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

doi:10.1059/0003-4819-128-5-199803010-00006

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

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.

Abstract

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.