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Yoon JS, Hong JH, Park SY, Kim SU, Kim HY, Kim JY, Hur MH, Park MK, Lee YB, Lee HA, Kim GA, Sinn DH, Park SJ, Lee YJ, Kim YJ, Yoon JH, Lee JH. High-dose proton pump inhibitor treatment is associated with a higher mortality in cirrhotic patients: A multicentre study. Aliment Pharmacol Ther 2024; 59:973-983. [PMID: 38389319 DOI: 10.1111/apt.17909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/11/2023] [Accepted: 02/07/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Proton pump inhibitors (PPI) are frequently used in patients with cirrhosis. AIMS This study aimed to determine whether PPI use is associated with the prognosis of cirrhotic patients. METHODS We conducted a multicentre retrospective cohort study involving 1485 patients who had experienced hepatic encephalopathy (HE) from 7 referral centres in Korea. The primary outcome was overall survival and secondary outcomes included the development of cirrhotic complications, including recurrent HE, spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS), and gastrointestinal bleeding. Patients treated with PPI with a mean defined daily dose (mDDD) ≥0.5 (high-dose PPI group) were compared to those treated with PPI of an mDDD < 0.5 (No or low-dose PPI group) for each outcome. RESULTS Among 1485 patients (median age, 61 years; male, 61%), 232 were assigned to the high-dose PPI group. High-dose PPI use was independently associated with a higher risk of death (adjusted HR [aHR] = 1.71, 95% confidence interval [CI] = 1.38-2.11, p < 0.001). This result was reproducible after propensity score-matching (PSM) (aHR = 1.90, 95% CI = 1.49-2.44, p < 0.001). High-dose PPI use was an independent risk factor of recurrent HE (before PSM: aHR = 2.04, 95% CI = 1.66-2.51, p < 0.001; after PSM: aHR = 2.16, 95% CI = 1.70-2.74, p < 0.001), SBP (before PSM: aHR = 1.87, 95% CI = 1.43-2.43, p < 0.001; after PSM: aHR = 1.76, 95% CI = 1.31-2.36, p = 0.002), HRS (before PSM: aHR = 1.48, 95% CI = 1.02-2.15, p = 0.04; after PSM: aHR = 1.47, 95% CI = 0.95-2.28, p = 0.09), and gastrointestinal bleeding (before PSM: aHR = 1.46, 95% CI = 1.12-1.90, p = 0.006; after PSM: aHR = 1.74, 95% CI = 1.28-2.37, p < 0.001). CONCLUSIONS The use of high-dose PPI was independently associated with increased risks of mortality and cirrhotic complications.
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Affiliation(s)
- Jun Sik Yoon
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Ji Hoon Hong
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Soo Young Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Seung Up Kim
- Department of Internal Medicine and Yonsei Liver Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hwi Young Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ju Yeon Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Moon Haeng Hur
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Min Kyung Park
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yun Bin Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Gi-Ae Kim
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Jae Park
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Youn Jae Lee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Yoon Jun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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Friis KH, Thomsen KL, Laleman W, Montagnese S, Vilstrup H, Lauridsen MM. Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis. J Clin Med 2023; 13:14. [PMID: 38202028 PMCID: PMC10779844 DOI: 10.3390/jcm13010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its' complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7-61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures.
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Affiliation(s)
- Karina Holm Friis
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, 3000 Leuven, Belgium
| | - Sara Montagnese
- Department of Medicine, University of Padova, 35122 Padova, Italy
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
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Sturm L, Hirose M, Stolz L, Schultheiss M, Zoldan K, Reincke M, Huber JP, Kaeser R, Boettler T, Thimme R, Albert E, Busch H, Künstner A, Bettinger D. Proton pump inhibitor treatment aggravates bacterial translocation in patients with advanced cirrhosis and portal hypertension. mBio 2023; 14:e0049223. [PMID: 37623323 PMCID: PMC10653923 DOI: 10.1128/mbio.00492-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 08/26/2023] Open
Abstract
IMPORTANCE Long-term prescription of proton pump inhibitors (PPIs) in patients with cirrhosis is common practice. However, in recent years, several observational studies have reported increased complications and negative prognostic effects of PPI treatment in these patients. Judging the significance of these associations is complicated by the fact that a plausible underlying pathomechanism has not been identified so far. In the present study, we address this important issue by investigating the impact of PPI treatment on subclinical bacterial translocation from the gut into the blood stream in patients with advanced cirrhosis and portal hypertension. Indeed, we report significantly aggravated bacterial translocation in cirrhosis patients receiving PPI treatment. This finding is highly relevant, as bacterial translocation is known to promote the development of complications and impair prognosis in patients with cirrhosis. Hence, the present study could establish a plausible link between PPI treatment and adverse effects in cirrhosis.
