TY - JOUR
T1 - Effects of Early Placement of Transjugular Portosystemic Shunts in Patients With High-Risk Acute Variceal Bleeding
T2 - a Meta-analysis of Individual Patient Data
AU - Nicoară-Farcău, Oana
AU - Han, Guohong
AU - Rudler, Marika
AU - Angrisani, Debora
AU - Monescillo, Alberto
AU - Torres, Ferran
AU - Casanovas, Georgina
AU - Bosch, Jaime
AU - Lv, Yong
AU - Thabut, Dominique
AU - Fan, Daiming
AU - Hernández-Gea, Virginia
AU - García-Pagán, Juan Carlos
AU - Bureau, Christophe
AU - Abraldes, Juan G
AU - Nevens, Frederik
AU - Caca, Karel
AU - Laleman, Wim
AU - Appenrodt, Beate
AU - Luca, Angelo
AU - Vinel, Jean Pierre
AU - Mössner, Joachim
AU - Di Pascoli, Marco
AU - Zipprich, Alexander
AU - Sauerbruch, Tilman
AU - Martinez-Lagares, Francisco
AU - Ruiz-Del-Arbol, Luis
AU - Sierra, Angel
AU - Guevara, Clemencia
AU - Jimenez, Elena
AU - Marrero, Jose Miguel
AU - Buceta, Enrique
AU - Sanchez, Juan
AU - Castellot, Ana
AU - Penate, Monica
AU - Cruz, Ana
AU - Pena, Elena
AU - Procopet, Bogdan
AU - Giráldez, Álvaro
AU - Amitrano, Lucio
AU - Villanueva, Candid
AU - Ibañez-Samaniego, Luis
AU - Silva-Junior, Gilberto
AU - Martinez, Javier
AU - Genescà, Joan
AU - Trebicka, Jonel
AU - Llop, Elba
AU - Palazon, Jose Maria
AU - pre-emptive TIPS individual data metanalysis, International Variceal Bleeding Study and Baveno Cooperation Study groups
A2 - Gluud, Lise L
A2 - Krag, Aleksander
N1 - Copyright © 2021 AGA Institute. All rights reserved.
PY - 2021/1/1
Y1 - 2021/1/1
N2 - BACKGROUND & AIMS: Compared with drugs plus endoscopy, placement of transjugular portosystemic shunt within 72 hours of admission to the hospital (early or preventive transjugular intrahepatic portosystemic shunt [TIPS], also called preemptive TIPS) increases the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survive for 1 year. However, the benefit of preemptive TIPS is less clear for patients with a Child-Pugh score of B and active bleeding (CP-B+AB). We performed an individual data meta-analysis to assess the efficacy of preemptive TIPS in these patients and identify factors associated with reduced survival of patients receiving preemptive TIPS.METHODS: We searched publication databases for randomized controlled trials and observational studies comparing the effects of preemptive TIPS versus endoscopy plus nonselective beta-blockers in the specific population of high-risk patients with cirrhosis and acute variceal bleeding (CP-B+AB or Child-Pugh C, below 14 points), through December 31, 2019. We performed a meta-analysis of data from 7 studies (3 randomized controlled trials and 4 observational studies), comprising 1327 patients (310 received preemptive TIPS and 1017 received drugs plus endoscopy). We built adjusted models to evaluate risk using propensity score for baseline covariates. Multivariate Cox regression models were used to assess the factors associated with survival time. The primary endpoint was effects of preemptive TIPS versus drugs plus endoscopy on 1-year survival in the overall population as well as CP-B+AB and Child-Pugh C patients.RESULTS: Overall, preemptive TIPS significantly increased the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survived for 1 year, compared with drugs plus endoscopy (hazard ratio [HR] 0.443; 95% CI 0.323-0.607; P < .001). This effect was observed in CP-B+AB patients (HR 0.524; 95% CI 0.307-0.896; P = .018) and in patients with Child-Pugh C scores below 14 points (HR 0.374; 95% CI 0.253-0.553; P < .001). Preemptive TIPS significantly improved control of bleeding and ascites without increasing risk of hepatic encephalopathy in Child-Pugh C and CP-B+AB patients, compared with drugs plus endoscopy. Cox analysis of patients who received preemptive TIPS showed that patients could be classified into 3 categories for risk of death, based on age, serum level of creatinine, and Child-Pugh score. In each of these risk categories, preemptive TIPS increased the proportion of patients who survived for 1 year, compared with drugs plus endoscopy.CONCLUSIONS: In a meta-analysis of data from 1327 patients with cirrhosis, acute variceal bleeding, and Child-Pugh score between 10 and 13 points or CP-B+AB, preemptive TIPS increased the proportion who survived for 1 year, in both subgroups separately, compared with drugs plus endoscopy.
