Study data published in Frontiers in Medicine outline the relative efficacies of various treatments for cirrhosis with portal hypertension. A systematic review of published randomized controlled trials identified 9 treatment strategies, among which transjugular intrahepatic portosystemic shunt (TIPS) and distal splenorenal shunt (DSRS) appeared to provide best hemorrhage control. Overall survival seemed best improved with endoscopic therapy combined with medication.
The treatment of portal hypertension caused by liver cirrhosis is difficult and varied, with no single therapeutic option recommended to prevent hemorrhage. To compare the relative efficacies of existing treatments, investigators conducted a Bayesian network meta-analysis of randomized controlled trials (RCTs) published to PubMed, Embase, Cochrane Library, or Web of Science through June 2020.
Eligible trials compared treatments for cirrhosis and portal hypertension and reported rebleeding and mortality as treatment outcomes. Two researchers independently reviewed and extracted study data.
Network meta-analysis was performed using a random effects model within a Bayesian framework; the framework was used to compute the odds ratios for all-cause bleeding, bleeding-related mortality, overall survival, treatment failure, and hepatic encephalopathy. Ranked probability analysis was used to illustrate the relative efficacies of each treatment method for these outcomes.
The literature search identified 9805 RCTs, among which 40 were selected for full-text review. The pooled study cohort consisted of 4006 patients from clinical sites in 15 countries. A total of 9 separate treatment strategies were explored: DSRS, endoscopic injection sclerotherapy (EIS), endoscopic tissue adhesive (ETA), endoscopic variceal ligation (EVL), medication, EVL with EIS, EVL with medication, EIS with medication, and TIPS. All 40 studies reported all-cause rebleeding rates.
Meta-analyses identified DSRS and TIPS as most effective for preventing rebleeding. The next-best methods for preventing rebleeding, in descending order, were as follows: EIS with medication, ETA, EVL with medication, EVL with EIS, EVL only, EIS only, and medication only. This hierarchy largely persisted at 1, 2, and 3 years of follow-up, though TIPS appeared to have greater long-term efficacy compared with DSRS.
Twenty-one articles each reported bleeding-related mortality and overall survival as study outcomes. Bleeding-related mortality appeared lowest with EVL and EIS. The best 1-year overall survival rate was observed with EVL with medication, followed by ETA only, EVL only, TIPS, DSRS, EIS only, and medication only.
Treatment failure, examined in just 9 direct comparisons, appeared lowest with EVL and medication, compared with other methods. A total of 1956 patients experienced hepatic encephalopathy in the pooled cohort. In this cohort, DSRS and TIPS were associated with a higher incidence of hepatic encephalopathy compared with EVL, medication, EIS, EVL with medication, and ETA.
These results provide evidence for the efficacy and safety of 9 treatment methods for cirrhosis with portal hypertension. Overall, TIPS and DSRS were associated with the lowest likelihood of variceal rebleeding, but were each correlated with greater risk for hepatic encephalopathy. Analyses were not adjusted for differential patient characteristics, such as Child-Pugh class, age, and sex; additionally, certain treatment subgroups were too small for investigation. As such, results should be interpreted with caution, and further research is necessary to better elucidate the efficacy of these treatment options.
“In conclusion, TIPS and DSRS should be given priority in patients with portal hypertension and cirrhosis to control rebleeding, which may not improve survival,” investigators wrote. “[Endoscopic therapy] together with medication may improve survival. Furthermore, medications should be used in combination with ET or other treatments rather than as the sole therapeutic intervention,” they concluded.
Yao Q, Chen W, Yan C, Yu J, Jiang T, Cao H. Efficacy and safety of treatments for patients with portal hypertension and cirrhosis: a systematic review and Bayesian network meta-analysis. Front Med (Lausanne). Published online September 3, 2021. doi: 10.3389/fmed.2021.712918