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Gut. Aug 2000; 47(2): 288–295.
PMCID: PMC1727992

Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study

Abstract

BACKGROUND—Recent small studies on hepatorenal syndrome (HRS) indicate some clinical benefit after transjugular intrahepatic portosystemic stent-shunt (TIPS) but sufficient long term data are lacking.
AIM—We studied prospectively feasibility, safety, and long term survival after TIPS in 41 non-transplantable cirrhotics with HRS (phase II study).
PATIENTS AND METHODS—HRS was diagnosed using current criteria (severe (type I) HRS, n=21; moderate (type II) HRS, n=20). Thirty one patients (14 type I, 17 type II) received TIPS (8-10 mm) while advanced liver failure excluded shunting in 10. During follow up (median 24 months) we analysed renal function and survival (Kaplan-Meier).
RESULTS—TIPS markedly reduced the portal pressure gradient (21 (5) to 13 (4) mm Hg (mean (SD)); p<0.001) with one procedure related death (3.2%). Renal function deteriorated without TIPS but improved (p<0.001) within two weeks after TIPS (creatinine clearance 18 (15) to 48 (42) ml/min; sodium excretion 9 (16) to 77 (78) mmol/24 hours) and stabilised thereafter. Following TIPS, three, six, 12, and 18 month survival rates were 81%, 71%, 48%, and 35%, respectively. As only 10% of non-shunted patients survived three months, total survival rates were 63%, 56%, 39%, and 29%, respectively. Multivariate Cox regression analysis revealed bilirubin (p<0.001) and HRS type (p<0.05) as independent survival predictors after TIPS.
CONCLUSIONS—TIPS provides long term renal function and probably survival benefits in the majority of non-transplantable cirrhotics with HRS. These data warrant controlled trials evaluating TIPS in the management of HRS.


Keywords: hepatorenal syndrome; transjugular intrahepatic portosystemic stent-shunt; liver cirrhosis; portal hypertension; ascites; renal failure

