TY - JOUR
T1 - Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS
AU - Trebicka, Jonel
AU - Gu, Wenyi
AU - Ibáñez-Samaniego, Luis
AU - Hernández-Gea, Virginia
AU - Pitarch, Carla
AU - Garcia, Elisabet
AU - Procopet, Bogdan
AU - Giráldez, Álvaro
AU - Amitrano, Lucio
AU - Villanueva, Candid
AU - Thabut, Dominique
AU - Silva-Junior, Gilberto
AU - Martinez, Javier
AU - Genescà, Joan
AU - Bureau, Cristophe
AU - Llop, Elba
AU - Laleman, Wim
AU - Palazon, Jose Maria
AU - Castellote, Jose
AU - Rodrigues, Susanag
AU - Gluud, Liselotte
AU - Ferreira, Carlos Noronha
AU - Barcelo, Rafael
AU - Cañete, Nuria
AU - Rodríguez, Manuel
AU - Ferlitsch, Arnulf
AU - Mundi, Jose Luis
AU - Gronbaek, Henning
AU - Hernández-Guerra, Manuel
AU - Sassatelli, Romano
AU - Dell'Era, Alessandra
AU - Senzolo, Marco
AU - Abraldes, Juan G.
AU - Romero-Gómez, Manuel
AU - Zipprich, Alexander
AU - Casas, Meritxell
AU - Masnou, Helena
AU - Primignani, Massimo
AU - Weiss, Emmanuel
AU - Catalina, Maria Vega
AU - Erasmus, Hans Peter
AU - Uschner, Frank Erhard
AU - Schulz, Martin
AU - Brol, Maximilian J.
AU - Praktiknjo, Michael
AU - Chang, Johannes
AU - Krag, Aleksander
AU - Nevens, Frederik
AU - Calleja, Jose Luis
AU - Torres, Ferran
PY - 2020/11
Y1 - 2020/11
N2 - Background & Aims: The relationship between acute-on-chronic liver failure (ACLF) and acute variceal bleeding (AVB) is poorly understood. Specifically, the prevalence and prognosis of ACLF in the context of AVB is unclear, while the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management in patients with ACLF has not been described to date. Methods: A multicenter, international, observational study was conducted in 2,138 patients from 34 centers between 2011 and 2015. ACLF was defined and graded according to the EASL-CLIF consortium definition. Placement of pre-emptive TIPS (pTIPS) was based on individual center policy. Patients were followed-up for 1 year, until death or liver transplantation. Cox regression and competing risk models (Gray's test) were used to identify independent predictors of rebleeding or mortality. Results: At admission, 380/2,138 (17.8%) patients had ACLF according to EASL-CLIF criteria (grade 1: 38.7%; grade 2: 39.2%; grade 3: 22.1%). The 42-day rebleeding (19% vs. 10%; p <0.001) and mortality (47% vs. 10%; p <0.001) rates were higher in patients with ACLF and increased with ACLF grades. Of note, the presence of ACLF was independently associated with rebleeding and mortality. pTIPS placement improved survival in patients with ACLF at 42 days and 1 year. This effect was also observed in propensity score matching analysis of 66 patients with ACLF, of whom 44 received pTIPs and 22 did not. Conclusions: This large multicenter international real-life study identified ACLF at admission as an independent predictor of rebleeding and mortality in patients with AVB. Moreover, pTIPS was associated with improved survival in patients with ACLF and AVB. Lay summary: Acute variceal bleeding is a deadly complication of liver cirrhosis that results from severe portal hypertension. This study demonstrates that the presence of acute-on-chronic liver failure (ACLF) is the strongest predictor of mortality in patients with acute variceal bleeding. Importantly, patients with ACLF and acute variceal (re)bleeding benefit from pre-emptive (early) placement of a transjugular intrahepatic portosystemic shunt.
AB - Background & Aims: The relationship between acute-on-chronic liver failure (ACLF) and acute variceal bleeding (AVB) is poorly understood. Specifically, the prevalence and prognosis of ACLF in the context of AVB is unclear, while the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management in patients with ACLF has not been described to date. Methods: A multicenter, international, observational study was conducted in 2,138 patients from 34 centers between 2011 and 2015. ACLF was defined and graded according to the EASL-CLIF consortium definition. Placement of pre-emptive TIPS (pTIPS) was based on individual center policy. Patients were followed-up for 1 year, until death or liver transplantation. Cox regression and competing risk models (Gray's test) were used to identify independent predictors of rebleeding or mortality. Results: At admission, 380/2,138 (17.8%) patients had ACLF according to EASL-CLIF criteria (grade 1: 38.7%; grade 2: 39.2%; grade 3: 22.1%). The 42-day rebleeding (19% vs. 10%; p <0.001) and mortality (47% vs. 10%; p <0.001) rates were higher in patients with ACLF and increased with ACLF grades. Of note, the presence of ACLF was independently associated with rebleeding and mortality. pTIPS placement improved survival in patients with ACLF at 42 days and 1 year. This effect was also observed in propensity score matching analysis of 66 patients with ACLF, of whom 44 received pTIPs and 22 did not. Conclusions: This large multicenter international real-life study identified ACLF at admission as an independent predictor of rebleeding and mortality in patients with AVB. Moreover, pTIPS was associated with improved survival in patients with ACLF and AVB. Lay summary: Acute variceal bleeding is a deadly complication of liver cirrhosis that results from severe portal hypertension. This study demonstrates that the presence of acute-on-chronic liver failure (ACLF) is the strongest predictor of mortality in patients with acute variceal bleeding. Importantly, patients with ACLF and acute variceal (re)bleeding benefit from pre-emptive (early) placement of a transjugular intrahepatic portosystemic shunt.
KW - Acute variceal bleeding
KW - Acute-on-chronic liver failure
KW - Cirrhosis
KW - Rebleeding
UR - http://www.scopus.com/inward/record.url?scp=85087285960&partnerID=8YFLogxK
U2 - 10.1016/j.jhep.2020.04.024
DO - 10.1016/j.jhep.2020.04.024
M3 - Artículo
C2 - 32339602
AN - SCOPUS:85087285960
VL - 73
SP - 1082
EP - 1091
JO - Journal of Hepatology
JF - Journal of Hepatology
SN - 0168-8278
IS - 5
ER -