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

Published:January 25, 2021DOI:https://doi.org/10.1016/j.jhep.2021.01.023

      Highlights

      • Risk stratification is a major challenge in patients undergoing TIPS implantation.
      • Age, bilirubin, albumin and creatinine emerged as the most significant predictors of 6-months survival after TIPS implantation.
      • These measures were summarized in a new score named the Freiburg index of post-TIPS survival (FIPS).
      • The FIPS score clearly identifies a high-risk group of patients with a markedly reduced survival after TIPS implantation.
      • Importantly, prognostic discrimination was superior to the MELD, MELD-Na, Child-Pugh score and the bilirubin-platelet model.

      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.

      Graphical abstract

      Keywords

      Linked Article

      • TIPS and liver transplantation should always be discussed together
        Journal of HepatologyVol. 75Issue 4
        • Preview
          We read with interest the study by Bettinger et al.,1 proposing a new prognostic model of survival after transjugular intrahepatic portosystemic shunt (TIPS) placement, called the Freiburg index of post-TIPS survival (FIPS). In a large cohort of 1,871 patients with cirrhosis who were candidates for elective TIPS placement (i.e. for refractory ascites or secondary prophylaxis of variceal bleeding), the authors reported that age, bilirubin, albumin and creatinine were factors strongly associated with post TIPS survival.
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      • Predicting survival after TIPS: Child Pugh score is not inferior to MELD and FIPS score – back to basics?
        Journal of HepatologyVol. 75Issue 6
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          With great interest, we read the publication by Bettinger et al. who reported a newly developed prognostic score for patients after transjugular intrahepatic portosystemic shunt (TIPS) – the Freiburg index for post TIPS survival (FIPS).1 In their multicenter cohort, the FIPS score showed a better survival prediction after TIPS implantation than widely known and used prognostic scores, namely the Child-Pugh and model for end-stage liver disease (MELD) score. When Kraglund et al. tried to validate the FIPS score in an independent patient cohort of 104 patients,2 the Child-Pugh was not inferior for prognostication than the MELD and FIPS score.
        • Full-Text
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      • Reply to: Correspondence on “Refining prediction of survival after TIPS with the novel Freiburg index of post-TIPS survival”
        Journal of HepatologyVol. 75Issue 3
        • Preview
          With great interest, we have read the letters from Kraglund et al.1 and Wang et al.2 who provided external validation of the FIPS score3 and also proposed a detailed risk stratification combining the Child-Pugh score and the FIPS score.
        • Full-Text
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      • External validation of the Freiburg index of post-TIPS survival
        Journal of HepatologyVol. 75Issue 3
        • Preview
          We read with great interest the article “Refining prediction of survival after TIPS with the novel Freiburg index of post-TIPS survival” by Bettinger et al.1 We congratulate the authors on developing a novel model (the FIPS score) to predict 3- and 6-month survival after planned transjugular intrahepatic portosystemic shunt (TIPS) implantation using 4 easily obtainable prognostic factors: age, creatinine, bilirubin, and albumin.
        • Full-Text
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      • Reply to: “Freiburg index of post-TIPS survival (FIPS) a valid prognostic score in patients with cirrhosis but also an advisor against TIPS?”
        Journal of HepatologyVol. 75Issue 2
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          We thank Dr. Stockhoff and her team for their interest in our study1 and their analyses that confirmed the prognostic impact of the Freiburg index of post-TIPS survival (FIPS) score and even expanded it to patients with decompensated cirrhosis without transjugular intrahepatic portosystemic shunt (TIPS) implantation.2 With great interest, we recognize their efforts in addressing some important remaining questions from our study, especially with respect to the clinical application of the FIPS score for allocation to TIPS implantation.
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      • Freiburg index of post-TIPS survival (FIPS) a valid prognostic score in patients with cirrhosis but also an advisor against TIPS?
        Journal of HepatologyVol. 75Issue 2
        • Preview
          With great interest we read the excellent article by Bettinger and colleagues. In their well-designed study the authors proposed the newly developed Freiburg index of post-TIPS survival (FIPS) as a valuable tool for risk stratification before transjugular intrahepatic portosystemic shunt (TIPS) implantation.1 The establishment of robust criteria for the selection of patients eligible for TIPS is crucial. Bettinger et al. collected a large, multicenter TIPS cohort and convincingly demonstrated the high prognostic capacity of the FIPS score for post-TIPS survival in various subgroups of patients including those with refractory ascites.
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      • Reply to: “TIPS and liver transplantation should always be discussed together”
        Journal of HepatologyVol. 75Issue 4
        • Preview
          With great interest, we read the letter by Rudler et al. focusing on the Freiburg index of post-TIPS survival (FIPS) score in the setting of liver transplantation (LT).1,2 This example of a multidisciplinary TIPS/LT board is an important step towards personalized treatment of patients with advanced cirrhosis and may serve as a model for other centers. The authors also analyzed the application of the FIPS score in this approach and they were able to show that the FIPS score adequately selects patients who need LT.
        • Full-Text
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      • FIPS score: Solid but we still need even better!
        Journal of HepatologyVol. 76Issue 1
        • Preview
          Bettinger and colleagues recently described a new score, the Freiburg index of post-TIPS survival (FIPS), which they developed to stratify mortality risk and identify good candidates for transjugular intrahepatic portosystemic shunt (TIPS) implantation.1 The FIPS score, a linear predictor composed of albumin, creatinine, bilirubin and age, showed good prognostic performances to predict 3 month (M3) and 6-month (M6) post-TIPS survival and the threshold of ≥0.92 (85th percentile of their derivation cohort) was defined as the cut-off for high-risk patients before TIPS implantation.
        • Full-Text
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      • Freiburg index of post-TIPS survival: The first score for individual prediction and a complementary tool for risk stratification
        Journal of HepatologyVol. 75Issue 3
        • Preview
          We have read with great interest the impressive study conducted by Bettinger et al. about the development of the Freiburg index of post-TIPS survival (FIPS) score.1 The authors established a prognostic model to achieve both individual outcome prediction (with the formula and the online calculator) and risk stratification (with a cut-off point), which had superior performance compared to previous prognostic models. Moreover, its ability to stratify patients at high and low risk remained robust in subgroups with different indications for transjugular intrahepatic portosystemic shunt (TIPS), different types of TIPS stents, well-preserved liver function, and impaired renal function.
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