New research led by Yael R. Nobel, MD, MS, and Elizabeth Verna, MD, MS, transplant hepatologists at NewYork-Presbyterian and Columbia, sheds light on which patients can achieve long-term transplant free survival following transjugular intrahepatic portosystemic shunt (TIPS) without significant risk of portal hypertensive complications.
The study, which was recently published in Hepatology, examined the long-term clinical outcomes after TIPS and identified factors associated with survival after the procedure. The findings could help alert healthcare provides to which patients will require liver transplant evaluation after TIPS and which patients are likely to remain stable with TIPS alone.
Below, Dr. Nobel shares results from the multicenter retrospective cohort study and explains why patients should be reassessed six months after TIPS.
For carefully selected patients, TIPS alone can provide both long-term transplant-free survival and freedom from portal hypertensive complications.
TIPS In the Modern Era
TIPS is performed in patients with advanced liver disease who are having complications of portal hypertension. Liver transplant is the only definitive management of end-stage liver disease and portal hypertension. But in the modern era, as technology for TIPS has improved and we’ve gained more clinical experience, hepatologists have found that some of our patients do very well in the long term with TIPS alone. The motivation for this study was to understand the factors that are associated with long-term transplant-free survival following TIPS so that clinicians can better risk-stratify our patients undergoing TIPS and understand their long-term outcomes.
We found that among patients who survived the first six months after TIPS without needing a liver transplant, more than half maintained transplant-free survival at three years after TIPS.
— Dr. Yael Nobel
Key Findings
The highest rate of death or liver transplant typically occurs within the first several months after TIPS, so we evaluated patients not only at the time of TIPS but also at six months following the procedure. We found that among patients who had early transplant-free survival, more than half maintained transplant-free survival at three years after TIPS. That was striking since TIPS has traditionally been considered a temporary solution.
Those patients who achieved long-term transplant free survival after TIPS had low rates of portal hypertension complications, including hospitalizations for hepatic encephalopathy.
— Dr. Yael Nobel
The study also identified a predictor of long-term outcomes after TIPS. The change in the patient’s MELD-Na (Model of End-stage Liver Disease plus sodium) score from the time of TIPS to six months after the procedure was a very strong predictor of long-term outcomes. Specifically, patients who had an increase of more than three points in their MELD-Na score had significantly reduced long-term survival after TIPS, regardless of their initial score. Finally, those patients who achieved long-term transplant free survival after TIPS had low rates of portal hypertension complications, including hospitalizations for hepatic encephalopathy.
How a patient weathers the dynamic period immediately after TIPS can help determine whether they would benefit from progressing to liver transplant evaluation.
— Dr. Yael Nobel
Practice Changes
Our findings provide an important update on the long-term clinical outcomes after TIPS and can help inform our conversations with patients about what to expect after undergoing TIPS. These findings can also help us reconsider which patients may be appropriate for TIPS. For instance, if a certain patient is not a candidate for transplant, they could still achieve long-term survival and freedom from portal hypertensive complications after TIPS alone. The study also highlights the importance of reevaluating a patients’ clinical status at six months after TIPS. How a patient weathers the dynamic period immediately after TIPS can help determine whether they would benefit from progressing to liver transplant evaluation. We are fortunate at NewYork-Presbyterian and Columbia to be able to offer our patients the full spectrum of expert, advanced liver care, from hepatology care to TIPS to liver transplantation.
