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Transjugular intrahepatic portosystemic shunts in hemodialysis-dependent patients and patients with advanced renal insufficiency: safety, caution, and encephalopathy.
J Vasc Interv Radiol. 2008 Apr; 19(4):516-20.JV

Abstract

PURPOSE

To retrospectively determine the acute safety and chronic outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with hemodialysis-dependent end-stage renal disease for control of bleeding and refractory ascites.

MATERIALS AND METHODS

Four dialysis-dependent patients and one renal transplant recipient (glomerular filtration rate, 27 mL/min) underwent TIPS creation for treatment of refractory ascites (n = 3) and recurrent portal hypertensive bleeding (n = 1). A sixth patient developed unrelated renal failure 3 years after initial TIPS formation and presented with encephalopathy at that time. All had nearly normal liver function test results and no previous baseline encephalopathy. Three dialysis recipients underwent dialysis immediately after the TIPS procedure in an intensive care unit; one did not.

RESULTS

There were no complications of fluid overload or pulmonary edema after TIPS creation in the patients who immediately underwent dialysis. The one patient in whom dialysis was delayed developed respiratory failure and shock liver (ie, ischemic hepatitis). Ascites resolved in all three patients, and no recurrent variceal bleeding occurred during a mean follow-up of 17 months. Severe, grade 2-4 hepatic encephalopathy developed in all patients; in one patient, its onset was delayed until the onset of renal failure 3 years after the original TIPS procedure. Shunt reduction was required in four cases and competitive variceal embolization was required in one to reduce portosystemic diversion. No less than grade 1 episodic baseline encephalopathy was present in all patients despite continued use of the maximum prescribed medical therapy thereafter.

CONCLUSIONS

TIPS creation is effective in controlling ascites and bleeding in functionally anephric patients, but at the cost of marked and disproportionate hepatic encephalopathy. Prompt, acute postprocedural dialysis and fluid management is critical for safe creation of a TIPS in dialysis-dependent patients.

Authors+Show Affiliations

Division of Vascular and Interventional Radiology, Columbia University College of Physicians and Surgeons, 177 Fort Washington Avenue, MHB 4-100, New York, NY 10032, USA. ziv1@mac.com <ziv1@mac.com>No affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

18375295

Citation

Haskal, Ziv J., and Jai Radhakrishnan. "Transjugular Intrahepatic Portosystemic Shunts in Hemodialysis-dependent Patients and Patients With Advanced Renal Insufficiency: Safety, Caution, and Encephalopathy." Journal of Vascular and Interventional Radiology : JVIR, vol. 19, no. 4, 2008, pp. 516-20.
Haskal ZJ, Radhakrishnan J. Transjugular intrahepatic portosystemic shunts in hemodialysis-dependent patients and patients with advanced renal insufficiency: safety, caution, and encephalopathy. J Vasc Interv Radiol. 2008;19(4):516-20.
Haskal, Z. J., & Radhakrishnan, J. (2008). Transjugular intrahepatic portosystemic shunts in hemodialysis-dependent patients and patients with advanced renal insufficiency: safety, caution, and encephalopathy. Journal of Vascular and Interventional Radiology : JVIR, 19(4), 516-20. https://doi.org/10.1016/j.jvir.2007.11.011
Haskal ZJ, Radhakrishnan J. Transjugular Intrahepatic Portosystemic Shunts in Hemodialysis-dependent Patients and Patients With Advanced Renal Insufficiency: Safety, Caution, and Encephalopathy. J Vasc Interv Radiol. 2008;19(4):516-20. PubMed PMID: 18375295.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Transjugular intrahepatic portosystemic shunts in hemodialysis-dependent patients and patients with advanced renal insufficiency: safety, caution, and encephalopathy. AU - Haskal,Ziv J, AU - Radhakrishnan,Jai, PY - 2007/08/01/received PY - 2007/11/11/revised PY - 2007/11/15/accepted PY - 2008/4/1/pubmed PY - 2008/8/6/medline PY - 2008/4/1/entrez SP - 516 EP - 20 JF - Journal of vascular and interventional radiology : JVIR JO - J Vasc Interv Radiol VL - 19 IS - 4 N2 - PURPOSE: To retrospectively determine the acute safety and chronic outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with hemodialysis-dependent end-stage renal disease for control of bleeding and refractory ascites. MATERIALS AND METHODS: Four dialysis-dependent patients and one renal transplant recipient (glomerular filtration rate, 27 mL/min) underwent TIPS creation for treatment of refractory ascites (n = 3) and recurrent portal hypertensive bleeding (n = 1). A sixth patient developed unrelated renal failure 3 years after initial TIPS formation and presented with encephalopathy at that time. All had nearly normal liver function test results and no previous baseline encephalopathy. Three dialysis recipients underwent dialysis immediately after the TIPS procedure in an intensive care unit; one did not. RESULTS: There were no complications of fluid overload or pulmonary edema after TIPS creation in the patients who immediately underwent dialysis. The one patient in whom dialysis was delayed developed respiratory failure and shock liver (ie, ischemic hepatitis). Ascites resolved in all three patients, and no recurrent variceal bleeding occurred during a mean follow-up of 17 months. Severe, grade 2-4 hepatic encephalopathy developed in all patients; in one patient, its onset was delayed until the onset of renal failure 3 years after the original TIPS procedure. Shunt reduction was required in four cases and competitive variceal embolization was required in one to reduce portosystemic diversion. No less than grade 1 episodic baseline encephalopathy was present in all patients despite continued use of the maximum prescribed medical therapy thereafter. CONCLUSIONS: TIPS creation is effective in controlling ascites and bleeding in functionally anephric patients, but at the cost of marked and disproportionate hepatic encephalopathy. Prompt, acute postprocedural dialysis and fluid management is critical for safe creation of a TIPS in dialysis-dependent patients. SN - 1051-0443 UR - https://www.unboundmedicine.com/medline/citation/18375295/Transjugular_intrahepatic_portosystemic_shunts_in_hemodialysis_dependent_patients_and_patients_with_advanced_renal_insufficiency:_safety_caution_and_encephalopathy_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S1051-0443(07)01472-8 DB - PRIME DP - Unbound Medicine ER -