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Affiliation(s)
- Lukas Sturm
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
- Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Misa Hirose
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
| | - Laura Stolz
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
- Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Zoldan
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Marlene Reincke
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Jan Patrick Huber
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Rafael Kaeser
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
- IMM-PACT-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Boettler
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Elisabeth Albert
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
| | - Hauke Busch
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
- Institute for Cardiogenetics, University of Luebeck, Luebeck, Germany
| | - Axel Künstner
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
- Institute for Cardiogenetics, University of Luebeck, Luebeck, Germany
| | - Dominik Bettinger
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
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Reincke M, Thimme R, Schultheiß M. [Complications of liver cirrhosis]. Dtsch Med Wochenschr 2023; 148:1371-1382. [PMID: 37820648 DOI: 10.1055/a-2001-4236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Liver cirrhosis is a chronic disease, progressing from a compensated and asymptomatic state to decompensated cirrhosis with the occurrence of multiple organ complications. This progression is accompanied by a significant increase of morbidity and mortality. Main complications include clinical manifestations of portal hypertension (ascites and varices) as well as consequences of liver insufficiency as hepatic encephalopathy. Besides, many other organ systems can be affected, as liver cirrhosis is today more and more seen as a multisystemic disease. Unfortunately, most therapy options of these complications are purely symptomatic, and the only curative treatment of advanced chronic liver disease is liver transplantation.
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Liao Y, Zhang L, Wang JT, Yue ZD, Fan ZH, Wu YF, Zhang Y, Dong CB, Wang XQ, Cui T, Meng MM, Bao L, Chen SB, Liu FQ, Wang L. A novel nomogram predicting overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in portal hypertension patients. Sci Rep 2023; 13:15244. [PMID: 37709823 PMCID: PMC10502141 DOI: 10.1038/s41598-023-42061-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023] Open
Abstract
We aim to develop a nomogram to predict overt hepatic encephalopathy (OHE) after transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension, according to demographic/clinical indicators such as age, creatinine, blood ammonia, indocyanine green retention rate at 15 min (ICG-R15) and percentage of Portal pressure gradient (PPG) decline. In this retrospective study, 296 patients with portal hypertension who received elective TIPS in Beijing Shijitan Hospital from June 2018 to June 2020 were included. These patients were randomly divided into a training cohort (n = 207) and a validation cohort (n = 89). According to the occurrence of OHE, patients were assigned to OHE group and non-OHE group. Both univariate and multivariate analyses were performed to determine independent variables for predicting OHE after TIPS. Accordingly, receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to compare the accuracy and superiority of a novel model with conventional Child-Pugh and MELD scoring model. Age (OR 1.036, 95% CI 1.002-1.070, p = 0.037), Creatinine (OR 1.011, 95% CI 1.003-1.019, p = 0.009), Blood ammonia (OR 1.025, 95% CI 1.006-1.044, p = 0.011), ICG-R15 (OR 1.030, 95% CI 1.009-1.052, p = 0.004) and Percentage decline in PPG (OR 1.068, 95% CI 1.029-1.109, p = 0.001) were independent risk factors for OHE after TIPS using multifactorial analysis. A nomogram was constructed using a well-fit calibration curve for each of these five covariates. When compared to Child-Pugh and MELD score, this new nomogram has a better predictive value (C-index = 0.828, 95% CI 0.761-0.896). Consistently, this finding was reproduceable in validation cohort and confirmed with DCA. A unique nomogram was developed to predict OHE after TIPS in patients with PHT, with a high prediction sensitivity and specificity performance than commonly applied scoring systems.
