Hepatic recompensation according to the Baveno VII criteria via a transjugular intrahepatic portosystemic shunt: Is this true?

Abstract

Hepatic recompensation is firstly described in the Baveno VII criteria, which requires the fulfillment of strict criteria. First, a primary cause of cirrhosis must be addressed, suppressed, or cured. Second, complications of liver cirrhosis, including ascites, encephalopathy, and variceal hemorrhage, must disappear without any intervention. Finally, liver function indicators must be improved. Moreover, without addressing/suppressing/curing cirrhosis and improvement in liver synthetic function, complications, including ascites and variceal hemorrhage can be improved by a transjugular intrahepatic portosystemic shunt (TIPS), which is not evidence of hepatic recompensation. Therefore, on the basis of the definition of hepatic recompensation, TIPS does not achieve hepatic recompensation.

Key Words: Hepatic recompensation; Transjugular intrahepatic portosystemic shunt; Liver function; Cirrhosis

Core Tip: The transjugular intrahepatic portosystemic shunt (TIPS) procedure is currently the most widely used method for treating cirrhotic portal hypertension and is known for causing minimal trauma and having satisfactory results. However, the TIPS procedure is not a perfect treatment. There are increased risks of shunt dysfunction and encephalopathy after TIPS. A TIPS functions as a side-to-side portocaval shunt and promptly reduces portal pressure. In conclusion, TIPSs cannot achieve hepatic recompensation, although they are effective in decreasing the incidence of complications caused by portal hypertension. Hepatic recompensation can be achieved by addressing, suppressing, or curing cirrhosis.

TO THE EDITOR

Hepatic recompensation refers to at least partial regression of the structural and functional changes in cirrhosis patients after addressing the cause of cirrhosis, which is described in the Baveno VII criteria[1]. The definition of “recompensation” requires the fulfillment of strict criteria. First, the primary cause of cirrhosis must be addressed, suppressed, or cured. Second, complications of liver cirrhosis, including ascites, encephalopathy, and variceal hemorrhage, must disappear without any intervention. Finally, liver function indicators must be improved. Recently, Shaaban et al[2] proposed that the use of a transjugular intrahepatic portosystemic shunt (TIPS) is a potential addition to achieve recompensation in patients with portal hypertension. However, it is explicitly stated that without removing/suppressing/curing the primary etiologic factor and improvement in liver synthetic function, complications, including ascites and variceal hemorrhage, are improved by TIPS are not evidence of recompensation[1]. Therefore, on the basis of the definition of hepatic recompensation, a TIPS cannot achieve hepatic recompensation.

DISADVANTAGES OF TIPS

Undoubtedly, the TIPS procedure is currently the most widely used method for treating cirrhotic portal hypertension and is known for causing minimal trauma and having satisfactory results. However, the TIPS procedure is not a perfect treatment. One of the main drawbacks of the TIPS procedure is its average dysfunction rate of 50% at 1 year[3]. When this occurs within the first 3 weeks, dysfunction is secondary to shunt thrombosis. The TIPS procedure requires the implantation of a vascular stent into the liver to achieve diversion of portal vein blood to the hepatic vein. With the advancement of stent materials, the use of polytetrafluoroethylene-covered stents has improved TIPS patency and decreased the number of clinical relapses and reinterventions without increasing the risk of encephalopathy[3]. Compared with bare stents, covered stents have a lower risk of shunt dysfunction and perhaps improved outcomes[4]. However, TIPS dysfunction caused by shunt stenosis or occlusion is inevitable. A total of 15.6% (15/96) of patients who underwent the TIPS procedure developed shunt stenosis or occlusion[5].

Physiologically, TIPSs most closely resemble side-to-side portocaval shunts. Theoretically, this permits some portal blood flow into the liver, thereby reducing the risk of hepatic encephalopathy. However, factors that have been reported to increase encephalopathy include increased stent diameter, an age older than 62 years, and advanced liver disease. Approximately 5%-35% of patients who undergo the TIPS procedure develop hepatic encephalopathy[6]. Small-diameter TIPSs and adjustable-diameter TIPSs might help reduce the risk of encephalopathy[7,8]. However, the risk of encephalopathy after the TIPS procedure was greater than that after sclerotherapy (30% vs 24%) in the treatment of variceal hemorrhage[9].

A controlled trial comparing TIPSs to distal splenorenal shunts (DSRSs) in the prevention of variceal hemorrhage suggested that both shunt types were effective in preventing variceal hemorrhage (rebleeding incidence in 5.5% of patients with DSRSs vs 10.5% of patients with TIPSs; not significant), with no difference in encephalopathy or survival rates[10]. Therefore, a TIPS functions as a side-to-side portocaval shunt. It is beneficial to reduce the hepatic sinusoidal pressure, which could decrease the risk of variceal bleeding and the formation of ascites. However, TIPSs may worsen liver function and increase the risk of hepatic encephalopathy in cirrhosis patients due to its bypass of portal blood flow.

CONCLUSION

In conclusion, TIPSs cannot achieve hepatic recompensation, although they are effective in decreasing the incidence of complications caused by portal hypertension. Hepatic recompensation could be achieved by removing, suppressing, or curing cirrhosis.