Recurrent Portal Hypertension after Liver Transplant: Impact on Survival and the Role of Transjugular Intrahepatic Portosystemic Shunt Creation in Management

Purpose: To evaluate the impact of transjugular intrahepatic portosystemic shunt (TIPS) on outcomes of recurrent portal hypertension (PH) after liver transplant (LT). Materials and Methods: From a cohort of 1,846 LT recipients, 36 patients who underwent TIPS creation after LT were identified. To streamline comparison with the remaining LT patients without TIPS, a representative subset comprising more than 20% of the entire population (381/1,810) was randomly selected as controls. 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 patients with recurrent PH with and without TIPS. Survival analysis with multivariable Cox regression analysis was used for risk factors of survival. Results: Of 1,846 patients, 36 (2%) underwent TIPS creation after LT. Among the control group, 24 (of 381, 6.3%) patients had recurrent PH. TIPS creation resulted in ascites resolution in 25 (of 36, 74%). Repeat transplant was more frequent in recurrent PH without TIPS than in recurrent PH with TIPS (33% vs 11%; P = .035). Median overall survival after TIPS creation was 2.4 years (95% CI, 0.6–3.2). Transplant-free survival after initial LT was not different between patients with and without TIPS (8.6 years vs 7.6 years; P = .360). Multivariable Cox regression showed that repeat transplant was associated with reduced mortality in recurrent PH (hazard ratio, 0.15; P = .016). Conclusions: Recurrent PH after LT is rare but adversely affects patient outcomes. However, TIPS in recurrent PH improves ascites without worsening survival.