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Affiliation(s)
- Yong Liao
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
- Department of Hepatobiliary Interventional Therapy, Beijing Tsinghua Changgung Hospital, Beijing, China
- School of Clinical Medicine, Tsinghua University, Beijing, 100038, People's Republic of China
- Department of Hepatobiliary Surgery, Xingtai People's Hospital of Hebei Medical University, Xingtai, 054001, Hebei, People's Republic of China
| | - Lin Zhang
- Department of Hepatobiliary Interventional Therapy, Beijing Tsinghua Changgung Hospital, Beijing, China
- School of Clinical Medicine, Tsinghua University, Beijing, 100038, People's Republic of China
| | - Ji-Tao Wang
- Department of Hepatobiliary Surgery, Xingtai People's Hospital of Hebei Medical University, Xingtai, 054001, Hebei, People's Republic of China
| | - Zhen-Dong Yue
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Zhen-Hua Fan
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Yi-Fan Wu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Yu Zhang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Cheng-Bin Dong
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Xiu-Qi Wang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Ting Cui
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Ming-Ming Meng
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People's Republic of China
| | - Li Bao
- Department of Pharmacy, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People's Republic of China
| | - Shu-Bo Chen
- Department of Hepatobiliary Surgery, Xingtai People's Hospital of Hebei Medical University, Xingtai, 054001, Hebei, People's Republic of China
| | - Fu-Quan Liu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China.
| | - Lei Wang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China.
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[Current pathophysiological concepts of acute decompensation in patients with liver cirrhosis and prognostic scores in different stages of disease]. Dtsch Med Wochenschr 2022; 147:662-669. [PMID: 35636416 DOI: 10.1055/a-1671-9114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Acute decompensation and acute-on chronic liver failure (ACLF) are associated with a significant reduced prognosis. Previously, the pathophysiological concept of acute decompensation was mainly based on the peripheral vasodilatation hypothesis. However, during the last years, systemic inflammation was recognized as a major driver for decompensation of liver cirrhosis and ACLF. Further, it has been shown that systemic inflammation is associated with the clinical course and the prognosis of the patients. Inflammation also affects the function of extrahepatic organs and therefore leads to the development of an inflammatory cirrhotic multi-organ syndrome. The importance of systemic inflammation in the context of decompensated liver cirrhosis is also transferred to new clinical scores such as the CLIF-C AD and CLIF-C ACLF score. In this article, we provide an overview of the new systemic inflammation hypothesis of decompensated cirrhosis and also discuss current clinical scores for prognostication in different stages of liver cirrhosis.
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Gairing SJ, Müller L, Kloeckner R, Galle PR, Labenz C. Review article: post-TIPSS hepatic encephalopathy-current knowledge and future perspectives. Aliment Pharmacol Ther 2022; 55:1265-1276. [PMID: 35181894 DOI: 10.1111/apt.16825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/23/2022] [Accepted: 02/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In light of the global rise in the burden of chronic liver diseases and liver cirrhosis, the number of patients suffering from decompensation events is expected to increase. Transjugular intrahepatic portosystemic shunts (TIPSS) provide effective long-term symptom control and may prolong transplant-free survival in portal hypertension-driven recurrent ascites and variceal bleeding. New-onset or recurrent hepatic encephalopathy (HE) after TIPSS insertion (post-TIPSS HE) represents the most severe post-interventional complication. AIMS To provide insight into the epidemiology and risk factors for post-TIPSS HE and scrutinize the current state of the art in treatment and drug therapy options. METHODS We conducted a literature search on post-TIPSS HE in patients with liver cirrhosis. RESULTS Post-TIPSS HE occurs in up to 54.5% of cases and particularly early recurrent HE is associated with a dismal prognosis. In recent years, several risk factors for the development of post-TIPSS HE have been identified. These include not only parameters reflecting liver function (model for end-stage liver disease score/Child-Pugh score) as well as cognitive dysfunction caused by minimal HE but also extrahepatic factors such as sarcopenia and common medications such as proton pump inhibitors. In addition, new data on the benefit of rifaximin and of smaller stent grafts emerged and may improve the prevention of post-TIPSS HE. CONCLUSIONS Careful selection of TIPSS candidates is of utmost importance to reduce the risk of post-TIPSS HE. In this narrative review, we provide a concise overview of the current epidemiology and risk factors of the treatment options for post-TIPSS HE.
