TIPS for Hepatorenal Syndrome: Current Indication
TIPS for hepatorenal syndrome (both type 1 and type 2) remains experimental and is not a standard indication, though it may be considered in highly selected patients as a bridge to liver transplantation. 1
Guideline Recommendation
The 2020 Gut guidelines provide a weak recommendation with very low-level evidence that TIPS for HRS remains experimental, despite observations of renal function improvement following the procedure. 1
Why TIPS is Generally Not Recommended for HRS
Physiologic Concerns
The severity of liver disease in HRS patients typically precludes TIPS placement due to poor residual liver function that cannot cope with reduced portal inflow. 1
Risk of hepatic encephalopathy is significantly increased when already compromised liver function is further stressed by the shunt. 1
Potential unmasking of cirrhotic cardiomyopathy occurs when the hemodynamic changes from TIPS stress an already compromised cardiovascular system. 1
Evidence Quality Issues
A 2024 Cochrane systematic review found very low-certainty evidence regarding TIPS effects on mortality, serious adverse events, and transplant rates in HRS patients. 2
Heterogeneity in patient selection and outcomes across studies makes it difficult to draw firm conclusions about efficacy. 1
Only two small randomized trials exist (130 total participants) comparing TIPS to conventional treatment, both with significant methodological limitations. 2
When TIPS Might Be Considered (Exceptional Circumstances)
Type 2 HRS with Better Liver Function
TIPS may be considered in type 2 HRS patients with relatively preserved liver function (Child-Pugh 10-12) as a bridge to transplantation, particularly when:
- Bilirubin is <50 μmol/L and platelets >75×10⁹/L 3
- No pre-existing hepatic encephalopathy 3, 4
- Absence of severe cardiac failure or pulmonary hypertension 3, 4
Sequential Treatment Approach
One small study demonstrated success using a staged approach: medical therapy with midodrine, octreotide, and albumin first to improve renal function (serum creatinine <135 μmol/L), followed by TIPS in responders. 5
- This approach normalized glomerular filtration rate (96 ± 20 mL/min) and urinary sodium excretion (119 ± 15 mmol/24 hours) by 12 months post-TIPS in 5 patients. 5
- However, this was a small uncontrolled study requiring validation. 5
Outcomes Data (Limited Evidence)
Renal Function Improvement
Observational studies show renal function may improve with TIPS (creatinine clearance improving from 18 to 48 mL/min within 2 weeks). 6
One trial showed TIPS may improve kidney function (RR 0.53,95% CI 0.27 to 1.02), but certainty of evidence is low. 2
Survival Data
Long-term survival in non-transplantable cirrhotics with HRS after TIPS: 3-month (81%), 6-month (71%), 12-month (48%), and 18-month (35%) survival rates. 6
Bilirubin level and HRS type are independent predictors of survival after TIPS placement. 6
We are uncertain about mortality benefit compared to conventional treatment based on current evidence (RR 0.88,95% CI 0.55 to 1.38; very low-certainty evidence). 2
Critical Pitfalls to Avoid
Do not place TIPS in type 1 HRS with rapidly progressive liver failure as mortality risk is prohibitive. 1
Do not proceed without cardiac evaluation as cirrhotic cardiomyopathy may be unmasked by the hemodynamic changes. 1
Do not use TIPS as first-line therapy when standard medical management (vasopressors, albumin) has not been attempted. 2
Recognize that most published data predates modern PTFE-covered stents and current patient selection criteria, limiting applicability. 1
Standard of Care Remains
The definitive treatment for HRS remains liver transplantation, with medical management (terlipressin or norepinephrine plus albumin) as the evidence-based bridge therapy rather than TIPS. 2