To the Editor:
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 score[3]
and also proposed a detailed risk stratification combining the Child-Pugh score and the FIPS score.Kraglund et al. analyzed 104 patients who received transjugular intrahepatic portosystemic shunt (TIPS) implantation. In their cohort, only 5 patients presented with a FIPS score ≥0.92 and were therefore classified as high-risk patients. Due to the low number of high-risk patients the FIPS score did not show superior prognostic accuracy compared to the model for end-stage liver disease (MELD) and Child-Pugh score.
[1]
Importantly, the authors mention that their cohort was similar to our FIPS cohort.
[3]
However, after reviewing the detailed description of the baseline characteristics of their study cohort,[4]
it has to be mentioned that there are important differences compared to the FIPS cohort. Indeed, Kraglund et al. included 18 patients with emergency TIPS and 3 patients with urgent TIPS implantation (20.2% of the included 104 patients).[4]
These patients with preemptive or urgent TIPS implantation were not included for development of the FIPS score as these patients are clinically different to elective TIPS patients. With these differences in mind, we performed a subgroup analysis in patients with preemptive TIPS implantation. In this analysis, we could confirm that the FIPS score showed no sufficient prognostic discrimination in these patients. Indeed, other factors such as bleeding in the index endoscopy or hemorrhagic shock are more relevant important prognostic factors in these patients that are not included in the FIPS score.[5]
Therefore, it has to be emphasized that the FIPS score is not intended for use in these patients.Moreover, Kraglund et al. also included 13 non-cirrhotic patients (12.5%).
[1]
,[4]
We also decided not to include these patients in our cohort. Again, in these patients, other factors such as thrombophilia or immunosuppression are also important factors that are not considered in the FIPS score. In summary, the reduced prognostic discrimination of the FIPS score in the cohort of Kraglund et al. may be mainly due to the selection of patients that fall outside the intended scope of the FIPS score.Moreover, information concerning bilirubin and creatinine levels as the main parameters in the FIPS score, have not been reported.
[4]
As almost all patients were allocated to the low-risk FIPS group, this may represent a well-selected patient cohort for TIPS implantation with a priori exclusion of high-risk patients. Therefore, analyzing the prognostic impact of a score that stratifies patients into low- and high-risk groups would be limited.Further, we fully agree that independent external validation is necessary before a prediction model should be used in clinical practice. Meanwhile, our results have been reproduced in 2 other independent cohorts of patients receiving TIPS.
[2]
,[6]
Massoumy et al.[6]
and Wang et al.[2]
discussed if a modification of the cut-off for defining high-risk patients is necessary. Indeed, further validation of the FIPS score is necessary and these analyses should also focus on the determination of an optimal cut-off for selection of high-risk patients.Interestingly, Wang et al. showed that the FIPS score was able to provide further prognostic stratification in patients within Child-Pugh grade A and B.
[2]
Their conclusion that the FIPS score could serve as a complementary tool for risk stratification together with the Child-Pugh score is of clinical relevance and we highly recommend analyzing this proposal in further clinical studies.Financial support
DB is supported by the Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg.
Authors’ contributions
Drafting the manuscript: DB, RT, MS.
Conflict of interest
DB: Consultant: Bayer Healthcare, Boston Scientific, Shionogi. Lectures: Falk Foundation. MS: Consultant: Bayer Healthcare, L.W. Gore Lectures: Falk Foundation.
Supplementary data
The following is the supplementary data to this article:
- Multimedia component 1
References
- External validation of the Freiburg index of post-TIPS survival.J Hepatol. 2021; 75: 746-747
- Freiburg index of post-TIPS survival: the first score for individual prediction and a complementary tool for risk stratification.J Hepatol. 2021; : 747-749https://doi.org/10.1016/j.jhep.2021.05.042
- Refining prediction of survival after TIPS with the novel Freiburg index of post-TIPS survival.J Hepatol. 2021; 74: 1362-1372
- Long-term effects and complications of the transjugular intrahepatic portosystemic shunt: a single-centre experience.Scand J Gastroenterol. 2019 Jul; 54: 899-904
- Early TIPS (transjugular intrahepatic portosystemic shunt) cooperative study group. Early use of TIPS in patients with cirrhosis and variceal bleeding.N Engl J Med. 2010 Jun 24; 362: 2370-2379
- Freiburg index of post-TIPS survival (FIPS) a valid prognostic score in patients with cirrhosis but also an advisor against TIPS?.J Hepatol. 2021 Mar 11; S0168-8278: 168-169
Article info
Publication history
Published online: June 19, 2021
Accepted:
June 2,
2021
Received:
June 2,
2021
Identification
Copyright
© 2021 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