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Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Lukas Müller
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Roman Kloeckner
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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Wehmeyer MH, Horvatits T, Buchholz A, Krause L, Walter S, Zapf A, Lohse AW, Kluwe J. Stop of proton-pump inhibitor treatment in patients with liver cirrhosis (STOPPIT): study protocol for a prospective, multicentre, controlled, randomized, double-blind trial. Trials 2022; 23:302. [PMID: 35414106 PMCID: PMC9003168 DOI: 10.1186/s13063-022-06232-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/27/2022] [Indexed: 11/21/2022] Open
Abstract
Background Proton-pump inhibitors (PPI) are liberally prescribed in patients with liver cirrhosis. Observational studies link PPI therapy in cirrhotic patients with an increased risk for infectious complications, hepatic encephalopathy and an increased risk for hospitalization and mortality. However, patients with liver cirrhosis are also considered to be at risk for peptic ulcer bleeding. The STOPPIT trial evaluates if discontinuation of a pre-existing PPI treatment delays a composite endpoint of re-hospitalization and/or death in patients (recently) hospitalized with liver cirrhosis compared to patients on continued PPI medication. Methods The STOPPIT-trial is a prospective, multicentre, randomized, double-blinded, placebo-controlled, parallel-group trial. In total, 476 patients with complicated liver cirrhosis who already receive long-term PPI therapy without evidence-based indication are 1:1 randomized to receive either esomeprazole 20 mg (control group) or placebo (intervention group) for 360 days. Patients with an indication for PPI therapy (such as a recent diagnosis of peptic ulcers, severe reflux esophagitis, severe hemorrhagic gastritis, recent endoscopic therapy for oesophageal varices) are excluded. The primary composite endpoint is the time-to re-hospitalization and/or death. Secondary endpoints include rates of re-hospitalization, mortality, occurrence of infections, hepatic decompensation and acute-on-chronic liver failure. The safety endpoint is defined as manifestation of an evidence-based indication for PPI re-therapy. The impact of PPI continuation or discontinuation on the intestinal microbiota will be studied. The recruitment will take place at 18 study sites throughout Germany. Recruitment has started in April 2021. Discussion The STOPPIT trial is the first clinical trial to study the effects of PPI withdrawal on relevant outcome variables in patients with complicated liver cirrhosis. If the hypothesis that PPI withdrawal improves clinical outcomes of cirrhosis patients is confirmed, this would argue for a strong restriction of the currently liberal prescription practice of PPIs in this population. If, on the other hand, the trial demonstrates an increased risk of gastrointestinal bleeding events in patients after PPI withdrawal, this could create a rationale for a more liberal, prophylactic PPI treatment in patients with liver cirrhosis. Trial registration EU clinical trials register EudraCT 2019-005008-16 (registered December 27, 2019). ClinicalTrials.gov NCT04448028 (registered June 25, 2020). German Clinical Trials Register DRKS00021290 (registered March 10, 2021).
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Affiliation(s)
- Malte H Wehmeyer
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Thomas Horvatits
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anika Buchholz
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Walter
- Coordinating Center for Clinical Trials Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Kluwe
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Liu YB, Chen MK. The impact of proton pump inhibitors in liver diseases and the effects on the liver. J Dig Dis 2022; 23:196-208. [PMID: 35357775 DOI: 10.1111/1751-2980.13093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/09/2022] [Accepted: 03/29/2022] [Indexed: 12/11/2022]
Abstract
In this systematic and comprehensive overview, we aimed to evaluate the impact of proton pump inhibitors (PPIs) on chronic liver diseases, especially on cirrhosis. A manual and comprehensive search of the PubMed database was conducted to obtain relevant literatures. PPIs altered the composition and function of the intestinal microflora and might lead to small intestinal bacterial overgrowth and bacterial translocation, which were associated with adverse effects in liver diseases. They might increase the risk of hepatic encephalopathy, spontaneous bacterial peritonitis, infections, and are related to an increased mortality in cirrhosis. PPIs might lead to an increased risk of hepatocellular carcinoma, although the mechanism is unknown, and the results are controversial. PPIs also had an impact on the direct-acting antiviral regimen in patients with chronic hepatitis C. They were associated with an increased risk of liver abscess and increased mortality. Additionally, PPIs might lead to metabolic risk events, such as liver steatosis and weight gain. PPIs are associated with several adverse outcomes in liver diseases. Cautious use of PPIs is recommended and clinicians should be aware of the indications for their use in patients with liver diseases.
