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International Congress Highlights 2004Clinical Update in GI disease
Portal Hypertension
P. Michielsen
University of Antwerp
20.11.2004
Discussed abstracts
• Bureau C. et al. A randomized study cmparing the use of polytrtrafluoroethylene (PFTE) covered stents and non-covered stents for TIPS: long term patency. Hepatology 2004;40 (suppl. 1): 186A.
• Bolondi L. et al. Potassium canrenoate decreases the incidence of portal hypertension-related complications in compensated cirrhosis. A double-blind randomized study. Hepatology 2004;40 (suppl. 1): 224A
• Thabut C. et al. Diagnostic value of fibrosis biochemical markers (Fibrotest-Fibrosure) for the prediction of severe portal hypertension in patients with and without cirrhosis. Hepatology 2004;40 (supppl. 1): 202A
Covered TIPS (Viatorr) vs uncovered stentsC. Bureau et al. (Toulouse, Barcelona, Montréal)
• Background– 50% dysfunction rate at 1 year major
drawback TIPS procedure– Use of polytetrafluoroethylene (PTFE)
covered stents decreases rate TIPS dysfunction at 1 year (Bureau et al. Gastroenterology 2004;126:469-75)
• Aim: report long-term patency at 2 years
Covered TIPS (Viatorr) vs uncovered stentsC. Bureau et al. (Toulouse, Barcelona, Montréal)
• Methods– 80 cirrhotic patients treated by TIPS
• 24 for active variceal bleeding• 24 for prevention of rebleeding• 32 for refractory ascites
– Randomization• Group A (n=39): PTFE covered stent• Group B (n=41): uncovered stent
– Follow-up• Doppler US day 7, 1 month, then every 3 months• Angiography and HVPG measurement every 6 months and when stent
dysfunction suspected
– Shunt dysfunction• stenosis > 50% of lumen and/or• HVPG > 12 mm Hg
Covered TIPS (Viatorr) vs uncovered stentsC. Bureau et al. (Toulouse, Barcelona, Montréal)
• Results at 2 years– Shunt dysfunction
• Group A (covered): 15%• Group B (uncovered): 44% (p<0.005)
– Primary patency• Group A (covered): 76%• Group B (uncovered): 36% (p=0.001)
– Recurrent complications portal hypertension• Group A (covered): 19%• Group B (uncovered): 38% (p=0.002)
– Survival: similar– Encephalopathy
• Group A (covered): 33%• Group B (uncovered): 49% (p<0.05)
Covered TIPS (Viatorr) vs uncovered stentsC. Bureau et al. (Toulouse, Barcelona, Montréal)
• Conclusions : PTFE covered stents – improve long-term patency of TIPS– prevent clinical relapses– decrease rate of encephalopathy
Covered TIPS (Viatorr) vs uncovered stentsComment: M. Rössle (Freiburg) and K.D. Mullen
(Cleveland, OH), Hepatology 2004;40:495-7
• Risk HE lower in covered stents explained by decreased need to revise TIPS
• But: diameter bare stents 11.70.8 mm vs covered 10.50.9 mm– Greater bare stents to prevent early
insufficiency– Smaller covered stents to reduce risk HE
Covered TIPS (Viatorr) vs uncovered stentsComment: M. Rössle (Freiburg) and K.D. Mullen
(Cleveland, OH), Hepatology 2004;40:495-7
• Proposal– Small diameter (8 mm) covered stents to be
used in patients with variceal bleeding (where partial pressure reduction may be effective in preventing rebleeding)
– Bare stents• In patients with higher risk HE and liver failure• In patients with refractory ascites (10-12 mm):
large stent more effective + protection against HE at long-term follow-up
K canrenoate and portal hypertension related complications in compensated cirrhosis
L. Bolondi et al., Italy
• Background– Aldosterone-dependent renal sodium retention
in compensated cirrhosis contributes to portal hypertension and ascites formation
– Chronic spironolactone administration has been shown to effectively reduce variceal pressure (Nevens et al., Hepatology 1996;23:1047-52)
