Digital ILC 2020: International collaborative study underpins a recommended but underused treatment for acute variceal bleeding in patients with high-risk liver cirrhosis, even in the presence of hepatic encephalopathy (HE).
EUROPEAN ASSOCIATION FOR THE STUDY OF THE LIVER (EASL)
28 August 2020: An international collaboration has provided new evidence in support of the early use of transjugular intrahepatic portosystemic shunts (TIPS) to treat patients with high-risk liver cirrhosis who are experiencing acute variceal bleeding (AVB). The results, presented at The Digital International Liver Congress™ 2020, pave the way towards closing an important clinical practice gap in liver disease due to concern about potential complications of TIPS, particularly in patients with existing hepatic encephalopathy.
TIPS is an important therapeutic procedure for patients with portal hypertension and one of its most life-threatening complications, variceal bleeding.1 While endoscopy has a role in the diagnosis and management of varices,1 the Baveno VI recommendations on the management of portal hypertension state that early TIPS must be considered in high-risk cirrhotic patients with AVB (patients with Child-Pugh B cirrhosis and active bleeding or with Child-Pugh C cirrhosis 10–13).2 Despite this, less than 10% of patients who are eligible for early TIPS undergo the procedure, according to real-world data.3 A key reason is thought to be the fear of developing hepatic encephalopathy (HE), where brain function is impaired by the inability of the liver to fully remove toxic molecules from the bloodstream. HE is recognized as a major potential complication following TIPS,4 and there is particular concern if patients eligible for the procedure already present with HE at admission.
This multicentre, observational study of over 2,000 patients from 34 centres (April 2013−April 2015) aimed to assess the prevalence of HE on admission in high-risk patients with AVB, the outcomes following early TIPS in these patients, and whether HE at admission is an independent factor predicting death or further HE development in high-risk cirrhotic patients. The study found that HE at admission was significantly more frequent in high- versus low-risk cirrhotic patients with AVB (38.1% vs 10.6%, p=0.008). Of the 671 patients considered to be high risk, 66 received early TIPS and 605 received endoscopic and drug treatment (TIPS placement was based on individual centre policy). Early-TIPS placement was associated with significantly better survival in patients with HE at admission than in those managed with endoscopic and drug treatment (HR 0.453 [95% CI 0.218–0.940], p=0.03), and less frequent recurrent HE events (16.7% vs 27.3%, p=0.04). In patients without HE at admission, early TIPS had no effect on the occurrence of HE during follow-up (16.7% vs 17.6% for endoscopic plus drug treatment, p=0.86). In a multivariate analysis, age, the presence of shock, a Model for End-Stage Liver Disease (MELD) score >15, endoscopic plus drug treatment, and HE at admission were independent factors predicting death in high-risk patients with AVB.
“Although HE at admission is independently associated with poor survival in high-risk patients with AVB, early TIPS significantly improved survival, recovery of HE and decreased the occurrence of new HE episodes after AVB”, explained Dr Marika Rudler of the Groupe Hospitalier Pitié-Salpêtrière-Charles in Paris, France. “There is no rationale for the fear of early TIPS in patients with AVB and HE at admission”.
“This landmark study will change daily practice in many centres that have so far been reluctant to consider an early TIPS in patients with acute variceal bleeding and hepatic encephalopathy at admission”, said Professor Pierre-Emmanuel Rautou of the University of Paris-Diderot, France, and Chair of the EASL Scientific Committee.
About The International Liver Congress™
This annual congress is EASL’s flagship event, attracting scientific and medical experts from around the world to learn about the latest in liver research and exchange clinical experience. Attending specialists present, share, debate and conclude on the latest science and research in hepatology, working to enhance the treatment and management of liver disease in clinical practice. This year, the congress is being held entirely digitally due to the global health situation. The Digital International Liver Congress™ 2020 will take place from 27–29 August 2020. For more information on attendance and registration, please visit https://ilc-congress.eu/.
Since its foundation in 1966, this not-for-profit organization has grown to over 4,500 members from all over the world, including many of the leading hepatologists in Europe and beyond. EASL is the leading liver association in Europe, having evolved into a major European association with international influence, and with an impressive track record in promoting research in liver disease, supporting wider education, and promoting changes in European liver policy.
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Session title: Portal hypertension
Date and time of session: Friday 28 August 2020, 11.00–11.15
Presenter: Marika Rudler
Abstract: Early-TIPS should be performed in high-risk cirrhotic patients despite the presence of hepatic encephalopathy at admission
Marika Rudler has no relevant disclosures.
- Al-Busafi SA, et al. Endoscopic management of portal hypertension. Int J Hepatol. 2012;2012:747095.
- de Franchis R, et al. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63(3):743–52.
- Thabut D, et al. Cirrhotic patients with portal hypertension-related bleeding and an indication for early-TIPS: A large multicentre audit with real-life results. J Hepatol. 2017;68(1):73–81.
- Tripathi D, et al. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut. 2020. doi: 10.1136/gutjnl-2019-320221 [Epub ahead of print].