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• W2096751496 abstract "Portal hypertensive bleeding of the gastrointestinal (GI) tract is a complication of end-stage liver disease. Bleeding can be controlled endoscopically and pharmacologically in up to 90% of patients.1 Transjugular intrahepatic portal systemic shunt (TIPS), or less often surgery, are alternative treatments for patients with recurrent or refractory variceal bleeding or bleeding from portal hypertensive gastropathy who have a contraindication to TIPS or who bleed despite a patent TIPS. The mortality rate in patients with recurrent or refractory variceal bleeding or bleeding from portal hypertensive gastropathy is close to 100%, but these clinical situations are difficult to quantify for the purpose of organ distribution. TIPS may be contraindicated in a number of patients with end-stage liver disease. Despite its minimally invasive nature, TIPS has been associated with a 30-day mortality rate as high as 48%.2 Many authors have looked at various factors associated with a poor prognosis after TIPS, which include serum bilirubin and creatinine levels, Child-Pugh score, and encephalopathy. The development of the Model for End-Stage Liver Disease (MELD) was based on predicting mortality in patients with a TIPS. This system has now been modified and applied to liver organ distribution in the United States.3 The ability to predict mortality was not improved by including GI bleeding in the MELD.4 Bilirubin has been shown by a number of investigators to be a good predictor of mortality after TIPS. Rajan and colleagues5 have shown that an “elevated pre-TIPS bilirubin level is a powerful independent predictor of 30-day mortality after TIPS creation” with a 40% increased risk of death for each 1 mg/dL increase above 3.0 mg/dL.5 Patients with a serum bilirubin >5 mg/dL had a 19-fold increased risk of early death.6 Bilirubin level features predominantly in several studies as an indicator of early mortality after TIPS.2, 7 Bilirubin, in the absence of an elevated serum creatinine or international normalized ratio, often does not affect the MELD score enough to result in timely transplantation. A serum bilirubin level >5 mg/dL after TIPS is highly predictive of death; thus, it is an objective, reasonable, and conservative cutoff for medical contraindication to TIPS. Anatomical variants, such as portal vein thrombosis, must also be considered as relative or absolute contraindications for TIPS shunt. Data on waiting list liver transplant candidates who develop GI bleeding should be collected to determine whether there is an objective surrogate for increased mortality that can guide the Regional Review Boards or a quantitative factor that can improve the prediction of mortality risk calculated by the current MELD score. It will be necessary to develop definitions that are clear and quantifiable. Refractory variceal bleeding can be defined as acute severe variceal bleed requiring airway intubation and the insertion of a Minnesota or Blakemore tube, in spite of optimal endoscopic treatment, coagulation support, and pharmacologic management. This definition should also include blood transfusions requiring more than 6 units in 24 hours or more than 2 units per day over 3 days, and that a TIPS is contraindicated as defined above. Each patient should be reassessed daily. Chronic recurrent variceal or portal hypertensive gastropathy bleeding can be defined as the requirement of more than 2 units of blood transfusion per week for more than 6 weeks in a patient with a TIPS or if TIPS is contraindicated. This terminology could be further refined to include documentation that the bleeding is not responsive to endoscopic and pharmacologic treatment. There are sufficient data to justify additional priority for patients with portal hypertensive GI bleeding. GI, gastrointestinal; TIPS, transjugular intrahepatic portal systemic shunt; MELD, Model for End-Stage Liver Disease. The following information should be required for all exceptional case applications for candidates with refractory GI bleeding: (1) precise reason for contraindication to TIPS, (2) presence or absence of portal vein thrombosis, (3) total GI blood loss for the previous 4 weeks, 3 days, and 24 hours (4) presence or absence of gastric varices, (5) use of mechanical balloon tamponade, and (6) history of endotracheal intubation to stabilize the patient to aid in the control GI bleeding. At this time, because of the lack of a quantifiable, verifiable, and reproducible method of documenting a mortality risk directly related to intractable GI bleeding, we propose that refractory portal hypertensive GI bleeding continue to be addressed by the Regional Review Boards and additional priority assigned after the above-described data have been submitted on a case-by-case basis. Additional priority should not be automatically granted at this time. The data elements described above should be prospectively collected by the Organ Procurement Transplantation Network/United Network for Organ Sharing for future revaluation of portal hypertensive GI bleeding as justification of additional MELD priority. There are no data that permit extrapolation of this recommendation to children." @default.
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• W2096751496 date "2006-01-01" @default.
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• W2096751496 title "Model for end-stage liver disease (MELD) exception for portal hypertensive gastrointestinal bleeding" @default.
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• W2096751496 doi "https://doi.org/10.1002/lt.20969" @default.
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