1. Determinants of mortality in patients with cirrhosis and uncontrolled variceal bleeding.
- Author
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Kumar R, Kerbert AJC, Sheikh MF, Roth N, Calvao JAF, Mesquita MD, Barreira AI, Gurm HS, Ramsahye K, Mookerjee RP, Yu D, Davies NH, Mehta G, Agarwal B, Patch D, and Jalan R
- Subjects
- Age Factors, Female, Humans, Intensive Care Units statistics & numerical data, Leukocyte Count methods, London epidemiology, Male, Middle Aged, Mortality, Organ Dysfunction Scores, Prognosis, Risk Assessment, Treatment Failure, Acute-On-Chronic Liver Failure blood, Acute-On-Chronic Liver Failure diagnosis, Acute-On-Chronic Liver Failure etiology, Acute-On-Chronic Liver Failure mortality, Blood Transfusion methods, Blood Transfusion statistics & numerical data, Esophageal and Gastric Varices complications, Esophageal and Gastric Varices diagnosis, Gastrointestinal Hemorrhage etiology, Gastrointestinal Hemorrhage mortality, Gastrointestinal Hemorrhage surgery, Hemostasis, Surgical methods, Hemostasis, Surgical statistics & numerical data, Liver Cirrhosis complications, Liver Cirrhosis diagnosis, Portasystemic Shunt, Transjugular Intrahepatic methods
- Abstract
Background & Aims: Failure to control oesophago-gastric variceal bleeding (OGVB) and acute-on-chronic liver failure (ACLF) are both important prognostic factors in cirrhosis. The aims of this study were to determine whether ACLF and its severity define the risk of death in OGVB and whether insertion of rescue transjugular intrahepatic shunt (TIPS) improves survival in patients with failure to control OGVB and ACLF., Methods: Data on 174 consecutive eligible patients, with failure to control OGVB between 2005 and 2015, were collected from a prospectively maintained intensive care unit registry. Rescue TIPS was defined as technically successful TIPS within 72 hours of presentation with failure to control OGVB. Cox-proportional hazards regression analyses were applied to explore the impact of ACLF and TIPS on survival in patients with failure to control OGVB., Results: Patients with ACLF (n = 119) were significantly older, had organ failures and higher white cell count than patients with acute decompensation (AD, n = 55). Mortality at 42-days and 1-year was significantly higher in patients with ACLF (47.9% and 61.3%) than in those with AD (9.1% and 12.7%, p <0.001), whereas there was no difference in the number of endoscopies and transfusion requirements between these groups. TIPS was inserted in 78 patients (AD 21 [38.2%]; ACLF 57 [47.8%]; p = 0.41). In ACLF, rescue TIPS insertion was an independent favourable prognostic factor for 42-day mortality. In contrast, rescue TIPS did not impact on the outcome of patients with AD., Conclusions: This study shows that in patients with failure to control OGVB, the presence and severity of ACLF determines the risk of 42-day and 1-year mortality. Rescue TIPS is associated with improved survival in patients with ACLF., Lay Summary: Variceal bleeding that is not controlled by initial endoscopy is associated with high risk of death. The results of this study showed that in the occurrence of failure of the liver and other organs defines the risk of death. In these patients, insertion of a shunt inside the liver to drain the portal vein improves survival., Competing Interests: Conflict of interest Rajiv Jalan has research collaborations with Yaqrit and Takeda. Rajiv Jalan is the inventor of OPA, which has been patented by UCL and licensed to Mallinckrodt Pharma. He is also the founder of Yaqrit Ltd, a spin out company from University College London. He is also a Founder of Thoeris Ltd. All the other authors do not have any potential conflict of interest to declare. Please refer to the accompanying ICMJE disclosure forms for further details., (Copyright © 2020 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)
- Published
- 2021
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