We appreciate the interest of Libbrecht et al. in our article. As they correctly point out, and as we have carefully detailed in our article, the results of our study should be interpreted cautiously because of the retrospective nature of its design.1 However, while the possibility of a selection bias cannot be completely excluded, the adequate sample size, the careful matching and statistical procedures, and the similar cumulative incidence of hepatocellular carcinoma (HCC) observed in the non–transjugular intrahepatic portosystemic shunt cohort with respect to other published series gives a solid estimation of a possible greater risk of HCC in the transjugular intrahepatic portosystemic shunt (TIPS) cohort.
Regarding the interesting information provided by Libbrecht et al., it is important to emphasize the long follow-up period after TIPS insertion (median 30 months [range 7.8–110.8]) in our study. This length allows the detection of the potential influence of TIPS in the development of HCC. In the Libbrecht et al. series, the maximum follow-up period was only 21 months. Timing is very important, because the 1-year probability of developing HCC in our study was quite similar in both groups. Therefore, the time between TIPS insertion and histological analysis in the Libbrecht et al. cohort may be too short for detecting the possible influence of TIPS on HCC. Another interesting point is that the Libbrecht et al. study was designed to evaluate the incidence of HCC and dysplastic nodules in explanted organs as well as the accuracy of imaging techniques for early detection of these focal lesions in the pretransplantation time. We believe the design of their study makes it difficult to draw conclusions about the risk of HCC associated with TIPS, because it does not represent the whole population at risk (i.e., patients who received TIPS irrespective of the indication of liver transplantation).2 Therefore, we believe the information provided by Libbrecht et al. does not clarify whether TIPS insertion increases the risk of HCC development.
We agree with Libbrecht et al. regarding the benefits of TIPS when adequately indicated according to recently published guidelines.3 However, we completely disagree with the suggestion that a 1.5-fold increase of risk of developing HCC is not meaningful. While adequate prospective studies confirm our results, the increase of risk of HCC after TIPS insertion described in our study should be taken into account when planning the follow-up of these patients.