AB - BACKGROUND & AIMS: Compared with drugs plus endoscopy, placement of transjugular portosystemic shunt within 72 hours of admission to the hospital (early or preventive transjugular intrahepatic portosystemic shunt [TIPS], also called preemptive TIPS) increases the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survive for 1 year. However, the benefit of preemptive TIPS is less clear for patients with a Child-Pugh score of B and active bleeding (CP-B+AB). We performed an individual data meta-analysis to assess the efficacy of preemptive TIPS in these patients and identify factors associated with reduced survival of patients receiving preemptive TIPS.METHODS: We searched publication databases for randomized controlled trials and observational studies comparing the effects of preemptive TIPS versus endoscopy plus nonselective beta-blockers in the specific population of high-risk patients with cirrhosis and acute variceal bleeding (CP-B+AB or Child-Pugh C, below 14 points), through December 31, 2019. We performed a meta-analysis of data from 7 studies (3 randomized controlled trials and 4 observational studies), comprising 1327 patients (310 received preemptive TIPS and 1017 received drugs plus endoscopy). We built adjusted models to evaluate risk using propensity score for baseline covariates. Multivariate Cox regression models were used to assess the factors associated with survival time. The primary endpoint was effects of preemptive TIPS versus drugs plus endoscopy on 1-year survival in the overall population as well as CP-B+AB and Child-Pugh C patients.RESULTS: Overall, preemptive TIPS significantly increased the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survived for 1 year, compared with drugs plus endoscopy (hazard ratio [HR] 0.443; 95% CI 0.323-0.607; P < .001). This effect was observed in CP-B+AB patients (HR 0.524; 95% CI 0.307-0.896; P = .018) and in patients with Child-Pugh C scores below 14 points (HR 0.374; 95% CI 0.253-0.553; P < .001). Preemptive TIPS significantly improved control of bleeding and ascites without increasing risk of hepatic encephalopathy in Child-Pugh C and CP-B+AB patients, compared with drugs plus endoscopy. Cox analysis of patients who received preemptive TIPS showed that patients could be classified into 3 categories for risk of death, based on age, serum level of creatinine, and Child-Pugh score. In each of these risk categories, preemptive TIPS increased the proportion of patients who survived for 1 year, compared with drugs plus endoscopy.CONCLUSIONS: In a meta-analysis of data from 1327 patients with cirrhosis, acute variceal bleeding, and Child-Pugh score between 10 and 13 points or CP-B+AB, preemptive TIPS increased the proportion who survived for 1 year, in both subgroups separately, compared with drugs plus endoscopy.
KW - AVB
KW - HE
KW - Liver Disease
KW - Treatment
KW - Humans
KW - Middle Aged
KW - Male
KW - Treatment Outcome
KW - Female
KW - Aged
KW - Esophageal and Gastric Varices/complications
KW - Portasystemic Shunt, Transjugular Intrahepatic
KW - Gastrointestinal Hemorrhage/etiology
UR - http://www.scopus.com/inward/record.url?scp=85097664689&partnerID=8YFLogxK
U2 - 10.1053/j.gastro.2020.09.026
DO - 10.1053/j.gastro.2020.09.026
M3 - Journal article
C2 - 32980344
SN - 0016-5085
VL - 160
SP - 193-205.e10
JO - Gastroenterology
JF - Gastroenterology
IS - 1
ER -