Highlights
- •Failure to control variceal bleeding in cirrhosis is associated with high mortality and frequently causes ACLF.
- •ACLF is the most important determinant of 42-day and 1-year mortality in cirrhotic patients with failure to control variceal bleeding.
- •Transjugular intrahepatic shunt insertion improves 42-day and 1-year survival in patients with ACLF secondary to failure to control variceal bleeding.
Background & Aims
Failure to control oesophago-gastric variceal bleeding (OGVB) and acute-on-chronic
liver failure (ACLF) are both important prognostic factors in cirrhosis. The aims
of this study were to determine whether ACLF and its severity define the risk of death
in OGVB and whether insertion of rescue transjugular intrahepatic shunt (TIPS) improves
survival in patients with failure to control OGVB and ACLF.
Methods
Data on 174 consecutive eligible patients, with failure to control OGVB between 2005
and 2015, were collected from a prospectively maintained intensive care unit registry.
Rescue TIPS was defined as technically successful TIPS within 72 hours of presentation
with failure to control OGVB. Cox-proportional hazards regression analyses were applied
to explore the impact of ACLF and TIPS on survival in patients with failure to control
OGVB.
Results
Patients with ACLF (n = 119) were significantly older, had organ failures and higher
white cell count than patients with acute decompensation (AD, n = 55). Mortality at
42-days and 1-year was significantly higher in patients with ACLF (47.9% and 61.3%)
than in those with AD (9.1% and 12.7%, p <0.001), whereas there was no difference in the number of endoscopies and transfusion
requirements between these groups. TIPS was inserted in 78 patients (AD 21 [38.2%];
ACLF 57 [47.8%]; p = 0.41). In ACLF, rescue TIPS insertion was an independent favourable prognostic
factor for 42-day mortality. In contrast, rescue TIPS did not impact on the outcome
of patients with AD.
Conclusions
This study shows that in patients with failure to control OGVB, the presence and severity
of ACLF determines the risk of 42-day and 1-year mortality. Rescue TIPS is associated
with improved survival in patients with ACLF.
Lay summary
Variceal bleeding that is not controlled by initial endoscopy is associated with high
risk of death. The results of this study showed that in the occurrence of failure
of the liver and other organs defines the risk of death. In these patients, insertion
of a shunt inside the liver to drain the portal vein improves survival.
Graphical abstract
Graphical Abstract
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of HepatologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis.Gastroenterology. 2013; 144: 1426-1437
- Acute variceal bleeding.Semin Respir Crit Care Med. 2012; 33: 46-54
- Survival in infection-related acute-on-chronic liver failure is defined by extrahepatic organ failures.Hepatology. 2014; 60: 250-256
- Predictors of mortality among patients with compensated and decompensated liver cirrhosis: the role of bacterial infections and infection-related acute-on-chronic liver failure.Scand J Gastroenterol. 2015; 50: 875-883
- Characteristics, diagnosis and prognosis of acute-on-chronic liver failure in cirrhosis associated to hepatitis B.Sci Rep. 2016; 6: 25487
- Systemic inflammation in decompensated cirrhosis: characterization and role in acute-on-chronic liver failure.Hepatology. 2016; 64: 1249-1264
- Patients with acute-on-chronic liver failure have increased numbers of regulatory immune cells expressing the receptor tyrosine kinase MERTK.Gastroenterology. 2015; 148: 603-615
- Predicting early mortality after acute variceal hemorrhage based on classification and regression tree analysis.Clin Gastroenterol Hepatol. 2009; 7: 1347-1354
- EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis.J Hepatol. 2018; 69: 406-460
- Revising consensus in portal hypertension: report of the Baveno v consensus workshop on methodology of diagnosis and therapy in portal hypertension.J Hepatol. 2010; 53: 762-768
- Expanding consensus in portal hypertension report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension.J Hepatol. 2015; 63: 743-752
- Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators.Hepatology. 2003; 38: 599-612
- Recombinant factor VIIa for upper gastrointestinal bleeding in patients with cirrhosis: a randomized, double-blind trial.Gastroenterology. 2004; 127: 1123-1130
- Early use of TIPS in patients with cirrhosis and variceal bleeding.N Engl J Med. 2010; 362: 2370-2379
- Early transjugular intrahepatic portosystemic shunt in US patients hospitalized with acute esophageal variceal bleeding.J Gastroenterol Hepatol. 2017; 32: 852-858
- Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the Study of Liver Diseases.Hepatology. 2017; 65: 310-335
- Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study.J Hepatol. 2013; 58: 45-50
- Randomized controlled trial of emergency transjugular intrahepatic portosystemic shunt versus emergency portacaval shunt treatment of acute bleeding esophageal varices in cirrhosis.J Gastrointest Surg. 2012; 16: 2094-2111
- Systemic inflammation is associated with increased intrahepatic resistance and mortality in alcohol-related acute-on-chronic liver failure.Liver Int. 2015; 35: 724-734
- Inflammation and portal hypertension-The undiscovered country.J Hepatol. 2014; 61: 155-163
- TIPS: 25 years later.J Hepatol. 2013; 59: 1081-1093
- Timing affects measurement of portal pressure gradient after placement of transjugular intrahepatic portosystemic shunts in patients with portal hypertension.Gastroenterology. 2017; 152: 1358-1365
- Transjugular intrahepatic portosystemic shunt: short-term and long-term effects on hepatic and systemic hemodynamics in patients with cirrhosis.Hepatology. 1999; 29: 632-639
- Evolving consensus in portal hypertension report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension.J Hepatol. 2005; 43: 167-176
- Validation of CLIF-C ACLF score to define a threshold for futility of intensive care support for patients with acute-on-chronic liver failure.Crit Care. 2018; 22: 254
- Development of an organ failure score in acute liver failure for transplant selection and identification of patients at high risk of futility.PLoS One. 2017; 12: e0188151
- Prognostic role of ammonia in patients with cirrhosis.Hepatology. 2019; 70: 982-994
- Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure.J Hepatol. 2014; 61: 1038-1047
- Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy: a double blind controlled trial.Gastroenterology. 1977; 72: 573-583
- Bacterial infection in the pathogenesis of variceal bleeding.Lancet. 1999; 353: 139-142
- Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013.J Hepatol. 2014; 60: 1310-1324
- Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis.J Hepatol. 2001; 35: 590-597
- Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS.J Hepatol. 2020; https://doi.org/10.1016/j.hep.2020.02.024
- Treatment with non-selective beta blockers is associated with reduced severity of systemic inflammation and improved survival of patients with acute-on-chronic liver failure.J Hepatol. 2015; 64: 574-582
- Factors associated with survival of patients with severe acute-on-chronic liver failure before and after liver transplantation.Gastroenterology. 2019; 156: 1381-1391
Article info
Publication history
Published online: June 16, 2020
Accepted:
June 8,
2020
Received in revised form:
June 4,
2020
Received:
February 16,
2020
Footnotes
Author names in bold designate shared co-first authorship
Identification
Copyright
© 2020 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
