Background: The number of complications in patients admitted for cirrhosis has increased over time. Portal hypertension is the driver of many complications of cirrhosis. TIPS placement is the most effective treatment of portal hypertension. The aim of this study was to analyze the use and impact of TIPS placement in the last decade in a nationwide study in Germany. Methods: We analyzed 14,598 admissions of patients for TIPS insertions in Germany from 2007 to 2018 using the DRG system, 12,877 out of 2,000,765 total admissions of patients with cirrhosis. All diagnoses and procedures were coded according to ICD-10-CM and OPS codes. The data were analyzed, focusing on the number of admissions and in-hospital mortality. Results: The number of TIPS placements increased over the last decade. In-hospital mortality of cirrhotic patients with TIPS decreased when it was placed for severe bleeding (15.2% [TIPS] vs. 19.5% [endoscopy treatment]), ascites (8.7% [TIPS] vs. 14.4% [paracentesis]), and hepatorenal syndrome (HRS) (17.1% [TIPS] vs. 43.3% [no-TIPS]). In the case of bleeding, TIPS significantly decreased in-hospital mortality and also in ascites and HRS. During hospitalization, 22.6% admissions of patients with TIPS insertion showed HE. However, in-hospital mortality in patients admitted with HE grades 1 or 2 and TIPS was lower than in patients without TIPS. In the logistic regression, a higher HE grade(3 and 4), infection, and circulatory disease were found to be independently associated with in-hospital mortality in patients with TIPS insertion. Conclusion: Our nationwide study demonstrates that TIPS insertion is increasingly used in Germany. TIPS improves outcomes, especially in patients with ascites and HRS, regardless of lower HE grades, while higher HE grades, infection, and circulatory diseases seem to be associated with risk of in-hospital mortality. Export

Purpose of Review: Clinically significant portal hypertension (CSPH) is a serious clinical condition causing decompensation and potentially fatal complications especially in the presence of advanced liver disease. This article aims to critically review the current literature on non-invasive assessment of CSPH. Recent Findings: The Baveno VII consensus encouraged non-invasive assessment of CSPH to identify patients at risk and avoid unnecessary screening endoscopies. Novel machine learning and omics-based laboratory scores have been introduced, which can be combined with liver stiffness measurement (LSM). Spleen stiffness measurement (SSM) is an increasingly used novel elastography modality. Elastography and cross-sectional imaging methods have reached similar predictive power, while the accuracy of non-invasive tests can only be improved when used sequentially. Summary: In this review, we provide a detailed discussion of advantages and limitations of non-invasive assessment of CSPH, highlighting their diagnostic accuracy, reproducibility, and feasibility in clinical practice.

Portale Hypertonie ist mit erheblicher Morbidität und Mortalität verbunden. Die Leberzirrhose macht bis zu 90 % der Fälle von portaler Hypertonie aus, während etwa 10 % auf nicht-zirrhotische Faktoren, einschließlich vaskulärer Lebererkrankungen, zurückzuführen sind. Diese Erkrankung kann zu schweren Komplikationen führen, wie der Entwicklung von gastroösophagealen Varizen, die das Risiko von varikösen Blutungen erheblich erhöhen. Weitere häufige Komplikationen der portalen Hypertonie sind Aszites und hepatorenales Syndrom (HRS). Eine transjuguläre intrahepatische portosystemische Shunt (TIPS)-Implantation wird als die effektivste Behandlung zur Bewältigung der portalen Hypertonie angesehen. Studien zeigen, dass die TIPS-Implantation die Überlebensraten bei Patienten mit wiederkehrendem Aszites sowie bei ausgewählten Patienten mit refraktärem Aszites und varikösen Blutungen verbessern kann. Allerdings können periinterventionelle und postinterventionelle Komplikationen die Anwendung von TIPS einschränken. Neueste Entwicklungen bei Geräten, Techniken und prophylaktischen Medikamenten zielen darauf ab, das Risiko von Komplikationen nach dem Eingriff zu minimieren. Dieses interdisziplinäre Positionspapier fasst Empfehlungen und Anleitung zur Patientenwahl, zu Indikationen und Kontraindikationen, zu Techniken sowie zur Nachsorge von Patienten zusammen, die in Deutschland ein TIPS-Verfahren erhalten. Portal hypertension is associated with significant morbidity and mortality. Liver cirrhosis accounts for up to 90 % of portal hypertension cases, while approximately 10 % are due to non-cirrhotic factors, including vascular liver diseases. This condition can lead to various complications, such as the development of gastroesophageal varices, which greatly increase the risk of variceal bleeding. Other common complications of portal hypertension include ascites and hepatorenal syndrome (HRS). The transjugular intrahepatic portosystemic shunt (TIPS) procedure is regarded as the most effective treatment for managing portal hypertension. Research shows that TIPS insertion can improve survival rates for patients with recurrent ascites, as well as for select individuals with refractory ascites and variceal bleeding. However, peri-interventional and post-interventional complications may pose challenges to the use of TIPS. Recent advancements in devices, techniques, and prophylactic medications aim to minimize the risk of complications following this procedure. This interdisciplinary position paper summarizes recommendations and guidance regarding patient selection, indications and contraindications, techniques, and follow-up care for patients undergoing TIPS in Germany. ^* Teilen die erste oder die letzte Autorschaft. Received: 25 November 2024 Accepted after revision: 08 May 2025 Article published online: 10 November 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Metabolic dysfunction-associated Steatohepatitis (MASH), is a prominent cause for liver cirrhosis. MASH-cirrhosis is responsible for liver complications and there is no specific treatment. To develop new therapeutic approaches, animal models are needed. The aim of this study was to develop a fast animal model of MASH-cirrhosis in rats reflecting the human disease. Carbon tetrachloride (CCl₄) injections in combination with a high-fat Western diet (WD) were used to induce MASH-cirrhosis. To accelerate liver injury, animals received phenobarbital (PB) in their drinking water using two different regimens. Rats developed advanced MASH-cirrhosis characterized by portal hypertension, blood biochemistry, hepatic ballooning, steatosis, inflammation and fibrosis. Importantly, rats receiving low-dose PB for the long term (LT) showed ascites after 6 weeks, whereas rats with high-dose short-term (ST) PB developed ascites after 8 weeks. ST- and LT-treated rats showed increased portal pressure (PP) and decreased mean arterial pressure (MAP). Of note, hepatocyte ballooning was only observed in the LT group. The LT administration of low-dose PB with CCl₄ intoxication and WD represents a fast and reproducible rat model mimicking decompensated MASH-cirrhosis in humans. Thus, CCl₄ + WD with LT low-dose phenobarbital treatment might be the preferred rat animal model for drug development in MASH-cirrhosis.

