International Congress Highlights 2004 Clinical Update in GI disease Portal Hypertension P. Michielsen University of Antwerp 20.11.2004

International Congress Highlights 2004Clinical Update in GI disease

Portal Hypertension

P. Michielsen

University of Antwerp

20.11.2004

55th Annual Meeting AASLD

https://www.aasld.org/eweb/StartPage.aspx?site=aasld3

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


• 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


• 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)


• 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)



• 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



• 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



• 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



• 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



• 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



• 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



• 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)





• Conclusions– In cirrhosis, FT can discriminate patients with

severe PH– In non cirrhosis, FT can help to detect severe

PH

Documents

International Congress Highlights 2004 Clinical Update in GI disease Portal Hypertension P. Michielsen University of Antwerp 20.11.2004