The Freiburg Index of Post-TIPS Survival (FIPS) identifies patients at risk for further decompensation and ACLF after TIPS

The Freiburg Index of Post-TIPS Survival (FIPS) defines a high-risk group of patients with significantly reduced survival following transjugular intrahepatic portosystemic shunt (TIPS) implantation. However, the clinical hallmarks responsible for these patients' unfavorable outcome remain to be identified. Therefore, the present study aimed to characterize the clinical course after TIPS implantation according to the FIPS. A total of 1359 patients with cirrhosis allocated to TIPS implantation for treatment of recurrent or refractory ascites or secondary prophylaxis of variceal bleeding from eight tertiary centers were retrospectively included. The patients' clinical course following TIPS placement was analyzed, stratified according to the FIPS. Primary study outcome was further decompensation of cirrhosis within 90 days after TIPS, secondary outcomes were acute-on-chronic liver failure (ACLF) within 90 days and one-year transplant-free survival. Further decompensation after TIPS implantation was significantly more frequent in FIPS high-risk patients compared to low-risk patients (cumulative incidence function 0.58 vs. 0.38, p < 0.001). Moreover, FIPS high-risk patients developed ACLF significantly more often (0.18 vs. 0.08; p = 0.008). Uni- and multivariable competing risk regression analyses confirmed that the FIPS high-risk group independently predicted further decompensation (sHR 1.974, 95 % CI 1.531 - 2.544, p < 0.001) and ACLF after TIPS (sHR 2.586, 95 % CI 1.449 - 4.616, p = 0.001). Importantly, further decompensation and ACLF after TIPS were associated with significantly reduced transplant-free survival. The present study reveals that the FIPS predicts development of further decompensation and ACLF after TIPS implantation. These events are responsible for impaired transplant-free survival in FIPS high-risk patients. These results pave the way for the development of tailored clinical management strategies.