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. 2025 May 31;7(8):101469.
doi: 10.1016/j.jhepr.2025.101469. eCollection 2025 Aug.

Risk of portal hypertensive complications preventable by TIPS in patients with ascites

Lorenz Balcar  1   2 , Marta Tonon  3 , Joan Valls  4   5   6 , Valeria Calvino  3 , Lucie Simonis  1   2 , Jan Embacher  1   2 , Roberta Gagliardi  3 , Christian Sebesta  1   2 , Leonie Hafner  1   2 , Antonio Accetta  3 , Lukas Hartl  1   2 , Mattias Mandorfer  1   2 , Michael Trauner  1 , Paolo Angeli  3 , Thomas Reiberger  1   2 , Juan Carlos García-Pagán  7   8 , Georg Semmler  1   2   9   10 , Salvatore Piano  3
Affiliations

Risk of portal hypertensive complications preventable by TIPS in patients with ascites

Lorenz Balcar et al. JHEP Rep. .

Abstract

Background & aims: Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment of recurrent/refractory ascites in patients with cirrhosis. The aim of this study is to identify patients with ascites as index decompensation who are at risk of developing portal hypertension (PH)-related complications within 12 months that seem preventable by TIPS.

Methods: We included 451 patients from two tertiary care centres (Vienna and Padua, derivation cohort) with clinically significant ascites (grade 2/3) as a single first decompensating event and without contraindications for TIPS placement. Multivariable logistic regression analysis was used to identify variables independently associated with a composite endpoint of PH-related complications (encephalopathy excluded), liver transplantation, or liver-related death. A classification tree was used to identify patients at highest risk for these PH-related complications. Risk estimates were validated in a temporal validation cohort from Vienna (n = 84).

Results: In the derivation cohort (mean age 56 ± 11 years; 69% male; 51% alcohol-related cirrhosis; 44% ascites grade 3; median model for end-stage liver disease [MELD] 12 points), 152 (34%) patients developed the composite endpoint within 12 months. A model including ascites grade, sodium, and MELD accurately predicted the occurrence of this composite endpoint (area under the receiver operator characteristics curve: 0.79 [95% CI: 0.75-0.84]). Two high-risk clusters were identified: patients with grade 3 ascites and either (i) sodium ≤135 mmol/L, or (ii) MELD ≥12 points, with a pooled absolute risk of 64.3% (derivation cohort) and 68.9% (validation cohort) to develop the composite endpoint.

Conclusions: Patients with first decompensation caused by ascites grade 3 and either sodium ≤135 mmol/L or MELD ≥12 are at high risk for PH-related complications that are likely preventable by early TIPS placement. A trial investigating 'early' TIPS in this at-risk population is warranted.

Impact and implications: We identified ascites grade, sodium, and model for end-stage liver disease (MELD) as key predictors of portal hypertension-related complications that may be preventable by TIPS in patients with ascites. Specifically, patients with ascites grade 3 and either sodium ≤135 mmol/L or MELD ≥12 are at risk to experience early clinical deterioration and may benefit from TIPS. A trial investigating 'early' TIPS in this at-risk population is warranted.

Keywords: Ascites; Cirrhosis; Portal hypertension; TIPS.

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Conflict of interest statement

MTo received travel support from Gilead and Grifols. MM received grant support from Echosens, served as a consultant and/or advisory board member and/or speaker for AbbVie, Collective Acumen, Echosens, Gilead, Ipsen, Takeda, and W.L. Gore & Associates and received travel support from AbbVie and Gilead. MT received speaker fees from Agomab, BMS, Chemomab, Falk Foundation, Gilead, Intercept, Ipsen, Jannsen, Madrigal, MSD, and Roche; he advised for AbbVie, Albireo, BiomX, Boehringer Ingelheim, Cymabay, Falk Pharma GmbH, Genfit, Gilead, Hightide, Intercept, Ipsen, Janssen, MSD, Novartis, Phenex, Pliant, Rectify, Regulus, Siemens, and Shire. He further received travel support from AbbVie, Falk, Gilead, Intercept, and Jannsen and research grants from Albireo, Alnylam, Cymabay, Falk, Gilead, Intercept, MSD, Takeda and UltraGenyx. He is also a co-inventor of patents on the medical use of norUDCA filed by the Medical Universities of Graz and Vienna. TR received grant support from AbbVie, Boehringer Ingelheim, Gilead, MSD, Philips Healthcare, Pliant Pharmaceuticals, Siemens, and W.L. Gore & Associates, honoraria for advising/consulting from AbbVie, Bayer, Boehringer Ingelheim, Gilead, Intercept, MSD, and Siemens, speaker fees from AbbVie, Gilead, Intercept, MSD, Roche, and W. L. Gore & Associates as well as and travel support from Boehringer Ingelheim, Gilead, and Roche. JCG-P received grant support from Gore & Associates, Astra Zeneca, Cook, and Mallinckrodt. GS received travel support from Amgen. SP received fees for consulting/advising from Plasma Protein Therapeutics Association, Boehringer Ingelheim, Mallinckrodt and speaking fees from Grifols, Ferring, and Medscape. All the other authors have no conflicts of interest to declare.

Figures

Image 1
Graphical abstract
Fig. 1
Fig. 1
Cumulative incidence curve (Kaplan-Meier method) for the time to clinical deterioration preventable by TIPS. TIPS, transjugular intrahepatic portosystemic shunt.
Fig. 2
Fig. 2
Nomogram to predict the risk of clinical deterioration in the derivation cohort (derived from the multvariate logistic regression model). MELD, model for end-stage liver disease; TIPS, transjugular intrahepatic portosystemic shunt.
Fig. 3
Fig. 3
Classification tree to select patients at high risk for clinical deterioration within 12 months after index decompensation with ascites. MELD, model for end-stage liver disease OLT, orthotopic liver transplantation; RCT, randomised controlled trial.
Fig. 4
Fig. 4
Kaplan-Meier curves depicting the incidence of clinical deterioration potentially preventable by TIPS in the derivation cohort in four risk groups. The four risk groups: (i) ascites grade 2, (ii) ascites grade 3 and sodium >135 mmol/L and MELD <12, (iii) ascites grade 3 and sodium >135 mmol/L and MELD ≥12, and (iv) ascites grade 3 and sodium <135 mmol/L. Number of patients at risk and total number of events shown (at 0, 3, 6, 9, and 12 months). MELD, model for end-stage liver disease; TIPS, transjugular intrahepatic portosystemic shunt.
See this image and copyright information in PMC

References

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