Short-term mortality is reduced and low grade ACLF reversed by TIPS in patients with fluid overload: a case-control study

Introduction: Portal hypertension characterizes decompensated cirrhosis and its complications. It may trigger acute-on-chronic liver failure (ACLF) which carries a high mortality. Transjugular intrahepatic portosystemic shunt (TIPS) is the most efficient therapy for most portal hypertension-related complications including fluid overload (FO) defined as refractory or recurrent ascites, hepatorenal syndrome and/or hydrothorax. However, TIPS for FO in ACLF is questioned. Methods: In this case-control study, patients from the prospective cohorts CANONIC (n= 1324) and German TIPS-Registry (n= 724) were screened for cases of FO and matched 1:1 by sex, age, MELD and presence and grade of ACLF. Clinical outcomes, ACLF status and mortality were assessed. Results: The total population was 118 ACLF patients of whom 59 received TIPS and 59 did not. The main indication for TIPS was hepatorenal syndrome (61.0%). ACLF patients who did not receive TIPS had a higher 28-day cumulative mortality rate (22.0% vs. 5.1%, p= 0.009). At 28 days TIPS insertion in ACLF associated with a 78% mortality reduction (HR 0.22 [0.06 – 0.77]). It further led to improvement of hepatic encephalopathy and the MELD-score. Additionally, ACLF resolution occurred in 61% of TIPS ACLF patients. The presence of coagulation and circulatory organ failures, and increased bilirubin, INR, MELD and CLIF-C OF associated with 28-day mortality. The survival benefit of TIPS was no longer observed after 90 days. Conclusions: TIPS decreased the 28-day mortality of patients with FO and ACLF. Thus, TIPS should be regarded as a bridging strategy – ideally for liver transplantation.