Original articlePancreas, biliary tract, and liverMulticenter External Validation of Risk Stratification Criteria for Patients With Variceal Bleeding
Section snippets
Study Design and Data Collection
The study was conceived as an observational, multicenter, international, validation cohort study based on the analysis of previously collected clinical data from patients from the participating centers. The study cohort was assembled by pooling already collected individual data from published studies on the prognosis of 4 different groups from Canada (Alberta University, Edmonton), Italy (Ospedalle Cardarelli, Naples), and Spain (Hospital Universitari Bellvitge and Hospital Universitari Vall
Patients and Treatments
A total of 915 patients fulfilled the inclusion criteria. The main outcome (6-week mortality) was not available in 11 patients. The remaining 904 patients were included for evaluation (288 from Naples, 269 from Alberta, 215 from Bellvitge-Barcelona, and 132 from Vall d’Hebron-Barcelona). Baseline characteristics of patients and therapies for the whole cohort are detailed in Supplementary Table 3. For a description of the patients from each individual center see Supplementary Table 4.
Thus,
Discussion
The efficacy and safety of the early TIPS approach for high-risk patients with AVB was shown clearly in the original early TIPS trials8 and has been confirmed afterward.9, 16 However, the definition of high-risk patients in this setting is still a matter of debate. More specifically, the consideration of Child–Pugh B patients as high risk has been questioned.10, 11, 14 As a consequence, several alternatives to the original early TIPS criteria have been proposed. Among these, the ChildC-C1 rule
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EASL Clinical Practice Guidelines on acute-on-chronic liver failure
2023, Journal of HepatologyCLIF-C AD score predicts survival benefit from pre-emptive TIPS in individuals with Child-Pugh B cirrhosis and acute variceal bleeding
2022, JHEP ReportsCitation Excerpt :Currently, the only available risk stratification tool for Child-Pugh B cirrhosis is active bleeding at endoscopy despite intravenous vasoactive drug therapy. However, active bleeding at endoscopy has been criticised for overestimating the risk of death in individuals with Child-Pugh B cirrhosis and because of its subjectivity14–16. A recent meta-analysis of individual patient data suggested that only individuals with Child-Pugh scores of 8-9 and active bleeding at endoscopy (Child B8-9+AB criteria) are at high risk of death and can derive survival benefit from pre-emptive TIPS.7
Management of Decompensated Cirrhosis and Associated Syndromes
2022, Surgical Clinics of North AmericaCitation Excerpt :TIPS within 72 hours has been proposed based on an early randomized controlled trial for patients with cirrhosis and Child-Pugh class B with active bleeding or Child-Pugh class C regardless of endoscopic findings.70 More recently, a large multicenter study demonstrated that Child-Pugh B patients had reduced mortality with standard therapy than Child-Pugh C patients, suggesting that they may not benefit from early TIPS, while those with Child-Pugh C and/or MELD ≥19 had the highest mortality.71 While additional refinement of the criteria for early TIPS is needed, those with Child-Pugh C should be considered for early TIPS and involving gastroenterology, hepatology, and interventional radiology early on is likely beneficial.56,72
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Conflicts of interest The authors disclose no conflicts.
Funding Irene Conejo is a PhD student at the Universitat Autònoma de Barcelona, Barcelona, Spain and is supported by Hospital Universitari Vall d'Hebron. Salvador Augustin is a recipient of a Juan Rodés grant from the Instituto de Salud Carlos III and Joan Genescà is a recipient of a Research Intensification grant from the Instituto de Salud Carlos III, Madrid, Spain. This study was partially funded by grants PI13/01289, PI14/00331, PI15/00066 and PI17/00310 from the Instituto de Salud Carlos III, and co-financed by the European Regional Development Fund/European Social Fund (ERDF/ESF, “Investing in your future”). The Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) is supported by the Instituto de Salud Carlos III.