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Affiliation(s)
- Yuan Bin Liu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Ming Kai Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
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Proton pump inhibitor therapy is associated with reduced survival following first-time transarterial chemoembolization in patients with hepatocellular carcinoma. Eur J Gastroenterol Hepatol 2021; 33:e247-e253. [PMID: 33323760 DOI: 10.1097/meg.0000000000002018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Several studies have reported associations of proton pump inhibitor (PPI) treatment with the incidence of complications and even increased mortality in patients with liver cirrhosis. Up to now, there are no studies on the impact of PPI treatment in patients with hepatocellular carcinoma (HCC). Therefore, the aim of our study was to investigate the prognostic effects of PPI treatment in a cohort of patients with HCC treated by transarterial chemoembolization (TACE). METHODS Three hundred fifty-eight patients with HCC that received first-time TACE were included in a retrospective analysis. We explored effects of PPI treatment using uni- and multivariable regression models. RESULTS One hundred sixty-seven of the 358 patients (46.6%) received PPI treatment. Median transplant-free survival after TACE was significantly lower in patients treated with PPIs compared to patients without PPI treatment [16.0 (10.7-21.3) months vs. 26 (22.2-29.8) months, P = 0.006]. Importantly, PPI treatment remained a significant prognostic factor for reduced survival after adjustment for patient demographics, tumor stadium and liver function [hazard ratio (HR) 1.40, 95% confidence interval (CI) 1.09-1.78, P = 0.005]. We observed a dose-dependent association of PPI treatment with survival: A higher daily PPI dose was an independent prognostic factor for reduced survival (HR 1.32, 95% CI 1.14-1.54, P < 0.001). Notably, 58.1% of patients receiving PPIs had no clear indication therefor. CONCLUSION PPI treatment is associated with reduced survival in patients with HCC in a dose-dependent manner. Thus, indication for PPI treatment should be evaluated attentively in these patients. Further, prospective studies are needed to validate the findings of this study.
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Dai R, Sag AA, Martin JG, Befera NT, Pabon-Ramos WM, Suhocki PV, Smith TP, Kim CY, Muir AJ, Ronald J. Proton pump inhibitor use is associated with increased rates of post-TIPS hepatic encephalopathy: Replication in an independent patient cohort. Clin Imaging 2021; 77:187-192. [PMID: 33940357 DOI: 10.1016/j.clinimag.2021.04.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/18/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Proton pump inhibitor (PPI) use is a potential risk factor for hepatic encephalopathy (HE), but few studies have examined the effect on post-TIPS HE. The purpose of this study was to determine whether PPIs are associated with increased rates of post-TIPS HE in an independent patient cohort. MATERIALS AND METHODS This single-institution retrospective study analyzed 86 patients (54 male, mean age 58.2) following TIPS from 1/1/2017 to 12/31/2019. Dates of PPI usage and episodes of new or worsening HE were recorded. Poisson regression with generalized estimating equations was used to test for association between PPI use and post-TIPS HE and to test for dose dependence. Post-TIPS HE was also analyzed using the Andersen-Gill survival model for recurrent events. RESULTS There were 1.88 episodes of new or worsening post-TIPS HE per person-year among 35 patients on uninterrupted PPIs therapy, 1.95 on PPIs and 0.94 off PPIs among 35 patients on intermittent therapy, and 0.47 among 16 patients never on PPIs. PPI use was significantly associated with post-TIPS HE in both univariable (incidence rate ratio (IRR) = 2.62; CI = 1.41-4.84; p = 0.002) and multivariable (IRR = 2.31; CI = 1.37-3.89; p = 0.002) regression. Analysis of only those patients on PPIs showed increased rates of HE with higher doses (IRR = 1.17 per 10 mg omeprazole equivalent; CI = 1.04-1.33; p = 0.011). Recurrent events survival analysis supported the association between PPI use and HE in univariable (hazard ratio (HR) = 2.17; CI = 1.19-3.95; p = 0.011) and multivariable (HR = 1.87; CI = 1.12-3.13; p = 0.017) analysis. CONCLUSION In an independent patient cohort PPI use was associated with increased rates of new or worsening post-TIPS HE.
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Affiliation(s)
- Rui Dai
- Duke University School of Medicine, DUMC 3710, Durham, NC 27710, USA
| | - Alan A Sag
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Jonathan G Martin
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Nicholas T Befera
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Waleska M Pabon-Ramos
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Paul V Suhocki
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Tony P Smith
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Charles Y Kim
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, DUMC 3913, Durham, NC 27710, USA
| | - James Ronald
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, DUMC 3808, Durham, NC 27710, USA.