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Selected References

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  • Ginès A, Escorsell A, Ginès P, Saló J, Jiménez W, Inglada L, Navasa M, Clària J, Rimola A, Arroyo V, et al. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology. 1993 Jul;105(1):229–236. [PubMed]
  • Arroyo V, Ginès P, Gerbes AL, Dudley FJ, Gentilini P, Laffi G, Reynolds TB, Ring-Larsen H, Schölmerich J. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology. 1996 Jan;23(1):164–176. [PubMed]
  • Gonwa TA, Morris CA, Goldstein RM, Husberg BS, Klintmalm GB. Long-term survival and renal function following liver transplantation in patients with and without hepatorenal syndrome--experience in 300 patients. Transplantation. 1991 Feb;51(2):428–430. [PubMed]
  • Keller F, Heinze H, Jochimsen F, Passfall J, Schuppan D, Büttner P. Risk factors and outcome of 107 patients with decompensated liver disease and acute renal failure (including 26 patients with hepatorenal syndrome): the role of hemodialysis. Ren Fail. 1995 Mar;17(2):135–146. [PubMed]
  • Ochs A, Rössle M, Haag K, Hauenstein KH, Deibert P, Siegerstetter V, Huonker M, Langer M, Blum HE. The transjugular intrahepatic portosystemic stent-shunt procedure for refractory ascites. N Engl J Med. 1995 May 4;332(18):1192–1197. [PubMed]
  • Lebrec D, Giuily N, Hadengue A, Vilgrain V, Moreau R, Poynard T, Gadano A, Lassen C, Benhamou JP, Erlinger S. Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial. French Group of Clinicians and a Group of Biologists. J Hepatol. 1996 Aug;25(2):135–144. [PubMed]
  • 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 Apr;25(2):1766–1767. [PubMed]
  • Spahr L, Fenyves D, N'Guyen VV, Roy L, Legault L, Dufresne MP, Pomier-Layrargues G. Improvement of hepatorenal syndrome by transjugular intrahepatic portosystemic shunt. Am J Gastroenterol. 1995 Jul;90(7):1169–1171. [PubMed]
  • Lerut J, Goffette P, Laterre PF, Donataccio M, Reynaert MS, Otte JB. Sequential treatment of hepatorenal syndrome and posthepatic cirrhosis by intrahepatic portosystemic shunt (TIPSS) and liver transplantation. Hepatogastroenterology. 1995 Nov-Dec;42(6):985–987. [PubMed]
  • Sturgis TM. Hepatorenal syndrome: resolution after transjugular intrahepatic portosystemic shunt. J Clin Gastroenterol. 1995 Apr;20(3):241–243. [PubMed]
  • Brensing KA, Textor J, Strunk H, Klehr HU, Schild H, Sauerbruch T. Transjugular intrahepatic portosystemic stent-shunt for hepatorenal syndrome. Lancet. 1997 Mar 8;349(9053):697–698. [PubMed]
  • Guevara M, Ginès P, Bandi JC, Gilabert R, Sort P, Jiménez W, Garcia-Pagan JC, Bosch J, Arroyo V, Rodés J. Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems. Hepatology. 1998 Aug;28(2):416–422. [PubMed]
  • Rössle M, Haag K, Ochs A, Sellinger M, Nöldge G, Perarnau JM, Berger E, Blum U, Gabelmann A, Hauenstein K, et al. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med. 1994 Jan 20;330(3):165–171. [PubMed]
  • Conn HO. Transjugular intrahepatic portal-systemic shunts: the state of the art. Hepatology. 1993 Jan;17(1):148–158. [PubMed]
  • Stanley AJ, Jalan R, Forrest EH, Redhead DN, Hayes PC. Longterm follow up of transjugular intrahepatic portosystemic stent shunt (TIPSS) for the treatment of portal hypertension: results in 130 patients. Gut. 1996 Sep;39(3):479–485. [PMC free article] [PubMed]
  • Brensing KA, Neubrand M, Textor J, Raab P, Müller-Miny H, Scheurlen C, Görich J, Schild H, Sauerbruch T. Endoscopic manometry of esophageal varices: evaluation of a balloon technique compared with direct portal pressure measurement. J Hepatol. 1998 Jul;29(1):94–102. [PubMed]
  • Fevery J, Van Cutsem E, Nevens F, Van Steenbergen W, Verberckmoes R, De Groote J. Reversal of hepatorenal syndrome in four patients by peroral misoprostol (prostaglandin E1 analogue) and albumin administration. J Hepatol. 1990 Sep;11(2):153–158. [PubMed]
  • Lenz K, Hörtnagl H, Druml W, Reither H, Schmid R, Schneeweiss B, Laggner A, Grimm G, Gerbes AL. Ornipressin in the treatment of functional renal failure in decompensated liver cirrhosis. Effects on renal hemodynamics and atrial natriuretic factor. Gastroenterology. 1991 Oct;101(4):1060–1067. [PubMed]
  • Saló J, Ginès A, Quer JC, Fernández-Esparrach G, Guevara M, Ginès P, Bataller R, Planas R, Jiménez W, Arroyo V, et al. Renal and neurohormonal changes following simultaneous administration of systemic vasoconstrictors and dopamine or prostacyclin in cirrhotic patients with hepatorenal syndrome. J Hepatol. 1996 Dec;25(6):916–923. [PubMed]
  • Cervoni JP, Lecomte T, Cellier C, Auroux J, Simon C, Landi B, Gadano A, Barbier JP. Terlipressin may influence the outcome of hepatorenal syndrome complicating alcoholic hepatitis. Am J Gastroenterol. 1997 Nov;92(11):2113–2114. [PubMed]
  • Guevara M, Ginès P, Fernández-Esparrach G, Sort P, Salmerón JM, Jiménez W, Arroyo V, Rodés J. Reversibility of hepatorenal syndrome by prolonged administration of ornipressin and plasma volume expansion. Hepatology. 1998 Jan;27(1):35–41. [PubMed]
