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Multicenter Study
. 2025 Aug;83(2):348-357.
doi: 10.1016/j.jhep.2025.01.030. Epub 2025 Feb 4.

Freiburg index of post-TIPS survival (FIPS) identifies patients at risk of further decompensation and ACLF after TIPS

Lukas Sturm  1 , Michael Schultheiss  1 , Fabian Stöhr  2 , Christian Labenz  3 , Benjamin Maasoumy  4 , Anja Tiede  4 , Michael Praktiknjo  5 , Leon Louis Seifert  6 , Timo Alexander Auer  7 , Uli Fehrenbach  7 , Felix Piecha  8 , Aenne Harberts  8 , Johannes Kluwe  8 , Tony Bruns  9 , Maike Rebecca Pollmanns  9 , Johannes Chang  10 , Jakub Grobelski  10 , Christian Jansen  10 , Carsten Meyer  11 , Marlene Reincke  12 , Charlotte Rohrer  12 , Sina Rastin Philipp Arbabi  12 , Markus Kimmann  5 , Cristina Ripoll  13 , Alexander Zipprich  13 , Jan Hinrichs  14 , Michael Koehler  15 , Jonel Trebicka  5 , Roman Kloeckner  16 , Cornelius Engelmann  17 , Robert Thimme  12 , Dominik Bettinger  18 ; German Cirrhosis Study Group of the DGVS
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Free article
Multicenter Study

Freiburg index of post-TIPS survival (FIPS) identifies patients at risk of further decompensation and ACLF after TIPS

Lukas Sturm et al. J Hepatol. 2025 Aug.
Free article

Abstract

Background & aims: The Freiburg index of post-TIPS survival (FIPS) defines a high-risk group of patients with significantly reduced survival following transjugular intrahepatic portosystemic shunt (TIPS) implantation. However, the clinical hallmarks responsible for these patients' unfavorable outcome remain to be identified. Therefore, the present study aimed to characterize the clinical course after TIPS implantation according to the FIPS.

Methods: A total of 1,359 patients with cirrhosis allocated to TIPS implantation for treatment of recurrent or refractory ascites or secondary prophylaxis of variceal bleeding from eight tertiary centers were retrospectively included. The patients' clinical course following TIPS placement was analyzed, stratified according to the FIPS. The primary study outcome was further decompensation within 90 days after TIPS; secondary outcomes were acute-on-chronic liver failure (ACLF) within 90 days and 1-year transplant-free survival.

Results: Further decompensation after TIPS implantation was significantly more frequent in FIPS high-risk patients compared to low-risk patients (cumulative incidence function 0.58 vs. 0.38, p <0.001). Moreover, FIPS high-risk patients developed ACLF significantly more often (0.18 vs. 0.08; p = 0.008). Uni- and multivariable competing risk regression analyses confirmed that high-risk FIPS independently predicted further decompensation (subdistribution hazard ratio 1.974; 95% CI 1.531-2.544; p <0.001) and ACLF (subdistribution hazard ratio 2.586; 95% CI 1.449-4.616; p = 0.001) after TIPS. Importantly, further decompensation and ACLF after TIPS were associated with significantly reduced transplant-free survival.

Conclusions: The present study reveals that the FIPS predicts development of further decompensation and ACLF after TIPS implantation. These events are responsible for impaired transplant-free survival in FIPS high-risk patients. These results pave the way for the development of tailored clinical management strategies.

Impact and implications: Prognostication after transjugular intrahepatic portosystemic shunt (TIPS) implantation is challenging. Several clinical scores have been proposed in this context, such as the Freiburg index of post-TIPS survival (FIPS). The FIPS can identify a high-risk group of patients with significantly reduced survival after TIPS. However, to understand the reasons for these patients' unfavorable outcome, their clinical course after TIPS needs to be characterized. This study reveals that the FIPS predicts development of further decompensation and acute-on-chronic liver failure after TIPS implantation, which are responsible for the poor prognosis of FIPS high-risk patients. Therefore, the present results may be useful for tailored decision making in patients allocated to TIPS implantation.

Keywords: acute-on-chronic liver failure; cirrhosis; portal hypertension; transjugular intrahepatic portosystemic shunt.

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Conflict of interest statement

Conflict of interest TB has received consulting fees from Intercept/Advanz Pharma, Grifols, and Sobi as well as honoraria for lectures, presentations, or educational events from Falk Foundation, CSL Behring, Merck, Gilead, Intercept/Advanz Pharma, and Gore. JT has received speaking and/or consulting fees from Versantis, Gore, Boehringer-Ingelheim, Falk, Grifols, Genfit and CSL Behring and was supported by the German Research Foundation (DFG) project ID 403224013 – SFB 1382 (A09), by the German Federal Ministry of Education and Research (BMBF) for the DEEP-HCC project and by the Hessian Ministry of Higher Education, Research and the Arts (HMWK) for the ENABLE and ACLF-I cluster projects. The MICROB-PREDICT (project ID 825694), DECISION (project ID 847949), GALAXY (project ID 668031), LIVERHOPE (project ID 731875), and IHMCSA (project ID 964590) projects have received funding from the European Union’s Horizon 2020 research and innovation program. The manuscript reflects only the authors’ views, and the European Commission is not responsible for any use that may be made of the information it contains. The funders had no influence on study design, data collection and analysis, decision to publish, or preparation of the manuscript. DB: Lecture fees: Falk Foundation, W. L. Gore & Associates; Travel Grants: Gilead Science; Research grants: Dr. Rolf M. Schwiete-Stiftung, German Research Foundation (DFG). Please refer to the accompanying ICMJE disclosure forms for further details.

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