Re-Evaluating Transjugular Intrahepatic Portosystemic Shunt Candidacy for Patients with Kidney Disease

People with cirrhosis of the liver are at increased risk of developing kidney dysfunction because of portal hypertension-induced splanchnic vasodilation which decreases effective arterial blood volume. This can lead to hepatorenal syndrome, which manifests clinically as ascites that is refractory to diuretics, a rise in creatinine, and hyponatremia. Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure that shunts blood directly from the portal vein to the hepatic vein, bypassing the high-pressure system of the cirrhotic liver. Among patients with diuretic-resistant ascites, TIPS decreases recurrence of ascites and improves kidney function. However, because less blood is passing through the hepatic sinusoids, postprocedure risks of TIPS, including worsening hepatic encephalopathy and liver ischemia, increase with the severity of liver disease. The model for end-stage liver disease score quantifies this risk using the international normalized ratio, bilirubin, and serum creatinine as variables and has been used to exclude high-risk patients from TIPS. The flaw in this method is that although serum creatinine can indicate worse hepatic function, it is a parameter of this composite score that may improve with TIPS. This review discusses the physiologic changes that occur after TIPS and recommends an individualized approach to TIPS selection in patients with kidney disease.