Transjugular intrahepatic portosystemic shunt does not independently increase risk of death in high model for end stage liver disease patients

Erin K Spengler; Lawrence G Hunsicker; Sanam Zarei; M Bridget Zimmerman; Michael D Voigt

doi:10.1002/hep4.1053

Transjugular intrahepatic portosystemic shunt does not independently increase risk of death in high model for end stage liver disease patients

Hepatol Commun. 2017 Jun 7;1(5):460-468. doi: 10.1002/hep4.1053. eCollection 2017 Jul.

Authors

Erin K Spengler^{1

2}, Lawrence G Hunsicker³, Sanam Zarei⁴, M Bridget Zimmerman⁵, Michael D Voigt¹

Affiliations

¹ Division of Gastroenterology and Hepatology Department of Internal Medicine, The University of Iowa Hospitals and Clinics Iowa City IA.
² University of Wisconsin, School of Medicine and Public Health Madison WI.
³ Division of Nephrology Department of Internal Medicine, The University of Iowa Hospitals and Clinics Iowa City IA.
⁴ Carver College of Medicine The University of Iowa Hospitals and Clinics Iowa City IA.
⁵ Department of Biostatistics The University of Iowa Hospitals and Clinics Iowa City IA.

Abstract

Physicians often exclude patients with a model for end-stage liver disease (MELD) score ≥ 18 from a transjugular intrahepatic portosystemic shunt (TIPS) procedure due to the concern for higher risk of death. We aimed to determine if TIPS increased the risk of death in these patients. We analyzed the interaction between TIPS and MELD in 106 patients with TIPS and 79 with intractable ascites without TIPS. We performed Cox proportional hazard regression, including both TIPS and MELD as time-dependent covariates together with their interaction, to calculate the impact of TIPS on the risk of death associated with a high MELD score. We found a negative interaction between a high MELD score and a history of TIPS, with potentially important effect sizes. Patients with MELD scores ≥18 had a 51% lower incremental risk of death (lower risk than would be expected from the combined independent risks of MELD and needing/receiving TIPS) associated with TIPS than patients with MELD scores <18 (hazard ratio for TIPS, 0.49; 95% confidence interval, 0.10-2.45) in the first 6 months following TIPS. There was an 80% lower incremental risk of death among patients with a MELD score ≥18 (hazard ratio for TIPS, 0.20; 95% confidence interval, 0.03-1.23) 6 months after the TIPS procedure. Conclusion: Risk of death is associated with underlying disease severity as shown by the MELD score and the need for TIPS, and both history of TIPS and high MELD score independently increased the risk of mortality. However, the risk of death after TIPS was progressively lower than expected as the MELD score increased. (Hepatology Communications 2017;1:460-468).