Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS

JOURNAL OF HEPATOLOGY

卷:73

Article

Trebicka, Jonel^1,2,3,4  Gu, Wenyi^1,3,5  Ibanez-Samaniego, Luis⁶  Hernandez-Gea, Virginia^7,8  Pitarch, Carla³  Garcia, Elisabet³  Procopet, Bogdan^9,10  Giraldez, Alvaro¹¹  Amitrano, Lucio¹²  Villanueva, Candid^8,13,14  Thabut, Dominique^15,16  Silva-Junior, Gilberto, Jr.⁷  Martinez, Javier¹⁷  Genesc, Joan^8,14,18  Bureau, Cristophe⁶  Llop, Elba^8,20  Laleman, Wim²¹  Palazon, Jose Maria²²  Castellote, Jose²³  Rodrigues, Susanag²⁴  Gluud, Liselotte²⁵  Ferreira, Carlos Noronha²⁶  Barcelo, Rafael²⁷  Canete, Nuria²⁸  Rodriguez, Manuel²⁹  Ferlitsch, Arnulf³⁰  Mundi, Jose Luis³¹  Gronbaek, Henning³²  Hernandez-Guerra, Manuel³³  Sassatelli, Romano³⁴  Dell'Era, Alessandra³⁵  Senzolo, Marco³⁶  Abraldes, Juan G.³⁷  Romero-Gomez, Manuel^8,38  Zipprich, Alexander³⁹  Casas, Meritxell⁴⁰  Masnou, Helena⁴¹  Primignani, Massimo⁴²  Weiss, Emmanuel³  Catalina, Maria-Vega⁶  Erasmus, Hans-Peter¹  Uschner, Frank Erhard¹  Schulz, Martin¹  Brol, Maximilian J.⁴³  Praktiknjo, Michael⁴³  Chang, Johannes⁴³  Krag, Aleksander²  Nevens, Frederik²¹  Calleja, Jose Luis^8,20  Robic, Marie Angele¹⁹  Conejo, Irene^8,14,18  Albillos, Agustin^8,17  Rudler, Marika^15,16  Alvarado, Edilmar^8,13,14  Guardascione, Maria Anna¹²  Tantau, Marcel^9,10  Bosch, Jaime^7,8,44  Torres, Ferran^27,45  Pavesi, Marco³  Garcia-Pagan, Juan Carlos^7,8  Jansen, Christian⁴³  Banares, Rafael^8,46 

[1] Goethe Univ Frankfurt, Dept Internal Med 1, Theodor Stern Kai 7, D-60590 Frankfurt, Germany

[2] Odense Univ Hosp, Dept Gastroenterol & Hepatol, Odense, Denmark

[3] European Fdn Study Chron Liver Failure EF CLIF, Barcelona, Spain

[4] Inst Bioengn Catalonia, Barcelona, Spain

[5] Shanghai Jiao Tong Univ, Ren Ji Hosp, Sch Med, Dept Gastroenterol, Shanghai, Peoples R China

[6] Hosp Gen Univ Gregorio Maranon, Serv Med Aparato Digest, CIBERehd, IiSGM, Madrid, Spain

[7] Univ Barcelona, Barcelona Hepat Hemodynam Lab, Liver Unit,IMDIM,Hlth Care Provider European Refe, Hosp Clin,Inst Invest Biomed August Pi & Sunyer, Barcelona, Spain

[8] Ctr Invest Biomed Red Enfermedades Hepat & Digest, Madrid, Spain

[9] Reg Inst Gastroenterol & Hepatol Octavian Fodor, Hepatol Dept, Cluj Napoca, Romania

[10] Iuliu Hatieganu Univ Med & Pharm, Med Clin 3, Cluj Napoca, Romania

[11] Univ Hosp Virgen del Rocio, Clin Management Unit Digest Dis, Seville, Spain

[12] Osped A Cardarelli, Gastroenterol Unit, Naples, Italy

[13] Hosp Santa Creu & Sant Pau, Serv Patol Digest, Barcelona, Spain

[14] CIBERehd, Barcelona, Spain

[15] Grp Hosp Pitie Salpetriere Charles Foix, Paris, France

[16] Paris Sorbonne Univ, Paris, France

[17] Univ Alcala, Dept Gastroenterol, Hosp Univ Ramon y Cajal, Inst Ramon y Cajal Invest Sanitaria IRYCIS,CIBERe, Madrid, Spain

