Skip to main content
NCBI home page
Gut logoLink to Gut
. 2000 Aug;47(2):288–295. doi: 10.1136/gut.47.2.288

Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study

K Brensing 1, J Textor 1, J Perz 1, P Schiedermaier 1, P Raab 1, H Strunk 1, H Klehr 1, H Kramer 1, U Spengler 1, H Schild 1, T Sauerbruch 1
PMCID: PMC1727992  PMID: 10896924

Abstract

BACKGROUND—Recent small studies on hepatorenal syndrome (HRS) indicate some clinical benefit after transjugular intrahepatic portosystemic stent-shunt (TIPS) but sufficient long term data are lacking.
AIM—We studied prospectively feasibility, safety, and long term survival after TIPS in 41 non-transplantable cirrhotics with HRS (phase II study).
PATIENTS AND METHODS—HRS was diagnosed using current criteria (severe (type I) HRS, n=21; moderate (type II) HRS, n=20). Thirty one patients (14 type I, 17 type II) received TIPS (8-10 mm) while advanced liver failure excluded shunting in 10. During follow up (median 24 months) we analysed renal function and survival (Kaplan-Meier).
RESULTS—TIPS markedly reduced the portal pressure gradient (21 (5) to 13 (4) mm Hg (mean (SD)); p<0.001) with one procedure related death (3.2%). Renal function deteriorated without TIPS but improved (p<0.001) within two weeks after TIPS (creatinine clearance 18 (15) to 48 (42) ml/min; sodium excretion 9 (16) to 77 (78) mmol/24 hours) and stabilised thereafter. Following TIPS, three, six, 12, and 18 month survival rates were 81%, 71%, 48%, and 35%, respectively. As only 10% of non-shunted patients survived three months, total survival rates were 63%, 56%, 39%, and 29%, respectively. Multivariate Cox regression analysis revealed bilirubin (p<0.001) and HRS type (p<0.05) as independent survival predictors after TIPS.
CONCLUSIONS—TIPS provides long term renal function and probably survival benefits in the majority of non-transplantable cirrhotics with HRS. These data warrant controlled trials evaluating TIPS in the management of HRS.


Keywords: hepatorenal syndrome; transjugular intrahepatic portosystemic stent-shunt; liver cirrhosis; portal hypertension; ascites; renal failure

Full Text

The Full Text of this article is available as a PDF (175.8 KB).

Figure 1  .

Figure 1  

Open in a new tab

Mean (SD) serum creatinine levels (mg/dl; to convert values to µmol/l multiply by 88.4), creatinine clearance (ml/min), and sodium excretion (mmol/24 hours) up to one year after diagnosis of hepatorenal syndrome in 41 patients of whom 31 received a transjugular intrahepatic portosystemic stent-shunt (TIPS) and 10 were excluded from receiving TIPS. p values were calculated using the Mann-Whitney U test and represent comparisons with baseline for patients at risk or between treatment groups at given time intervals: *p<0.05, **p<0.01, ***p<0.001. Note that all values prior to and up to one week after TIPS were determined without diuretics. Thereafter, moderate diuretic medication with furosemide (40-80 mg/day) and spironolactone (100-200 mg/day) was reintroduced and adapted to the patients' needs.

Figure 2  .

