Transjugular intrahepatic portosystemic shunts for adults with hepatorenal syndrome

Background Hepatorenal syndrome is a condition that occurs in people with chronic liver disease (such as alcoholic hepatitis, advanced cirrhosis, or fulminant liver failure) and portal hypertension. The prognosis is dismal, often with a survival of weeks to months. Hepatorenal syndrome is characterised by the development of intense splanchnic vasodilation favouring ascites and hypotension leading to renal vasoconstriction and acute renal failure. Therefore, treatment attempts focus on improving arterial pressure through the use of vasopressors, paracentesis, and increasing renal perfusion pressure. Several authors have reported that the placement of transjugular intrahepatic portosystemic shunts (TIPS) may be a therapeutic option because it decreases portal pressure and improves arterial and renal pressures. However, the evidence is not clearly documented and TIPS may cause adverse events. Accordingly, it is necessary to evaluate the evidence of the benefits and harms of TIPS to assess its value in people with hepatorenal syndrome. Objectives To evaluate the benefits and harms of transjugular intrahepatic portosystemic shunts (TIPS) in adults with hepatorenal syndrome compared with sham, no intervention, conventional treatment, or other treatments. Search methods We used standard, extensive Cochrane search methods. The latest search date was 2 June 2023. Selection criteria We included only randomised clinical trials with a parallel‐group design, which compared the TIPS placement with sham, no intervention, conventional therapy, or other therapies, in adults aged 18 years or older, regardless of sex or ethnicity, diagnosed with chronic liver disease and hepatorenal syndrome. We excluded trials of adults with kidney failure due to causes not related to hepatorenal syndrome, and we also excluded data from quasi‐randomised, cross‐over, and observational study designs as we did not design a separate search for such studies. Data collection and analysis We used standard Cochrane methods. Our primary outcomes were 1. all‐cause mortality, 2. morbidity due to any cause, and 3. serious adverse events. Our secondary outcomes were 1. health‐related quality of life, 2. non‐serious adverse events, 3. participants who did not receive a liver transplant, 4. participants without improvement in kidney function, and 5. length of hospitalisation. We performed fixed‐effect and random‐effects meta‐analyses using risk ratio (RR) or Peto odds ratio (Peto OR), with 95% confidence