Recurrent Portal Hypertension after Liver Transplant: Impact on Survival and the Role of TIPS Creation in Management

Introduction: Recurrent portal hypertension (PH) after liver transplant (LT) and its management are not well-studied. This study aims to evaluate the impact of transjugular intrahepatic portosystemic shunt (TIPS) on outcomes of recurrent PH.

Methods: From a cohort of 1846 LT recipients, 36 patients who underwent TIPS creation after LT were identified and considered as cases. To streamline comparison with the remaining LT patients without TIPS, a representative subset comprising more than 20% of the entire population (381/1810) was randomly selected. Diuretic refractory ascites, and endoscopic findings were reviewed to detect recurrent PH in patients without TIPS. Repeat transplantation, and graft and overall survival were compared between recurrent PH patients with and without TIPS. Survival analysis with multivariable Cox regression analysis was used for risk factors of survival.

Results: Out of 1846 patients, 36 (2%) underwent TIPS after LT. Among the control group, 24 (of 381, 6.3%) patients had recurrent PH. TIPS resulted in ascites resolution in 25 (of 36, 74%). Repeat transplant was more frequent in recurrent PH without TIPS, than recurrent PH with TIPS (33% vs. 11%, p=0.035). Median overall survival after TIPS was 2.4 years (95% CI: 0.6-3.2). Transplant-free survival after initial LT was not different between patients with or without TIPS (8.6 years vs. 7.6 years, p=0.360). Multivariable Cox regression showed that repeat transplant was associated with reduced mortality in recurrent PH (HR=0.15, p=0.016).

Conclusion: Recurrent PH after LT is rare, but adversely impacts patient outcomes. However, TIPS in recurrent PH improves ascites without worsening survival.