Figure 2  

Open in a new tab

Kaplan-Meier survival analysis. (A) Cohort of patients with hepatorenal syndrome (HRS) treated by transjugular intrahepatic portosystemic stent-shunt (TIPS) (n=31); (B) survival analysis after TIPS according to HRS subtypes at baseline; (C) survival analysis according to clinical response (improved sodium excretion and ascites control within one month) or no response after TIPS; (D) survival analysis of non-TIPS patients (n=10: type I HRS, n=7; type II HRS, n=3) receiving the best medical support. p values were derived from subgroup comparisons using the log rank test.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Angeli P., Volpin R., Gerunda G., Craighero R., Roner P., Merenda R., Amodio P., Sticca A., Caregaro L., Maffei-Faccioli A. Reversal of type 1 hepatorenal syndrome with the administration of midodrine and octreotide. Hepatology. 1999 Jun;29(6):1690–1697. doi: 10.1002/hep.510290629. [DOI] [PubMed] [Google Scholar]
  2. Arroyo V., Ginès P., Gerbes A. L., Dudley F. J., Gentilini P., Laffi G., Reynolds T. B., Ring-Larsen H., Schölmerich J. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology. 1996 Jan;23(1):164–176. doi: 10.1002/hep.510230122. [DOI] [PubMed] [Google Scholar]
  3. Bataller R., Ginès P., Guevara M., Arroyo V. Hepatorenal syndrome. Semin Liver Dis. 1997;17(3):233–247. doi: 10.1055/s-2007-1007201. [DOI] [PubMed] [Google Scholar]
  4. Brensing K. A., Neubrand M., Textor J., Raab P., Müller-Miny H., Scheurlen C., Görich J., Schild H., Sauerbruch T. Endoscopic manometry of esophageal varices: evaluation of a balloon technique compared with direct portal pressure measurement. J Hepatol. 1998 Jul;29(1):94–102. doi: 10.1016/s0168-8278(98)80183-9. [DOI] [PubMed] [Google Scholar]
  5. Brensing K. A., Textor J., Strunk H., Klehr H. U., Schild H., Sauerbruch T. Transjugular intrahepatic portosystemic stent-shunt for hepatorenal syndrome. Lancet. 1997 Mar 8;349(9053):697–698. doi: 10.1016/s0140-6736(97)24010-9. [DOI] [PubMed] [Google Scholar]
  6. Castells A., Saló J., Planas R., Quer J. C., Ginès A., Boix J., Ginès P., Gassull M. A., Terés J., Arroyo V. Impact of shunt surgery for variceal bleeding in the natural history of ascites in cirrhosis: a retrospective study. Hepatology. 1994 Sep;20(3):584–591. [PubMed] [Google Scholar]
  7. Cervoni J. P., Lecomte T., Cellier C., Auroux J., Simon C., Landi B., Gadano A., Barbier J. P. Terlipressin may influence the outcome of hepatorenal syndrome complicating alcoholic hepatitis. Am J Gastroenterol. 1997 Nov;92(11):2113–2114. [PubMed] [Google Scholar]
  8. Conn H. O. Transjugular intrahepatic portal-systemic shunts: the state of the art. Hepatology. 1993 Jan;17(1):148–158. [PubMed] [Google Scholar]
  9. D'Amico G., Pagliaro L., Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology. 1995 Jul;22(1):332–354. doi: 10.1002/hep.1840220145. [DOI] [PubMed] [Google Scholar]
  10. Epstein M., Goligorsky M. S. Endothelin and nitric oxide in hepatorenal syndrome: a balance reset. J Nephrol. 1997 May-Jun;10(3):120–135. [PubMed] [Google Scholar]
  11. Epstein M. The hepatorenal syndrome--newer perspectives. N Engl J Med. 1992 Dec 17;327(25):1810–1811. doi: 10.1056/NEJM199212173272509. [DOI] [PubMed] [Google Scholar]
  12. Fevery J., Van Cutsem E., Nevens F., Van Steenbergen W., Verberckmoes R., De Groote J. Reversal of hepatorenal syndrome in four patients by peroral misoprostol (prostaglandin E1 analogue) and albumin administration. J Hepatol. 1990 Sep;11(2):153–158. doi: 10.1016/0168-8278(90)90106-2. [DOI] [PubMed] [Google Scholar]
  13. Gerbes A. L., Gülberg V., Waggershauser T., Holl J., Reiser M. Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: comparison of patients with ascites, with refractory ascites, or without ascites. Hepatology. 1998 Sep;28(3):683–688. doi: 10.1002/hep.510280313. [DOI] [PubMed] [Google Scholar]
  14. Gerbes A. L., Møller S., Gülberg V., Henriksen J. H. Endothelin-1 and -3 plasma concentrations in patients with cirrhosis: role of splanchnic and renal passage and liver function. Hepatology. 1995 Mar;21(3):735–739. [PubMed] [Google Scholar]
