Predicting survival in patients with 'non-high-risk' acute variceal bleeding receiving b-blockers plus ligation to prevent re-bleeding

Background & Aims: Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for high -risk acute variceal bleeding (AVB; i.e., Child-Turcotte-Pugh [CTP] B8-9+active bleeding/C10-13). Nevertheless, some 'non -highrisk' patients have poor outcomes despite the combination of non -selective beta-blockers and endoscopic variceal ligation for secondary prophylaxis. We investigated prognostic factors for re -bleeding and mortality in 'non -high -risk' AVB to identify subgroups who may benefit from more potent treatments (i.e., TIPS) to prevent further decompensation and mortality. Methods: A total of 2,225 adults with cirrhosis and variceal bleeding were prospectively recruited at 34 centres between 20112015; for the purpose of this study, case definitions and information on prognostic indicators at index AVB and on day 5 were further refined in low -risk patients, of whom 581 (without failure to control bleeding or contraindications to TIPS) who were managed by non -selective beta-blockers/endoscopic variceal ligation, were finally included. Patients were followed for 1 year. Results: Overall, 90 patients (15%) re -bled and 70 (12%) patients died during follow-up. Using clinical routine data, no meaningful predictors of re -bleeding were identified. However, re -bleeding (included as a time -dependent co -variable) increased mortality, even after accounting for differences in patient characteristics (adjusted cause -specific hazard ratio: 2.57; 95% CI 1.434.62; p = 0.002). A nomogram including CTP, creatinine, and sodium measured at baseline accurately (concordance: 0.752) stratified the risk of death. Conclusion: The majority of 'non -high -risk' patients with AVB have an excellent prognosis, if treated according to current recommendations. However, about one -fifth of patients, i.e. those with CTP >-8 and/or high creatinine levels or hyponatremia, have a considerable risk of death within 1 year of the index bleed. Future clinical trials should investigate whether elective TIPS placement reduces mortality in these patients. (c) 2023 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.