Background & Aims: The relationship between acute-on-chronic liver failure (ACLF) and acute variceal bleeding (AVB) is poorly understood. Specifically, the prevalence and prognosis of ACLF in the context of AVB is unclear, while the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management in patients with ACLF has not been described to date. Methods: A multicenter, international, observational study was conducted in 2,138 patients from 34 centers between 2011 and 2015. ACLF was defined and graded according to the EASL-CLIF consortium definition. Placement of pre-emptive TIPS (pTIPS) was based on individual center policy. Patients were followed-up for 1 year, until death or liver transplantation. Cox regression and competing risk models (Gray's test) were used to identify independent predictors of rebleeding or mortality. Results: At admission, 380/2,138 (17.8%) patients had ACLF according to EASL-CLIF criteria (grade 1: 38.7%; grade 2: 39.2%; grade 3: 22.1%). The 42-day rebleeding (19% vs. 10%; p <0.001) and mortality (47% vs. 10%; p <0.001) rates were higher in patients with ACLF and increased with ACLF grades. Of note, the presence of ACLF was independently associated with rebleeding and mortality. pTIPS placement improved survival in patients with ACLF at 42 days and 1 year. This effect was also observed in propensity score matching analysis of 66 patients with ACLF, of whom 44 received pTIPs and 22 did not. Conclusions: This large multicenter international real-life study identified ACLF at admission as an independent predictor of rebleeding and mortality in patients with AVB. Moreover, pTIPS was associated with improved survival in patients with ACLF and AVB. Lay summary: Acute variceal bleeding is a deadly complication of liver cirrhosis that results from severe portal hypertension. This study demonstrates that the presence of acute-on-chronic liver failure (ACLF) is the strongest predictor of mortality in patients with acute variceal bleeding. Importantly, patients with ACLF and acute variceal (re)bleeding benefit from pre-emptive (early) placement of a transjugular intrahepatic portosystemic shunt.

Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS / J. Trebicka, W. Gu, L. Ibanez-Samaniego, V. Hernandez-Gea, C. Pitarch, E. Garcia, B. Procopet, A. Giraldez, L. Amitrano, C. Villanueva, D. Thabut, G. Silva-Junior, J. Martinez, J. Genesca, C. Bureau, E. Llop, W. Laleman, J.M. Palazon, J. Castellote, S. Rodrigues, L. Gluud, C.N. Ferreira, R. Barcelo, N. Canete, M. Rodriguez, A. Ferlitsch, J.L. Mundi, H. Gronbaek, M. Hernandez-Guerra, R. Sassatelli, A. Dell'Era, M. Senzolo, J.G. Abraldes, M. Romero-Gomez, A. Zipprich, M. Casas, H. Masnou, M. Primignani, E. Weiss, M.-. Catalina, H.-. Erasmus, F.E. Uschner, M. Schulz, M.J. Brol, M. Praktiknjo, J. Chang, A. Krag, F. Nevens, J.L. Calleja, M.A. Robic, I. Conejo, A. Albillos, M. Rudler, E. Alvarado, M.A. Guardascione, M. Tantau, J. Bosch, F. Torres, M. Pavesi, J.C. Garcia-Pagan, C. Jansen, R. Banares. - In: JOURNAL OF HEPATOLOGY. - ISSN 0168-8278. - 73:5(2020 Nov), pp. 1082-1091. [10.1016/j.jhep.2020.04.024]

Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS

A. Dell'Era
Membro del Collaboration Group
;
2020

Abstract

Background & Aims: The relationship between acute-on-chronic liver failure (ACLF) and acute variceal bleeding (AVB) is poorly understood. Specifically, the prevalence and prognosis of ACLF in the context of AVB is unclear, while the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management in patients with ACLF has not been described to date. Methods: A multicenter, international, observational study was conducted in 2,138 patients from 34 centers between 2011 and 2015. ACLF was defined and graded according to the EASL-CLIF consortium definition. Placement of pre-emptive TIPS (pTIPS) was based on individual center policy. Patients were followed-up for 1 year, until death or liver transplantation. Cox regression and competing risk models (Gray's test) were used to identify independent predictors of rebleeding or mortality. Results: At admission, 380/2,138 (17.8%) patients had ACLF according to EASL-CLIF criteria (grade 1: 38.7%; grade 2: 39.2%; grade 3: 22.1%). The 42-day rebleeding (19% vs. 10%; p <0.001) and mortality (47% vs. 10%; p <0.001) rates were higher in patients with ACLF and increased with ACLF grades. Of note, the presence of ACLF was independently associated with rebleeding and mortality. pTIPS placement improved survival in patients with ACLF at 42 days and 1 year. This effect was also observed in propensity score matching analysis of 66 patients with ACLF, of whom 44 received pTIPs and 22 did not. Conclusions: This large multicenter international real-life study identified ACLF at admission as an independent predictor of rebleeding and mortality in patients with AVB. Moreover, pTIPS was associated with improved survival in patients with ACLF and AVB. Lay summary: Acute variceal bleeding is a deadly complication of liver cirrhosis that results from severe portal hypertension. This study demonstrates that the presence of acute-on-chronic liver failure (ACLF) is the strongest predictor of mortality in patients with acute variceal bleeding. Importantly, patients with ACLF and acute variceal (re)bleeding benefit from pre-emptive (early) placement of a transjugular intrahepatic portosystemic shunt.
Acute variceal bleeding; Acute-on-chronic liver failure; Cirrhosis; Rebleeding;
Settore MED/12 - Gastroenterologia
nov-2020
Article (author)
File in questo prodotto:
File Dimensione Formato  
rebleeding ACLF TIPS.pdf

accesso aperto

Tipologia: Publisher's version/PDF
Dimensione 767.56 kB
Formato Adobe PDF
767.56 kB Adobe PDF Visualizza/Apri
Pubblicazioni consigliate

I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.

Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/2434/789870
Citazioni
  • ???jsp.display-item.citation.pmc??? 44
  • Scopus 120
  • ???jsp.display-item.citation.isi??? 109
social impact