Background & Aims: Definitions of primary biliary cholangitis (PBC) treatment response commonly include alkaline phosphatase (ALP) ULN is associated with active disease and reduced transplant-free survival, whereas ALP normalization is associated with better complication-free survival. Elafibranor, a peroxisome proliferator-activated receptor (PPAR)-α/δ agonist, has been shown to be effective and well-tolerated as a second-line treatment in patients with PBC and ALP ≥1.67x ULN. We report phase III ELSPIRE trial results, evaluating the effect of one year of elafibranor treatment on ALP normalization (ALP ≤ULN; ≤120 U/L) in patients with PBC and ALP >1–1–≤1.33× ULN vs. >1.33–<1.67× ULN). At Week 52, 85.3% of patients receiving elafibranor achieved the primary endpoint of ALP normalization, versus 23.3% receiving placebo (treatment difference: 62.0%; 95% CI: 44.3, 79.7; p <0.0001). Least squares mean percentage change from baseline in ALP at Week 52 was –36.5% with elafibranor versus –4.2% with placebo ( p 1–<1.67× ULN, with ALP normalization as an achievable treatment goal.

INTRODUCTION: Portal hypertension characterizes decompensated cirrhosis and its complications. It may trigger acute-on-chronic liver failure (ACLF), which carries a high mortality. Transjugular intrahepatic portosystemic shunt (TIPS) is the most efficient therapy for most portal hypertension-related complications including fluid overload (FO) defined as refractory or recurrent ascites, hepatorenal syndrome, and/or hydrothorax. However, TIPS for FO in ACLF is questioned. METHODS: In this case-control study, patients from the prospective cohorts CANONIC (n = 1,324) and German TIPS-Registry (n = 724) were screened for cases of FO and matched 1:1 by sex, age, Model for End-Stage Liver Disease (MELD) score, and presence and grade of ACLF. Clinical outcomes, ACLF status, and mortality were assessed. RESULTS: The total population was 118 patients with ACLF of whom 59 received TIPS and 59 did not. The main indication for TIPS was hepatorenal syndrome (61.0%). Patients with ACLF who did not receive TIPS had a higher 28-day cumulative mortality rate (22.0% vs 5.1%, P = 0.009). At 28 days, TIPS insertion in ACLF was associated with a 78% mortality reduction (hazard ratio 0.22 [0.06–0.77]). It further led to improvement of hepatic encephalopathy and the MELD score. In addition, ACLF resolution occurred in 61% of TIPS patients with ACLF. The presence of coagulation and circulatory organ failures, and increased bilirubin, INR, MELD score, and CLIF-C OF were associated with 28-day mortality. The survival benefit of TIPS was no longer observed after 90 days. DISCUSSION: TIPS decreased the 28-day mortality of patients with FO and ACLF. Thus, TIPS should be regarded as a bridging strategy—ideally for liver transplantation.