, Novack V, et al. Hospital volume and mortality after transjugular intrahepatic portosystemic shunt creation in the United States. Hepatology. 2018;67:690–699. https://doi.org/10.1002/hep.29354.

    Article  PubMed  Google Scholar 

  29. Barton RE, Rösch J, Saxon RR, Lakin PC, Petersen BD, Keller FS, eds. TIPS: Short-and Long-Term Results: A Survey of 1750 Patients. Copyright© 1995 by Thieme Medical Publishers, Inc.; 1995.

  30. Pillai AK, Andring B, Faulconer N, et al. Utility of intravascular US-guided portal vein access during transjugular intrahepatic portosystemic shunt creation: retrospective comparison with conventional technique in 109 patients. J Vasc Interv Radiol. 2016;27:1154–1159. https://doi.org/10.1016/j.jvir.2016.05.010.

    Article  PubMed  Google Scholar 

  31. HCUP NIS Trend Weights. Healthcare Cost and Utilization Project (HCUP), Rockville, MD. 2015. https://www.hcup-us.ahrq.gov/db/nation/nis/trendwghts.jsp. Accessed June 26, 2016.

  32. Houchens REA. Final Report on Calculating Nationwide Inpatient Sample (NIS) Variances for Data Years 2011 and Earlier. In: HCUP Method Series Report # 2003-02. U.S. Agency for Healthcare Research and Quality. 2015. https://www.hcup-us.ahrq.gov/reports/methods/2003_02.jsp. Accessed June 26, 2016.

  33. Houchens RRD, Elixhauser A. Final Report on Calculating National Inpatient Sample (NIS) Variances for Data Years 2012 and Later. In: HCUP Methods Series Report # 2015-09 ONLINE. U.S. Agency for Healthcare Research and Quality. 2015. https://www.hcup-us.ahrq.gov/reports/methods/2015-09.pdf. Accessed February 26, 2017.

  34. Colombato L. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension. J Clin Gastroenterol. 2007;41:S344–S351. https://doi.org/10.1097/MCG.0b013e318157e500.

    Article  PubMed  Google Scholar 

  35. Gines P, Uriz J, Calahorra B, et al. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology. 2002;123:1839–1847. https://doi.org/10.1053/gast.2002.37073.

    Article  PubMed  Google Scholar 

  36. Testino G, Ferro C, Sumberaz A, et al. Type-2 hepatorenal syndrome and refractory ascites: role of transjugular intrahepatic portosystemic stent-shunt in eighteen patients with advanced cirrhosis awaiting orthotopic liver transplantation. Hepatogastroenterology. 2003;50:1753–1755.

    PubMed  Google Scholar 

  37. Late-Breaking Abstracts—Presented at the 70th Annual Meeting of the American Association for the Study of Liver Diseases: The Liver Meeting™ 2019. Hepatology. 2019;70:1477A–1501A. https://doi.org/10.1002/hep.31033.

  38. Runyon BA, Aasld. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013;57:1651–1653. https://doi.org/10.1002/hep.26359.

    Article  PubMed  Google Scholar 

  39. Trivedi PS, Brown MA, Rochon PJ, Ryu RK, Johnson DT. Gender disparity in inpatient mortality after transjugular intrahepatic portosystemic shunt creation in patients admitted with hepatorenal syndrome: a nationwide study. J Am Coll Radiol. 2019;. https://doi.org/10.1016/j.jacr.2019.08.020.

    Article  PubMed  Google Scholar 

  40. Salerno F, Merli M, Cazzaniga M, et al. MELD score is better than Child-Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt. J Hepatol. 2002;36:494–500.

    Article  Google Scholar 

  41. Ferral H, Gamboa P, Postoak DW, et al. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score. Radiology. 2004;231:231–236. https://doi.org/10.1148/radiol.2311030967.

    Article  PubMed  Google Scholar 

Download references

Funding

None.

Author information

Authors and Affiliations

  1. Division of Gastroenterology & Hepatology, Saint Peter’s University Hospital/Rutgers – RWJ Medical School, New Brunswick, NJ, USA

    Paris Charilaou

  2. Division of Gastroenterology, East Tennessee State University, Johnson City, TN, USA

    Kalpit Devani & Chakradhar Reddy

  3. Department of Internal Medicine, Greenville Memorial Hospital, Greenville, SC, USA

    Romela Petrosyan

  4. Division of Gastroenterology and Hepatology, Newark University Hospital/Rutgers – New Jersey Medical School, Newark, NJ, USA

    Nikolaos Pyrsopoulos

Authors
  1. Paris Charilaou
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kalpit Devani
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Romela Petrosyan
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Chakradhar Reddy
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nikolaos Pyrsopoulos
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

PC, KD, RP, CR, NP were involved in the conception and design; PC, KD, RP, CR, NP helped in the analysis and interpretation; PC, KD, RP, CR, NP were involved in the drafting of the manuscript for important intellectual content; PC, KD, CR contributed to manuscript supervision and review.

Corresponding author

Correspondence to Paris Charilaou.

Ethics declarations

Conflict of interest

Dr. Charilaou, Dr Devani, Dr Petrosyan, Dr Reddy have no conflict of interest to declare. Dr. Pyrsopoulos has the following affiliations with the following commercial entities: Grant/Research Support—Allergan, Bayer, BeiGene, Bristol-Myers Squibb, Confirm, Conatus, Intercept, Mallinckrodt, Novartis, Resusix, Saro, Valeant, Gilead, Exelixis, Hologic, Shire, Genfit and Prometheus. Consultant—Bayer, Exelixis, Gilead, Novartis. There is no conflict of interest with any speakers’ bureau, patent holder, stock shareholder and/or other financial support.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 21 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Charilaou, P., Devani, K., Petrosyan, R. et al. Inpatient Mortality Benefit with Transjugular Intrahepatic Portosystemic Shunt for Hospitalized Hepatorenal Syndrome Patients. Dig Dis Sci 65, 3378–3388 (2020). https://doi.org/10.1007/s10620-020-06136-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-020-06136-2

Keywords

Search

Navigation