Decrease in Portal Hepatic Pressure Gradient Related to Shunts

A reduction in portal hepatic pressure gradient (PPG) soon after implantation of a transjugular intrahepatic portosystemic shunt (TIPS) greater than 60% was associated with improved ascites control at 6 weeks in a study published in Hepatology.

“The probability of ascites resolution is much higher if PPG reduction exceeded 60% of PPG before TIPS,” wrote the researchers, led by co–first authors Alexander Queck, MD, a postdoctoral researcher in the department of internal medicine at University Hospital Frankfurt (Germany) and Goethe University Frankfurt, and Louise Schwierz, MD, of the department of internal medicine in the University Hospital Bonn (Germany). “This study suggests that, even in patients with uncomplicated TIPS insertion, a short-term follow-up 6 weeks after TIPS should be scheduled to be able to predict their course of disease.”

The authors investigated the decrease of PPG in a single-center, retrospective analysis of 341 patients with liver cirrhosis undergoing TIPS insertion for recurrent or refractory ascites between March 1994 and July 2015. During each procedure, portal and inferior vena cava pressures were invasively measured and correlated with patients’ outcomes and ascites progression over time. In 241 patients, or 71%, chronic alcohol consumption was the reason for cirrhosis development, followed by 13% with chronic viral hepatitis (n = 43). Median survival after TIPS insertion was 102 weeks, and 19 patients received liver transplants over time.

Median portal pressure before TIPS placement was 28 mm Hg, which decreased to a median of 21 mm Hg after TIPS. Median PPG levels were 19 mm Hg before TIPS and 8 mm Hg immediately after TIPS placement.

At the time of TIPS placement, 65 patients, or 19%, had hepatic encephalopathy, and nine had severe hepatic encephalopathy. Six weeks after TIPS, two had episodes of hepatic encephalopathy.

After 6 weeks, ascites significantly improved through TIPS insertion. About 47% had a complete resolution of ascites at 6 weeks, whereas 29% had ascites detectable only by ultrasound and 24% of patients still needed large-volume paracentesis. There was an association between extent of PPG reduction and ascites resolution: Median PPG reduction was 55% of initial PPG in patients with persistence of severe ascites, 58% in patients with ascites detected by ultrasound, and 65% in patients with complete resolution of ascites at 6 weeks after TIPS.

Ascites resolved in 54% of patients with higher PPG reduction (60% or above), compared with 39% of patients with lower PPG reduction (below 60%). Ascites that was detected by ultrasound in another 27% of patients with higher PPG reduction, compared with 31% of patients with lower PPG reduction. In addition, persistent severe ascites was seen in 19% of patients with higher PPG reduction, compared with 30% of patients with lower PPG reduction.

The authors also noted the importance of timing follow-up evaluation: They noted that post-TIPS follow-up is a frequent question and not yet standardized; in this study, they found that, with follow-up at 6 weeks, they could “clearly stratify the course post TIPS” and this could “detect patients at high risk of unstable course of disease.”

PPG reduction of more than 60% after TIPS correlated with resolution of severe ascites 6 weeks after TIPS, the study authors concluded.

“This is one of the first studies that highlights the optimal goal for a portal pressure gradient in the setting of refractory ascites post TIPS procedure,” said Neeral Shah, MD, an associate professor of gastroenterology and hepatology and transplant hepatology specialist at the University of Virginia, Charlottesville.

“It is exciting to see some data from patients examining a question we have always thought to be true but have never quantified,” he said. “As a clinician who refers patients for TIPS, one of my biggest concerns is that significant shunting of blood past liver tissue through a TIPS can lead to the development of confusion.”

Shah, who wasn’t involved with the study, pointed to ongoing questions about hepatic encephalopathy around TIPS. The study authors didn’t find an issue with this among their study population, and some patients had improvements in their mental status after TIPS.

“This has not been my experience in those patients with hepatic encephalopathy at baseline pre-TIPS,” Shah said. “This point will need to be clarified further, especially if we are aiming for portal pressure gradients of 10 mm Hg or less in all patients with refractory ascites.”

The study authors declared that the research was conducted without commercial or financial relationships that could be construed as a potential conflict of interest. The authors were supported by the German Research Foundation, the German Federal Ministry of Education and Research, the European Union’s Horizon 2020 research program, and Goethe University Frankfurt. Shah reported no relevant disclosures.

This article originally appeared on, part of the Medscape Professional Network.

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