Published online Mar 22, 2023. doi: 10.4291/wjgp.v14.i2.34
Peer-review started: November 29, 2022
First decision: January 31, 2023
Revised: February 23, 2023
Accepted: March 10, 2023
Article in press: March 10, 2023
Published online: March 22, 2023
Processing time: 111 Days and 16.4 Hours
Transjugular intrahepatic portosystemic shunt (TIPS) is now established as the salvage procedure of choice in patients who have uncontrolled or severe recurrent variceal bleeding despite optimal medical and endoscopic treatment.
Although TIPS is a minimally invasive procedure, appropriate patient selection is crucial to identify patients who would benefit from the procedure, considering the substantial risks of hepatic encephalopathy, liver failure and increased overall morbidity and mortality in high-risk individuals.
In this study the accuracy of a novel CABIN score, which was developed to overcome limitations of existing scoring systems, was compared to established risk scores for the prediction of in-hospital mortality following sTIPS.
Eight risk scores were evaluated in a cohort which included all adult patients who underwent sTIPS for uncontrollable or life-threatening refractory variceal bleeding. A new five component CABIN score was devised in which each CABIN variable was scored from one to five and the cumulative total is calculated by adding the individual values of the five biochemical components (Creatinine, Albumin, Bilirubin, INR (international normalized ratio) and Na (sodium). The best total CABIN score computes at 5 points and the worst at 25 points. Four CABIN categories (A-D) were established (A: 5-10 points, B: 11-15, C: 16-20, D: 21-25). The CABIN score and seven previously described scoring systems, Acute Physiology and Chronic Health Evaluation (APACHE) II, Bonn TIPS early mortality (BOTEM), Child-Pugh, Emory, FIPS, model for end-stage liver disease (MELD), and MELD-Na scores were calculated based on clinical evaluation and laboratory values obtained before the sTIPS procedure. The primary study outcome measure was prediction of in-hospital mortality after sTIPS and compared the relative performances of the seven established scoring models and the new CABIN score.
In 34 patients (6%) who underwent sTIPS, bleeding was either uncontrollable ab initio (n = 11) or life-threatening refractory (n = 23) despite optimal endoscopic and pharmacological management. Ten patients (29.4%) died in hospital at a median of 5 d following the procedure (range 1-10 d). Nine of the 12 (75%) patients who required pre-sTIPS balloon tamponade died, while all nine (100%) patients who were hypotensive (systolic blood pressure < 70 mmHg) and with the combination of > 8 unit blood transfusion, inotropic support, balloon tamponade and mechanical ventilation died. The CABIN score [area under the receiver operating characteristic curve (AUROC) 0.967] had the highest discriminative ability in predicting in-hospital death compared to the APACHE II (AUROC 0.948), BOTEM (AUROC 0.877), C-P (AUROC 0.802), EMORY (AUROC 0.942), FIPS (AUROC 0.892), MELD (AUROC 0.792), and MELD-Na (AUROC 0.865) scores. The median CABIN score in the 24 in-hospital TIPS survivors was 8 (range 5-18) compared to a median of 17 (range 11-22) in the 10 deaths. CABIN A patients had a 100% survival, compared to 25% and 12.5% survival in CABIN B and CABIN C category patients respectively. CABIN points of 11 or more provided a clear survival cut-off. No patients with CABIN scores < 10 died while 83% of patients with CABIN scores of > 11 died.
The novel CABIN prognostic score, which is objective, quantitative, and reproducible, combines five easily obtained laboratory test results and provides improved statistical power predicting in-hospital mortality in patients with uncontrolled variceal bleeding undergoing sTIPS. The CABIN score identified high-risk patients and outperformed other scoring systems in predicting in-hospital mortality. Despite the fact that mortality was 75% for CABIN B, 87.5% for CABIN C, and 83% for CABIN scores > 10 in this study, this high-risk category should not be denied consideration for an emergency TIPS and be assessed on a case by case basis especially in units where there is prompt access to liver transplantation after sTIPS.
This study was based on a small defined cohort of predominantly alcoholic decompensated cirrhotic patients undergoing emergent TIPS and this newly developed derivative CABIN score will need further prospective external validation before being considered for general clinical application.