  • Kaffy F, Borderie C, Chagneau C, Ripault MP, Larzillière I, Silvain C, Beauchant M. Octreotide in the treatment of the hepatorenal syndrome in cirrhotic patients. J Hepatol. 1999 Jan;30(1):174–174. [PubMed]
  • Holt S, Goodier D, Marley R, Patch D, Burroughs A, Fernando B, Harry D, Moore K. Improvement in renal function in hepatorenal syndrome with N-acetylcysteine. Lancet. 1999 Jan 23;353(9149):294–295. [PubMed]
  • Angeli P, Volpin R, Gerunda G, Craighero R, Roner P, Merenda R, Amodio P, Sticca A, Caregaro L, Maffei-Faccioli A, et al. Reversal of type 1 hepatorenal syndrome with the administration of midodrine and octreotide. Hepatology. 1999 Jun;29(6):1690–1697. [PubMed]
  • Wong F, Blendis L. Therapy for hepatorenal syndrome. Gastroenterology. 1998 Aug;115(2):503–504. [PubMed]
  • Castells A, Saló J, Planas R, Quer JC, Ginès A, Boix J, Ginès P, Gassull MA, Terés J, Arroyo V, et al. Impact of shunt surgery for variceal bleeding in the natural history of ascites in cirrhosis: a retrospective study. Hepatology. 1994 Sep;20(3):584–591. [PubMed]
  • Henriksen JH. Cirrhosis: ascites and hepatorenal syndrome. Recent advances in pathogenesis. J Hepatol. 1995;23 (Suppl 1):25–30. [PubMed]
  • Bataller R, Ginès P, Guevara M, Arroyo V. Hepatorenal syndrome. Semin Liver Dis. 1997;17(3):233–247. [PubMed]
  • Koppel MH, Coburn JW, Mims MM, Goldstein H, Boyle JD, Rubini ME. Transplantation of cadaveric kidneys from patients with hepatorenal syndrome. Evidence for the functionalnature of renal failure in advanced liver disease. N Engl J Med. 1969 Jun 19;280(25):1367–1371. [PubMed]
  • Epstein M. The hepatorenal syndrome--newer perspectives. N Engl J Med. 1992 Dec 17;327(25):1810–1811. [PubMed]
  • Moore K, Wendon J, Frazer M, Karani J, Williams R, Badr K. Plasma endothelin immunoreactivity in liver disease and the hepatorenal syndrome. N Engl J Med. 1992 Dec 17;327(25):1774–1778. [PubMed]
  • Henriksen JH, Ring-Larsen H. Hepatorenal disorders: role of the sympathetic nervous system. Semin Liver Dis. 1994 Feb;14(1):35–43. [PubMed]
  • Sacerdoti D, Balazy M, Angeli P, Gatta A, McGiff JC. Eicosanoid excretion in hepatic cirrhosis. Predominance of 20-HETE. J Clin Invest. 1997 Sep 1;100(5):1264–1270. [PMC free article] [PubMed]
  • Wong F, Sniderman K, Liu P, Allidina Y, Sherman M, Blendis L. Transjugular intrahepatic portosystemic stent shunt: effects on hemodynamics and sodium homeostasis in cirrhosis and refractory ascites. Ann Intern Med. 1995 Jun 1;122(11):816–822. [PubMed]
  • Quiroga J, Sangro B, Núez M, Bilbao I, Longo J, García-Villarreal L, Zozaya JM, Betés M, Herrero JI, Prieto J. Transjugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: effect on clinical, renal, humoral, and hemodynamic parameters. Hepatology. 1995 Apr;21(4):986–994. [PubMed]
  • Somberg KA, Lake JR, Tomlanovich SJ, LaBerge JM, Feldstein V, Bass NM. Transjugular intrahepatic portosystemic shunts for refractory ascites: assessment of clinical and hormonal response and renal function. Hepatology. 1995 Mar;21(3):709–716. [PubMed]
  • Martinet JP, Legault L, Cernacek P, Roy L, Dufresne MP, Spahr L, Fenyves D, Pomier-Layrargues G. Changes in plasma endothelin-1 and Big endothelin-1 induced by transjugular intrahepatic portosystemic shunts in patients with cirrhosis and refractory ascites. J Hepatol. 1996 Nov;25(5):700–706. [PubMed]
  • Gerbes AL, Gülberg V, Waggershauser T, Holl J, Reiser M. Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: comparison of patients with ascites, with refractory ascites, or without ascites. Hepatology. 1998 Sep;28(3):683–688. [PubMed]
  • Gerbes AL, Møller S, Gülberg V, Henriksen JH. Endothelin-1 and -3 plasma concentrations in patients with cirrhosis: role of splanchnic and renal passage and liver function. Hepatology. 1995 Mar;21(3):735–739. [PubMed]
  • Epstein M, Goligorsky MS. Endothelin and nitric oxide in hepatorenal syndrome: a balance reset. J Nephrol. 1997 May-Jun;10(3):120–135. [PubMed]
  • Lang F, Tschernko E, Schulze E, Ottl I, Ritter M, Völkl H, Hallbrucker C, Häussinger D. Hepatorenal reflex regulating kidney function. Hepatology. 1991 Oct;14(4 Pt 1):590–594. [PubMed]
  • Jalan R, Forrest EH, Redhead DN, Dillon JF, Hayes PC. Reduction in renal blood flow following acute increase in the portal pressure: evidence for the existence of a hepatorenal reflex in man? Gut. 1997 May;40(5):664–670. [PMC free article] [PubMed]
  • D'Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology. 1995 Jul;22(1):332–354. [PubMed]

Figures and Tables

Figure 1
Mean (SD) serum creatinine levels (mg/dl; to convert values to µmol/l multiply by 88.4), creatinine clearance (ml/min), and sodium excretion (mmol/24 hours) up to one year after diagnosis of hepatorenal syndrome in 41 patients of whom ...
Figure 2
Kaplan-Meier survival analysis. (A) Cohort of patients with hepatorenal syndrome (HRS) treated by transjugular intrahepatic portosystemic stent-shunt (TIPS) (n=31); (B) survival analysis after TIPS according to HRS subtypes at baseline; (C) survival ...

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