How to manage transaminitis (elevated liver enzymes) after Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure?

Management of Transaminitis After TIPS Procedure

In patients with transaminitis following TIPS, close monitoring and supportive care are recommended as transient elevation of liver enzymes is a common self-limited complication that typically resolves without specific intervention. 1

Understanding Transaminitis After TIPS

• Transaminitis (elevated liver enzymes) is a recognized complication following TIPS placement, occurring as part of the spectrum of potential liver dysfunction after the procedure 1
• The elevation in liver enzymes is typically self-limited and resolves without specific intervention in most cases 1
• This complication may result from altered liver perfusion due to the creation of the portosystemic shunt, which can temporarily affect liver parenchyma 1

Evaluation of Post-TIPS Transaminitis

• Perform liver function tests to assess the severity of transaminitis and monitor its progression 1
• Conduct Doppler ultrasound to evaluate TIPS patency and rule out shunt dysfunction or thrombosis as a potential cause 1
• Consider other potential causes of transaminitis such as medication effects, viral hepatitis, or other liver insults 2
• In cases of severe transaminitis with signs of liver failure, more urgent evaluation is warranted 1

Management Algorithm

For Mild to Moderate Transaminitis (< 5x Upper Limit of Normal)

• Monitor liver function tests at regular intervals until resolution 1
• Continue standard post-TIPS care including management of underlying portal hypertension 3
• No specific intervention is typically required as this is usually self-limited 1

For Severe Transaminitis (> 5x Upper Limit of Normal) or Signs of Liver Dysfunction

• More frequent monitoring of liver function tests and clinical status 1
• Consider the following interventions if severe liver dysfunction is present:
  • In cases of acute clinical symptoms of over-shunting with parenchymal liver failure, TIPS reduction or occlusion may be necessary 1
  • Evaluate for competing collaterals that may be contributing to excessive shunting 1
  • If significant competing collaterals are identified, consider collateral embolization prior to TIPS reduction 1

For Transaminitis with Hepatic Encephalopathy

• Initiate lactulose as first-line therapy, titrated to achieve 2-3 soft bowel movements per day 4
• Add rifaximin if lactulose alone fails to control symptoms 4
• For refractory cases not responding to medical therapy, consider shunt reduction or occlusion 1, 4

Follow-up and Monitoring

• Perform Doppler ultrasound one week after TIPS implantation in patients with prothrombotic conditions, and at 6-12 month intervals in other patients 1
• Continue monitoring liver function tests until normalization of transaminases 1
• Assess for signs of hepatic encephalopathy, which affects approximately one-third of patients after TIPS 1, 4

Special Considerations

• Patients with pre-existing liver dysfunction may be at higher risk for significant transaminitis after TIPS 1
• The presence of transaminitis does not necessarily correlate with TIPS function or predict long-term outcomes 1
• In cases where transaminitis persists beyond the expected timeframe (typically days to weeks), consider other etiologies of liver injury 2

Common Pitfalls and Caveats

• Avoid premature TIPS reduction or occlusion for transient transaminitis alone without other signs of liver dysfunction, as this may lead to recurrence of the original condition that necessitated TIPS placement 1
• Do not confuse transient post-procedural transaminitis with rejection or serious procedure-related complications such as portal vein thrombosis 5
• Remember that the degree of transaminitis does not necessarily correlate with TIPS function or predict long-term outcomes 1, 5