Balcar Lorenz, Tonon Marta, Valls Joan, Calvino Valeria, Simonis Lucie, Embacher Jan, Gagliardi Roberta, Sebesta Christian, Hafner Leonie, Accetta Antonio, Hartl Lukas, Mandorfer Mattias, Trauner Michael, Angeli Paolo, Reiberger Thomas, García-Pagán Juan Carlos, Semmler Georg, Piano Salvatore
Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
JHEP Rep. 2025 May 31;7(8):101469. doi: 10.1016/j.jhepr.2025.101469. eCollection 2025 Aug.
BACKGROUND & AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment of recurrent/refractory ascites in patients with cirrhosis. The aim of this study is to identify patients with ascites as index decompensation who are at risk of developing portal hypertension (PH)-related complications within 12 months that seem preventable by TIPS.
We included 451 patients from two tertiary care centres (Vienna and Padua, derivation cohort) with clinically significant ascites (grade 2/3) as a single first decompensating event and without contraindications for TIPS placement. Multivariable logistic regression analysis was used to identify variables independently associated with a composite endpoint of PH-related complications (encephalopathy excluded), liver transplantation, or liver-related death. A classification tree was used to identify patients at highest risk for these PH-related complications. Risk estimates were validated in a temporal validation cohort from Vienna (n = 84).
In the derivation cohort (mean age 56 ± 11 years; 69% male; 51% alcohol-related cirrhosis; 44% ascites grade 3; median model for end-stage liver disease [MELD] 12 points), 152 (34%) patients developed the composite endpoint within 12 months. A model including ascites grade, sodium, and MELD accurately predicted the occurrence of this composite endpoint (area under the receiver operator characteristics curve: 0.79 [95% CI: 0.75-0.84]). Two high-risk clusters were identified: patients with grade 3 ascites and either (i) sodium ≤135 mmol/L, or (ii) MELD ≥12 points, with a pooled absolute risk of 64.3% (derivation cohort) and 68.9% (validation cohort) to develop the composite endpoint.
Patients with first decompensation caused by ascites grade 3 and either sodium ≤135 mmol/L or MELD ≥12 are at high risk for PH-related complications that are likely preventable by early TIPS placement. A trial investigating 'early' TIPS in this at-risk population is warranted.
We identified ascites grade, sodium, and model for end-stage liver disease (MELD) as key predictors of portal hypertension-related complications that may be preventable by TIPS in patients with ascites. Specifically, patients with ascites grade 3 and either sodium ≤135 mmol/L or MELD ≥12 are at risk to experience early clinical deterioration and may benefit from TIPS. A trial investigating 'early' TIPS in this at-risk population is warranted.
经颈静脉肝内门体分流术（TIPS）是治疗肝硬化患者复发性/难治性腹水的有效方法。本研究旨在确定以腹水作为首次失代偿指标、在12个月内有发生门静脉高压（PH）相关并发症风险且似乎可通过TIPS预防的患者。
我们纳入了来自两个三级医疗中心（维也纳和帕多瓦，推导队列）的451例患者，这些患者有临床上显著的腹水（2/3级）作为单一首次失代偿事件，且无TIPS置入的禁忌证。采用多变量逻辑回归分析来确定与PH相关并发症（不包括肝性脑病）、肝移植或肝脏相关死亡的复合终点独立相关的变量。使用分类树来确定发生这些PH相关并发症风险最高的患者。风险估计在来自维也纳的时间验证队列（n = 84）中进行验证。
在推导队列（平均年龄56±11岁；69%为男性；51%为酒精性肝硬化；44%腹水为3级；终末期肝病模型[MELD]中位数为12分）中，152例（34%）患者在12个月内发生了复合终点事件。一个包含腹水分级、血钠和MELD的模型准确预测了该复合终点事件的发生（受试者操作特征曲线下面积：0.79[95%CI：0.75 - 0.84]）。确定了两个高危组：3级腹水且（i）血钠≤135 mmol/L或（ii）MELD≥12分的患者，发生复合终点事件的合并绝对风险在推导队列中为64.3%，在验证队列中为68.9%。
由3级腹水导致首次失代偿且血钠≤135 mmol/L或MELD≥12的患者发生PH相关并发症的风险很高，早期置入TIPS可能预防这些并发症。有必要在这一高危人群中开展一项关于“早期”TIPS的试验。
我们确定腹水分级、血钠和终末期肝病模型（MELD）是门静脉高压相关并发症的关键预测因素，对于腹水患者，这些并发症可能可通过TIPS预防。具体而言，3级腹水且血钠≤135 mmol/L或MELD≥12的患者有早期临床病情恶化的风险，可能从TIPS中获益。有必要在这一高危人群中开展一项关于“早期”TIPS的试验。
