ArticleCureus2026
Early Prognostic Value of the Freiburg Index of Post-Transjugular Intrahepatic Portosystemic Shunt Survival in Patients With Hepatocellular Carcinoma Undergoing Liver Transplantation.
Article in Cureus, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundThe Freiburg Index of Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Survival (FIPS) integrates clinically relevant indicators of hepatic and renal function, but its prognostic value in patients with hepatocellular carcinoma (HCC) undergoing liver transplantation (LT) remains unclear. This study aimed to evaluate the association of pre-transplant FIPS with post-transplant overall survival (OS) and HCC recurrence and to compare its prognostic performance with that of the Model for End-Stage Liver Disease (MELD).
methodsAdult liver transplant recipients with HCC registered in the Scientific Registry of Transplant Recipients (SRTR) between January 1, 2010, and December 31, 2018, were included. Overall survival was evaluated using Kaplan-Meier analysis and multivariable Cox regression. Because FIPS did not satisfy the proportional hazards assumption, interval-specific effects were estimated for 0-1, 1-2, and 2-3 years after transplantation. Parallel FIPS- and MELD-based prognostic models were compared using Harrell's C-index, time-dependent area under the curve (AUC), calibration analysis, decision-curve analysis, and five-fold cross-validation. HCC recurrence was evaluated using Fine-Gray competing-risk regression, with death without recurrence treated as a competing event.
resultsPatients with high FIPS had consistently lower post-transplant survival than those with low FIPS, with one-, two-, and three-year overall survival rates of 89.5%, 84.7%, and 79.6% versus 93.1%, 88.3%, and 83.8%, respectively. After multivariable adjustment, each one-unit increase in FIPS was significantly associated with higher mortality during the first year after transplantation (hazard ratio (HR): 1.125; 95% confidence interval (CI): 1.069-1.183; P<0.001) and during years 2-3 (HR: 1.112; 95% CI: 1.040-1.190; P=0.002), demonstrating a time-dependent prognostic association. A sensitivity analysis excluding Milan criteria included 13,940 recipients and yielded directionally consistent associations, with significant estimates across all three follow-up intervals. FIPS-based risk prediction showed performance comparable to that of MELD across cross-validated C-index, time-dependent AUC, calibration, and decision-curve analyses. In competing-risk analysis, high FIPS showed a trend toward a higher risk of HCC recurrence (subdistribution hazard ratio (sHR): 1.22; 95% CI: 0.97-1.54; P=0.095).
conclusionPre-transplant FIPS captures time-dependent variation in early post-transplant survival among patients with HCC and provides prognostic information comparable to MELD. These findings support the potential use of FIPS as a complementary marker for pre-transplant risk stratification and early post-transplant prognostic assessment. Its relationship with post-transplant HCC recurrence warrants further investigation.
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