TIPS Was Tops for Refractory Hydrothorax in Cirrhosis

A transjugular intrahepatic portosystemic shunt (TIPS) was effective for refractory hepatic hydrothorax in people with cirrhosis, with most having a complete clinical response, according to a retrospective cohort study.

Among 147 patients who received a TIPS, 59.9% had a complete clinical response, 27.2% had a partial clinical response, and 12.9% had no clinical response, reported Carlo Alessandria, MD, of the University of Turin in Italy, at the European Association for the Study of the Liver annual meeting in Barcelona.

Patients with complete responses had significantly better overall survival, with a mortality rate of 1.54 per 100 patient-months at 12 months compared with rates of 5.34 and 11.4 per 100 patient-months among those with partial responses and no responses, translating to a 67% lower mortality risk versus partial responders (HR 0.33, 95% CI 0.15-0.73, P=0.006) and an 85% lower mortality risk compared with nonresponders (HR 0.15, 95% CI 0.06-0.37, P<0.001).

“TIPS was effective for the treatment of hydrothorax in most patients,” Alessandria said during his presentation. “These findings support the use of TIPS as a valuable treatment in patients with refractory hydrothorax.”

About 10% of people with cirrhosis develop refractory hydrothorax, presenting with respiratory symptoms that include dyspnea, cough, pleuritic chest pain, and respiratory failure. Refractory hydrothorax is linked to increased morbidity, more procedural interventions such as thoracentesis and pleural catheters, and lower odds of transplant-free survival.

Hepatic hydrothorax is an indication for TIPS, which lowers portal-vein pressure in cirrhosis by linking the portal vein to a hepatic vein with a shunt. Research on the value of TIPS in refractory hydrothorax is limited, Alessandria noted.

This study included adults with cirrhosis undergoing TIPS for refractory hydrothorax at 18 European centers from January 2008 to December 2023. These patients required at least two evacuative large-volume thoracenteses in the 3 weeks prior to TIPS. Those with nonhepatic hydrothorax, TIPS for other indications, bare stents, or severe comorbidities were excluded.

Median patient age was 61 years, 56.5% were male, and 19% had no abdominal ascites. Cirrhosis etiology was alcohol in nearly half of patients (47.6%), followed by hepatitis C virus infection (23.1%), metabolic dysfunction-associated steatotic liver disease (15.6%), hepatitis B virus infection (4.8%), and hepatitis D virus infection (1.4%).

Patients were followed for 12 months after TIPS placement or until liver transplant or death.

Complete response was defined as symptom resolution, no need for thoracentesis, and no pleural effusion on imaging, while partial response was defined as symptom improvement and at least a 50% reduction in thoracenteses and pleural effusion. Those with no response had minimal or no symptom relief and less than 50% or no reduction in thoracenteses and pleural effusion.

After a mean follow-up of 8 months, 49% of patients were still alive, 25% died, 15% had a liver transplant, and 12% were lost to follow-up. The leading causes of death were liver failure (42%) and sepsis (25%).

Transplant-free survival rates were significantly higher among complete responders compared with partial responders (HR 0.35, 95% CI 0.18-0.66, P=0.001) and nonresponders (HR 0.22, 95% CI 0.10-0.46, P<0.001).

Alessandria conceded “disappointment at not having found baseline variables significantly associated with clinical response,” with everything from dyspnea grade to pleural catheters and abdominal ascites grade failing to show a significant association. The only significant predictors of overall survival after TIPS were Model of End-stage Liver Disease-Sodium (MELD-Na) scores (HR 1.12, 95% CI 1.07-1.17, P<0.001) and clinical complete response (HR 0.30, 95% CI 0.14-0.64, P=0.002).

The most common adverse event was hepatic encephalopathy. Its prevalence increased over time, rising from 16.3% immediately after TIPS to 43.4% by 12 months after the procedure.