[18] Univ Autonoma Barcelona, Liver Unit, Hosp Univ Vall Hebron, Vall Hebron Inst Res VHIR, Barcelona, Spain

[19] Univ Paul Sabatier Toulouse, Rangueil Hosp, Dept Hepatol, CHU Toulouse, Chu Toulouse, France

[20] Univ Autonoma Madrid, Hosp Univ Puerta Hierro, Liver Unit, CIBERehd, Madrid, Spain

[21] Univ Hosp KU Leuven, Dept Gastroenterol & Hepatol, Leuven, Belgium

[22] Hosp Gen Univ Alicante, Alicante, Spain

[23] Univ Barcelona, Hosp Univ Bellvitge, IDIBELL, Barcelona, Spain

[24] Ctr Hosp Sao Joao, Gastroenterol & Hepatol Dept, Porto, Portugal

[25] Univ Copenhagen, Univ Hosp Hvidovre, Fac Hlth & Med Sci, Med Div,Gastrounit, Copenhagen, Denmark

[26] Ctr Hosp Lisboa Norte, Serv Gastrenterol & Hepatol, Hosp Santa Maria, Lisbon, Portugal

[27] Hosp Clin Barcelona, Inst Invest Biomed August Pi & Sunyer, Med Stat Core Facil, Barcelona, Spain

[28] Univ Autonoma Barcelona, Liver Sect, Gastroenterol Dept, IMIM Hosp del Mar Med Res Inst, Barcelona, Spain

[29] Hosp Cent Asturias, Dept Gastroenterol, Oviedo, Spain

[30] Med Univ Vienna, Dept Internal Med 3, Div Gastroenterol & Hepatol, Vienna, Austria

[31] Univ Hosp San Cecilio, Dept Gastroenterol, Granada, Spain

[32] Aarhus Univ Hosp, Dept Hepatol & Gastroenterol, Aarhus, Denmark

[33] Univ Hosp Canary Isl, Gastroenterol Dept, Tenerife, Spain

[34] Arcispedale Santa Maria Nuova IRCCS, Unit Gastroenterol & Digest Endoscopy, Reggio Emilia, Italy

[35] Univ Milan, Gastroenterol Unit, ASST Fatebenefratelli Sacco, Dept Clin & Biomed Sci, Milan, Italy

[36] Univ Hosp Padua, Dept Surg Oncol & Gastroenterol, Multivisceral Transplant Unit, Gastroenterol, Padua, Italy

[37] Univ Alberta, Cirrhosis Care Clin, Div Gastroenterol, Liver Unit,CEGIIR, Edmonton, AB, Canada

[38] Hosp Univ Valme, CIBERehd, Unidad Hepatol, Seville, Spain

[39] Martin Luther Univ Halle Wittenberg, Dept Internal Med 1, Halle, Saale, Germany

[40] Univ Autonoma Barcelona, Digest Dis Dept, Hepatol Unit, Hosp Sabadell, Sabadell, Spain

[41] Univ Autonoma Barcelona, Hosp Univ Germans Trias & Pujol, Badalona, Spain

[42] Fdn IRCCS CaGranda Osped Maggiore Policlin, CRC AM & A Miglaivacca Ctr Liver Dis, Div Gastroenterol & Hepatol, Milan, Italy

[43] Univ Bonn, Dept Internal Med 1, Bonn, Germany

[44] Bern Univ, Swiss Liver Ctr, Inselspital, Bern, Switzerland

[45] Univ Autonoma Barcelona, Fac Med, Biostat Unit, Barcelona, Spain

[46] Univ Complutense Madrid, Gregorio Maranon Univ, Fac Med, Gregorio Maranon Sanit Res Inst,Gen Hosp, Madrid, Spain

关键词: Acute variceal bleeding;    Acute-on-chronic liver failure;    Cirrhosis;    Rebleeding;   

DOI  :  10.1016/j.jhep.2020.04.024

来源: Elsevier

【 摘 要 】

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 trans-jugular 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 inpatients 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. (C) 2020 European Association for the Study of the Liver. Published by Elsevier B.V.

【 授权许可】

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