Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Early TIPS shows superiority to standard care for advanced cirrhosis with acute variceal bleeding

Key clinical point: For patients with advanced cirrhosis and acute variceal bleeding, early treatment with transjugular intrahepatic portosystemic shunt appears to improve transplantation-free survival.

Major finding: The 1-year transplantation-free survival was 86% among patients treated with early transjugular intrahepatic portosystemic shunt, compared with 73% among those who received standard care (P = .046).

Study details: An open-label, randomized, controlled trial involving 127 patients with cirrhosis and acute variceal bleeding.

Disclosures: The study was funded by the National Key Technology R&D Program, Boost Program of Xijing Hospital, Optimized Overall Project of Shaanxi Province, and National Natural Science Foundation of China. The investigators reported no conflicts of interest.

Citation:

Lv Y et al. Lancet Gastroenterol Hepatol. 2019 May 29. doi: 10.1016/S2468-1253(19)30090-1.

Commentary:

Although the paper published by Lv et al. supports early transjugular intrahepatic portosystemic shunt (TIPS) for some patients with cirrhosis and variceal bleeding, Dominique Thabut, MD, and Marika Rudler, MD, pointed out that this conclusion cannot be applied to all patients.

“First ... the landscape of cirrhosis with acute variceal bleeding in China is different from that in Europe,” they wrote. “Second, the authors chose to include patients with Child-Pugh B disease without active bleeding at endoscopy [the largest group of patients in this trial]; such patients are not often seen in Europe. Last, a survival benefit was only observed when the Child-Pugh B and Child-Pugh C patients were combined, with and without active bleeding. Hence, this study does not permit conclusions to be made for patients with Child-Pugh B disease.”

“Overall, the authors should be congratulated for tackling the much debated issue of preemptive TIPS,” Dr. Thabut and Dr. Rudler wrote. “There is now no doubt about the benefit of preemptive TIPS in patients with Child-Pugh C disease. The beneficial effects of preemptive TIPS on ascites should push us to consider this approach in all patients, in the absence of contraindication.”

Dr. Tabut and Dr. Rudler, of the Institute of Cardiometabolism and Nutrition, Paris, made their remarks in an accompanying editorial (Lancet Gastroenterol Hepatol. 2019 May 29. doi: 10.1016/S2468-1253[19]30172-4). They reported no conflicts of interest.