Refining prediction of survival after TIPS with the novel Freiburg index of post-TIPS survival

J Hepatol. 2021 Jun;74(6):1362-1372. doi: 10.1016/j.jhep.2021.01.023. Epub 2021 Jan 26.


Background & aims: Transjugular intrahepatic portosystemic shunt (TIPS) implantation is an effective and safe treatment for complications of portal hypertension. Survival prediction is important in these patients as they constitute a high-risk population. Therefore, the aim of our study was to develop an alternative prognostic model for accurate survival prediction after planned TIPS implantation.

Methods: A total of 1,871 patients with de novo TIPS implantation for ascites or secondary prophylaxis of variceal bleeding were recruited retrospectively. The study cohort was divided into a training set (80% of study patients; n = 1,496) and a validation set (20% of study patients; n = 375). Further, patients with early (preemptive) TIPS implantation due to variceal bleeding were included as another validation cohort (n = 290). Medical data and overall survival (OS) were assessed. A Cox regression model was used to create an alternative prediction model, which includes significant prognostic factors.

Results: Age, bilirubin, albumin and creatinine were the most important prognostic factors. These parameters were included in a new score named the Freiburg index of post-TIPS survival (FIPS). The FIPS score was able to identify high-risk patients with a significantly reduced median survival of 5.0 (3.1-6.9) months after TIPS implantation in the training set. These results were confirmed in the validation set (median survival of 3.1 [0.9-5.3] months). The FIPS score showed better prognostic discrimination compared to the Child-Pugh, MELD, MELD-Na score and the bilirubin-platelet model. However, the FIPS score showed insufficient prognostic discrimination in patients with early TIPS implantation.

Conclusions: The FIPS score is superior to established scoring systems for the identification of high-risk patients with a worse prognosis following elective TIPS implantation.

Lay summary: Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a safe and effective treatment for patients with cirrhosis and clinically significant portal hypertension. However, risk stratification is a major challenge in these patients as currently available scoring systems have major drawbacks. Age, bilirubin, albumin and creatinine were included in a new risk score which was named the Freiburg index of post-TIPS survival (FIPS). The FIPS score can identify patients at high risk and may guide clinical decision making.

Keywords: Child-Pugh score; MELD score; Prognosis; liver cirrhosis; risk stratification; transjugular intrahepatic portosystemic shunt.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • Aged
  • Ascites / surgery*
  • Bilirubin / blood
  • Clinical Decision-Making / methods
  • Creatinine / blood
  • Esophageal and Gastric Varices / surgery*
  • Female
  • Gastrointestinal Hemorrhage / surgery*
  • Humans
  • Liver Cirrhosis / surgery*
  • Male
  • Middle Aged
  • Portasystemic Shunt, Transjugular Intrahepatic / adverse effects*
  • Portasystemic Shunt, Transjugular Intrahepatic / mortality*
  • Prognosis
  • Research Design*
  • Retrospective Studies
  • Risk Factors
  • Secondary Prevention / methods
  • Serum Albumin, Human / analysis
  • Survival Rate
  • Treatment Outcome


  • Creatinine
  • Bilirubin
  • Serum Albumin, Human