  15. Ginès A., Escorsell A., Ginès P., Saló J., Jiménez W., Inglada L., Navasa M., Clària J., Rimola A., Arroyo V. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology. 1993 Jul;105(1):229–236. doi: 10.1016/0016-5085(93)90031-7. [DOI] [PubMed] [Google Scholar]
  16. Gonwa T. A., Morris C. A., Goldstein R. M., Husberg B. S., Klintmalm G. B. Long-term survival and renal function following liver transplantation in patients with and without hepatorenal syndrome--experience in 300 patients. Transplantation. 1991 Feb;51(2):428–430. doi: 10.1097/00007890-199102000-00030. [DOI] [PubMed] [Google Scholar]
  17. Guevara M., Ginès P., Bandi J. C., Gilabert R., Sort P., Jiménez W., Garcia-Pagan J. C., Bosch J., Arroyo V., Rodés J. Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems. Hepatology. 1998 Aug;28(2):416–422. doi: 10.1002/hep.510280219. [DOI] [PubMed] [Google Scholar]
  18. Guevara M., Ginès P., Fernández-Esparrach G., Sort P., Salmerón J. M., Jiménez W., Arroyo V., Rodés J. Reversibility of hepatorenal syndrome by prolonged administration of ornipressin and plasma volume expansion. Hepatology. 1998 Jan;27(1):35–41. doi: 10.1002/hep.510270107. [DOI] [PubMed] [Google Scholar]
  19. Henriksen J. H. Cirrhosis: ascites and hepatorenal syndrome. Recent advances in pathogenesis. J Hepatol. 1995;23 (Suppl 1):25–30. [PubMed] [Google Scholar]
  20. Henriksen J. H., Ring-Larsen H. Hepatorenal disorders: role of the sympathetic nervous system. Semin Liver Dis. 1994 Feb;14(1):35–43. doi: 10.1055/s-2007-1007296. [DOI] [PubMed] [Google Scholar]
  21. Holt S., Goodier D., Marley R., Patch D., Burroughs A., Fernando B., Harry D., Moore K. Improvement in renal function in hepatorenal syndrome with N-acetylcysteine. Lancet. 1999 Jan 23;353(9149):294–295. doi: 10.1016/s0140-6736(05)74933-3. [DOI] [PubMed] [Google Scholar]
  22. Jalan R., Forrest E. H., Redhead D. N., Dillon J. F., Hayes P. C. Reduction in renal blood flow following acute increase in the portal pressure: evidence for the existence of a hepatorenal reflex in man? Gut. 1997 May;40(5):664–670. doi: 10.1136/gut.40.5.664. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Kaffy F., Borderie C., Chagneau C., Ripault M. P., Larzillière I., Silvain C., Beauchant M. Octreotide in the treatment of the hepatorenal syndrome in cirrhotic patients. J Hepatol. 1999 Jan;30(1):174–174. doi: 10.1016/s0168-8278(99)80025-7. [DOI] [PubMed] [Google Scholar]
  24. Keller F., Heinze H., Jochimsen F., Passfall J., Schuppan D., Büttner P. Risk factors and outcome of 107 patients with decompensated liver disease and acute renal failure (including 26 patients with hepatorenal syndrome): the role of hemodialysis. Ren Fail. 1995 Mar;17(2):135–146. doi: 10.3109/08860229509026250. [DOI] [PubMed] [Google Scholar]
  25. Koppel M. H., Coburn J. W., Mims M. M., Goldstein H., Boyle J. D., Rubini M. E. Transplantation of cadaveric kidneys from patients with hepatorenal syndrome. Evidence for the functionalnature of renal failure in advanced liver disease. N Engl J Med. 1969 Jun 19;280(25):1367–1371. doi: 10.1056/NEJM196906192802501. [DOI] [PubMed] [Google Scholar]
  26. Lake J. R., Ring E., LaBerge J., Gordon R., Roberts J., Ascher N. Transjugular intrahepatic portacaval stent shunts in patients with renal insufficiency. Transplant Proc. 1993 Apr;25(2):1766–1767. [PubMed] [Google Scholar]
  27. Lang F., Tschernko E., Schulze E., Ottl I., Ritter M., Völkl H., Hallbrucker C., Häussinger D. Hepatorenal reflex regulating kidney function. Hepatology. 1991 Oct;14(4 Pt 1):590–594. doi: 10.1016/0270-9139(91)90043-u. [DOI] [PubMed] [Google Scholar]
  28. Lebrec D., Giuily N., Hadengue A., Vilgrain V., Moreau R., Poynard T., Gadano A., Lassen C., Benhamou J. P., Erlinger S. Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial. French Group of Clinicians and a Group of Biologists. J Hepatol. 1996 Aug;25(2):135–144. doi: 10.1016/s0168-8278(96)80065-1. [DOI] [PubMed] [Google Scholar]
  29. Lenz K., Hörtnagl H., Druml W., Reither H., Schmid R., Schneeweiss B., Laggner A., Grimm G., Gerbes A. L. Ornipressin in the treatment of functional renal failure in decompensated liver cirrhosis. Effects on renal hemodynamics and atrial natriuretic factor. Gastroenterology. 1991 Oct;101(4):1060–1067. doi: 10.1016/0016-5085(91)90734-3. [DOI] [PubMed] [Google Scholar]
