Severe hyperbilirubinemia after creation of transjugular intrahepatic portosystemic shunts: Natural history and predictors of outcome

Background: Hyperbilirubinemia after creation of transjugular intrahepatic portosystemic shunts (TIPS) has been attributed to hemolysis and portal diversion, but the causes and natural history of this condition remain unknown. Objective: To determine clinical outcomes and predictors of severe hyperbilirubinemia after TIPS creation. Design: Retrospective analysis of all patients who underwent TIPS creation from June 1990 to September 1996. Setting: Academic medical center. Patients: 19 adults who developed severe hyperbilirubinemia (bilirubin level > 171.0 mu mol/L) within 1 month after TIPS creation were compared with 213 adults who did not develop hyperbilirubinemia after TIPS creation. Intervention: TIPS creation. Measurements: Laboratory measures and clinical outcomes. Results: According to laboratory indices, hemolysis was unlikely to have occurred. By 90 days, 95% of patients with hyperbilirubinemia had died or had undergone liver transplantation compared with 17% of controls (P < 0.001). Predictors of hyperbilirubinemia included nonalcoholic causes of liver disease (P = 0.01) and a pre-TIPS prothrombin time of 17 seconds or more (P = 0.016). Conclusions: Severe hyperbilirubinemia after TIPS creation heralds a high risk for death or need for liver transplantation. Reduced hepatic reserve predicts the development of hyperbilirubinemia.