K canrenoate and portal hypertension related complications in compensated cirrhosis
L. Bolondi et al., Italy
• Aim:
Evaluation oral K canrenoate in patients with preascitic cirrhosis for 1 year on– Appearance of esophageal varices– Worsening stage F1 esophageal varices– De novo appearance of ascites
K canrenoate and portal hypertension related complications in compensated cirrhosis
L. Bolondi et al., Italy
• Methods– Multicenter prospective double-blind randomized
controlled study with 2 arms.– Inclusion:
• Child A viral cirrhosis• No present or past ascites• F1 or no varices• Presence of endoscopic or US signs portal hypertension
– 120 patients enrolled• Group 1: K canrenoate 100 mg/d (n=66)• Group 2: placebo (n = 54)
– Evaluation: baseline, wk 2, 17, 34, 52
K canrenoate and portal hypertension related complications in compensated cirrhosis
L. Bolondi et al., Italy
• Results– Complete follow-up
• K canreanoate: 50/66• Placebo: 43/54
– Worsening varices: 30.1% in placebo vs 18% in K canrenoate (ns)
– Appearance ascites: 10.6% in placebo vs 2% in K canrenoate (ns)
– Any primary endpoint (risk ascites, appearance or worsening esophageal varices): 38.3% in placebo vs 17.6% in K canrenoate (p<0.05)
– Adverse events: no difference
K canrenoate and portal hypertension related complications in compensated cirrhosis
L. Bolondi et al., Italy
• Conclusion
Oral K canrenoate is well tolerated and significantly decreases development of portal hypertension related complications in compensated liver disease over 1 year.
Diagnostic value fibrosis biochemical markers (Fibrotest-Fibrosure) for prediction of severe portal hypertension
Thabut et al., Paris, France
• Background
– Best way to estimate degree PH is measurement HVPG
– Fibrotest® (Biopredictive) is a marker of liver fibrosis, combining 5 components
• 3 proteins: – α2 macroglobulin
– apolipoprotein-A2
– haptoglobin
• bilirubin• γ-GT
adjusted to age and gender. It ranges from 0 to 1
Diagnostic value fibrosis biochemical markers (Fibrotest-Fibrosure) for prediction of severe portal hypertension
Thabut et al., Paris, France
• Aim– Assess predictive value Fibrotest (FT) for
diagnosis of severe PH in cirrhosis– Determine if FT can help in diagnosis severe
PH in patients without cirrhosis• Methods
– Transjugular catheterisation (end point HVPG > 12 mm Hg) and biopsy
– Measurement biochemical values
Diagnostic value fibrosis biochemical markers (Fibrotest-Fibrosure) for prediction of severe portal hypertension
Thabut et al., Paris, France
• Results : 179 patients included
Histology FibrotestHVPG
Normal architecture (26%) 0.43 4
Fibrosis (21%) 0.76* 10*
Cirrhosis (53%) 0.93* 18*
*p<0.001
Significant correlation HVPG and FT
Diagnostic value fibrosis biochemical markers (Fibrotest-Fibrosure) for prediction of severe portal hypertension
Thabut et al., Paris, France
• Results :Cirrhosis HVPG FT
<12 mm Hg (n=8) 0.76>12 mm Hg 0.87 (p=0.04)
Fibrosis (n = 38)HVPG FT<12 mm Hg 0.67>12 mm Hg (n=12) 0.86 (p=0.003)
Normal liver architecture (n = 46)HVPG FT<12 mm Hg 0.47>12 mm Hg (n = 3) 0.97 (p=0.02)
Diagnostic value fibrosis biochemical markers (Fibrotest-Fibrosure) for prediction of severe portal hypertension
Thabut et al., Paris, France
Diagnostic value fibrosis biochemical markers (Fibrotest-Fibrosure) for prediction of severe portal hypertension
Thabut et al., Paris, France
• Conclusions– In cirrhosis, FT can discriminate patients with
severe PH– In non cirrhosis, FT can help to detect severe
PH
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