  30. Lerut J., Goffette P., Laterre P. F., Donataccio M., Reynaert M. S., Otte J. B. Sequential treatment of hepatorenal syndrome and posthepatic cirrhosis by intrahepatic portosystemic shunt (TIPSS) and liver transplantation. Hepatogastroenterology. 1995 Nov-Dec;42(6):985–987. [PubMed] [Google Scholar]
  31. Martinet J. P., Legault L., Cernacek P., Roy L., Dufresne M. P., Spahr L., Fenyves D., Pomier-Layrargues G. Changes in plasma endothelin-1 and Big endothelin-1 induced by transjugular intrahepatic portosystemic shunts in patients with cirrhosis and refractory ascites. J Hepatol. 1996 Nov;25(5):700–706. doi: 10.1016/s0168-8278(96)80241-8. [DOI] [PubMed] [Google Scholar]
  32. Moore K., Wendon J., Frazer M., Karani J., Williams R., Badr K. Plasma endothelin immunoreactivity in liver disease and the hepatorenal syndrome. N Engl J Med. 1992 Dec 17;327(25):1774–1778. doi: 10.1056/NEJM199212173272502. [DOI] [PubMed] [Google Scholar]
  33. Ochs A., Rössle M., Haag K., Hauenstein K. H., Deibert P., Siegerstetter V., Huonker M., Langer M., Blum H. E. The transjugular intrahepatic portosystemic stent-shunt procedure for refractory ascites. N Engl J Med. 1995 May 4;332(18):1192–1197. doi: 10.1056/NEJM199505043321803. [DOI] [PubMed] [Google Scholar]
  34. Quiroga J., Sangro B., Núez M., Bilbao I., Longo J., García-Villarreal L., Zozaya J. M., Betés M., Herrero J. I., Prieto J. Transjugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: effect on clinical, renal, humoral, and hemodynamic parameters. Hepatology. 1995 Apr;21(4):986–994. [PubMed] [Google Scholar]
  35. Rössle M., Haag K., Ochs A., Sellinger M., Nöldge G., Perarnau J. M., Berger E., Blum U., Gabelmann A., Hauenstein K. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med. 1994 Jan 20;330(3):165–171. doi: 10.1056/NEJM199401203300303. [DOI] [PubMed] [Google Scholar]
  36. Sacerdoti D., Balazy M., Angeli P., Gatta A., McGiff J. C. Eicosanoid excretion in hepatic cirrhosis. Predominance of 20-HETE. J Clin Invest. 1997 Sep 1;100(5):1264–1270. doi: 10.1172/JCI119640. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Saló J., Ginès A., Quer J. C., Fernández-Esparrach G., Guevara M., Ginès P., Bataller R., Planas R., Jiménez W., Arroyo V. Renal and neurohormonal changes following simultaneous administration of systemic vasoconstrictors and dopamine or prostacyclin in cirrhotic patients with hepatorenal syndrome. J Hepatol. 1996 Dec;25(6):916–923. doi: 10.1016/s0168-8278(96)80297-2. [DOI] [PubMed] [Google Scholar]
  38. Somberg K. A., Lake J. R., Tomlanovich S. J., LaBerge J. M., Feldstein V., Bass N. M. Transjugular intrahepatic portosystemic shunts for refractory ascites: assessment of clinical and hormonal response and renal function. Hepatology. 1995 Mar;21(3):709–716. [PubMed] [Google Scholar]
  39. Spahr L., Fenyves D., N'Guyen V. V., Roy L., Legault L., Dufresne M. P., Pomier-Layrargues G. Improvement of hepatorenal syndrome by transjugular intrahepatic portosystemic shunt. Am J Gastroenterol. 1995 Jul;90(7):1169–1171. [PubMed] [Google Scholar]
  40. Stanley A. J., Jalan R., Forrest E. H., Redhead D. N., Hayes P. C. Longterm follow up of transjugular intrahepatic portosystemic stent shunt (TIPSS) for the treatment of portal hypertension: results in 130 patients. Gut. 1996 Sep;39(3):479–485. doi: 10.1136/gut.39.3.479. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Sturgis T. M. Hepatorenal syndrome: resolution after transjugular intrahepatic portosystemic shunt. J Clin Gastroenterol. 1995 Apr;20(3):241–243. [PubMed] [Google Scholar]
  42. Wong F., Blendis L. Therapy for hepatorenal syndrome. Gastroenterology. 1998 Aug;115(2):503–504. doi: 10.1016/s0016-5085(98)70225-2. [DOI] [PubMed] [Google Scholar]
  43. Wong F., Sniderman K., Liu P., Allidina Y., Sherman M., Blendis L. Transjugular intrahepatic portosystemic stent shunt: effects on hemodynamics and sodium homeostasis in cirrhosis and refractory ascites. Ann Intern Med. 1995 Jun 1;122(11):816–822. doi: 10.7326/0003-4819-122-11-199506010-00002. [DOI] [PubMed] [Google Scholar]

Articles from Gut are provided here courtesy of BMJ Publishing Group

RESOURCES