Abstract
Dr Blendis discusses possible explanations for the different survival rates following TIPS reported by 5 RCTs. His suggestion that a different rate of liver transplantation could have affected a survival advantage for TIPS is appealing but difficult to prove. A meta-analysis performed with individual data is the right tool to do this, but the total number of patients included in the 5 RCTs is quite low (n = 330) and this makes such an analysis likely to be unsuccessful. An alternate hypothesis we strongly support is that survival rates were significantly affected by subtle differences in the inclusion criteria of the different trials. Unlike our trial (Hepatology 2004;40:629–635), the 2 recent trials that did not find an improved survival for TIPS (Gastroenterology 2002;123:1839–1847, Gastroenterology 2003;124:634–641) did not exclude cirrhotic patients with a Child score greater than 11. The presence of a few of such patients, who have a considerable risk of death after TIPS because of early end-stage liver failure, could have negatively affected the average survival of the patients treated with TIPS and masked the possible survival advantage that resulted from the prevention of renal failure, hyponatremia, and other complications related to refractory ascites. If such a hypothesis is established, TIPS could become the treatment of choice for patients with refractory ascites, but the exclusion of patients at high risk would remain a significant limiting factor to perform TIPS in all patients. Trial for treatment of refractory ascites TIPS the scalesGastroenterologyVol. 128Issue 3PreviewSalerno F, Merli M, Riggio O, Cazzaniga M, Valeriano V, Pozzi M, Nicolini A, Salvatori F, Gruppo Italiano per lo Studio TIPS (Departments of Internal Medicine and Radiology, University and Ospedale Maggiore Policlinico Instituto di Ricera e Cura a carattere Scientifico, Milan; Departments of Gastroenterology and Radiology, University “La Sapienza” and Policlinico “Umberto 1,” Rome; Department of Internal Medicine, 2nd University of Milan, Ospedale San Gerardo, Monza, Italy). Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites. Full-Text PDF
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