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Severe Hyperbilirubinemia after Creation of Transjugular Intrahepatic Portosystemic Shunts: Natural History and Predictors of Outcome

Smita S. Rouillard, MD; Nathan M. Bass, MD, PhD; John P. Roberts, MD; Catherine A. Doherty, RN; Lauren Gee, MPH; Peter Bacchetti, PhD; and Kenneth A. Somberg, MD
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From the University of California, San Francisco, San Francisco, California. Grant Support: In part by National Institutes of Health Institutional National Research Service Award T32DK07007 (Dr. Rouillard) and Clinical and Biostatistics Core Facility of National Institutes of Health Liver Center grant 5 P30 DK26743-17 (Dr. Bacchetti and Ms. Gee). Requests for Reprints: Kenneth A. Somberg, MD, Division of Gastroenterology, S-357, University of California, San Francisco, 513 Parnassus Avenue, Box 0538, San Francisco, CA 94143. Current Author Addresses: Drs. Rouillard, Bass, and Somberg and Ms. Doherty: Division of Gastroenterology, S-357, University of California, San Francisco, 513 Parnassus Avenue, Box 0538, San Francisco, CA 94143.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;128(5):374-377. doi:10.7326/0003-4819-128-5-199803010-00006
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Background: Hyperbilirubinemia after creation of transjugular intrahepatic portosystemic shunts (TIPS) has been attributed to hemolysis and portal diversion, but the causes and natural history of this condition remain unknown.

Objective: To determine clinical outcomes and predictors of severe hyperbilirubinemia after TIPS creation.

Design: Retrospective analysis of all patients who underwent TIPS creation from June 1990 to September 1996.

Setting: Academic medical center.

Patients: 19 adults who developed severe hyperbilirubinemia (bilirubin level > 171.0 µmol/L) within 1 month after TIPS creation were compared with 213 adults who did not develop hyperbilirubinemia after TIPS creation.

Intervention: TIPS creation.

Measurements: Laboratory measures and clinical outcomes.

Results: According to laboratory indices, hemolysis was unlikely to have occurred. By 90 days, 95% of patients with hyperbilirubinemia had died or had undergone liver transplantation compared with 17% of controls (P < 0.001). Predictors of hyperbilirubinemia included nonalcoholic causes of liver disease (P = 0.01) and a pre-TIPS prothrombin time of 17 seconds or more (P = 0.016).

Conclusions: Severe hyperbilirubinemia after TIPS creation heralds a high risk for death or need for liver transplantation. Reduced hepatic reserve predicts the development of hyperbilirubinemia.


Grahic Jump Location
Figure 1.
Liver function and hematologic indices among 19 patients with hyperbilirubinemia 1 day before insertion of the transjugular intrahepatic portosystemic shunt (TIPS), 1 day after insertion, and within or at 30 days after insertion.Top left.Top right.Bottom left.Bottom right.

Total serum bilirubin level. Prothrombin time. Aspartate aminotransferase (AST) level, expressed as fold-increase above the patient's pre-TIPS level. Serum hemoglobin level.

Grahic Jump Location




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