Outcomes after technically successful transjugular intrahepatic portosystemic shunt for conventional indications and high-risk clinical subgroups: a multicenter cohort study

Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for refractory ascites and variceal bleeding. However, its role in special populations such as those with hepatorenal syndrome–acute kidney injury (HRS-AKI) and acute-on-chronic liver failure (ACLF) remains less defined, which we aimed to assess. In this retrospective study, patients undergoing TIPS across six centers were included. The primary objective was to evaluate transplant-free survival (TFS) following technically successful TIPS. Secondary objectives included descriptive assessment of recorded variceal re-bleeding, complete off-diuretic ascites resolution, hydrothorax response, and post-TIPS complications. TFS associations in high-risk clinical subgroups, including patients with physician-documented HRS-AKI within the preceding three months, chronic kidney disease (CKD), ACLF and splenoportal-axis thrombosis, were evaluated as exploratory analyses. The mean age of the included 207 patients was 55.8 ± 11.7 years, and 73% were men. The most common indications were refractory ascites/hydrothorax (46.8%) and variceal bleeding (39.6%). TFS was 65.2% (135/207; 58.3–71.7). TIPS prevented variceal re-bleeding in 96.3% (79/82) of patients, controlled ascites in 51% (49/97), and resulted in 37.5% complete and 37.5% partial resolution of hydrothorax. TFS was 52.1% in patients with physician-documented HRS-AKI, with ascites control in 51% and prevention of variceal re-bleeding in 89.5%. TFS was 33% in patients with ACLF. After adjustment for recruiting center and baseline disease severity, preceding physician-documented HRS-AKI was not associated with death/transplant either in the Frieberg index of post-TIPS survival (FIPS)-based model (HR, 1.43; 95% CI, 0.80–2.55; P = 0.227) or the model for end-stage liver disease (MELD)-based model (HR, 1.54; 95% CI, 0.88–2.69; P = 0.130). TIPS is safe and effective for controlling variceal bleeding but suboptimal for controlling ascites. The efficacy of TIPS in special populations (HRS-AKI, ACLF) needs further large randomized studies.