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Helzberg JH, Dai R, Muir AJ, Wilder J, Lee TH, Martin JG, Kim CY, Ronald J. Socioeconomic Status Is Associated with the Risk of Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation. J Vasc Interv Radiol 2021; 32:950-960.e1. [PMID: 33663923 DOI: 10.1016/j.jvir.2020.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To determine whether socioeconomic status (SES) is associated with hepatic encephalopathy (HE) risk after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS This single-institution retrospective study included 368 patients (mean age = 56.7 years; n = 229 males) from 5 states who underwent TIPS creation. SES was estimated using the Agency for Healthcare Research and Quality SES index, a metric based on neighborhood housing, education, and income statistics. Episodes of new or worsening HE after TIPS creation, defined as hospitalization for HE or escalation in outpatient medical therapy, were identified from medical records. Multivariable ordinal regression, negative binomial regression, and competing risks survival analysis were used to identify factors associated with SES quartile, the number of episodes of new or worsening HE per unit time after TIPS creation, and mortality after TIPS creation, respectively. RESULTS There were 83, 113, 99, and 73 patients in the lowest, second, third, and highest SES quartiles, respectively. In multivariable regression, only older age (β = 0.04, confidence interval [CI] = 0.02-0.05; P < .001) and white, non-Hispanic ethnicity (β = 0.64, CI = 0.07-1.21; P = .03) were associated with higher SES quartile. In multivariable regression, lower SES quartile (incidence rate ratio [IRR] = 0.80, CI = 0.68-0.94; P = .004), along with older age, male sex, higher model for end-stage liver disease score, nonalcoholic steatohepatitis, and proton pump inhibitor use were associated with higher rates of HE after TIPS creation. Ethnicity was not associated with the rate of HE after TIPS creation (IRR = 0.77, CI = 0.46-1.29; P = .28). In multivariable survival analysis, neither SES quartile nor ethnicity predicted mortality after creation of a TIPS. CONCLUSION Lower SES is associated with higher rates of new or worsening HE after TIPS creation.
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Affiliation(s)
- James H Helzberg
- Department of Medicine, Duke University School of Medicine, Durham
| | - Rui Dai
- Duke University School of Medicine, Durham
| | - Andrew J Muir
- Department of Medicine, Duke University School of Medicine, Durham; Duke Clinical Research Institute, Duke University School of Medicine, Durham
| | - Julius Wilder
- Department of Medicine, Duke University School of Medicine, Durham; Duke Clinical Research Institute, Duke University School of Medicine, Durham
| | - Tzu-Hao Lee
- Department of Medicine, Duke University School of Medicine, Durham
| | - Jonathan G Martin
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University School of Medicine, Durham
| | - Charles Y Kim
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University School of Medicine, Durham
| | - James Ronald
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University School of Medicine, Durham.
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Abstract
Hepatic encephalopathy (HE) is a complex condition with multiple causes each with varying degrees of severity. HE negatively impacts patients' quality of life, and it is associated with significant burdens to patients and their caregivers. The prevalence of cirrhosis, the most common risk factor for HE, has steadily increased during recent years. In turn, an upsurge in the clinical and health care burdens related to HE is expected in the upcoming years. This article provides a comprehensive review of the epidemiology of HE.
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Affiliation(s)
- Mohamed I Elsaid
- Department of Medicine, Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Medical Education Building, 1 Robert Wood Johnson, Room 479, New Brunswick, NJ 08903, USA.
| | - Vinod K Rustgi
- Center for Liver Diseases and Liver Masses, Robert Wood Johnson School of Medicine, MedEd Building, Room 466, 1 Robert Wood Johnson Place, New Brunswick, NJ 08901, USA
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Proton Pump Inhibitor Therapy and Hepatic Encephalopathy Risk in Cirrhotic Patients: A Systematic Review with Meta-analysis. Clin Drug Investig 2019; 39:847-856. [DOI: 10.1007/s40261-019-00810-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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15
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Tantai XX, Yang LB, Wei ZC, Xiao CL, Chen LR, Wang JH, Liu N. Association of proton pump inhibitors with risk of hepatic encephalopathy in advanced liver disease: A meta-analysis. World J Gastroenterol 2019; 25:2683-2698. [PMID: 31210719 PMCID: PMC6558434 DOI: 10.3748/wjg.v25.i21.2683] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/21/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Several studies have explored the association between the use of proton pump inhibitors (PPIs) and the risk of developing hepatic encephalopathy (HE) in patients with advanced liver disease. However, the evidence-based conclusions are controversial. We hypothesized that using PPIs may increase the risk of HE in patients with advanced liver disease. If confirmed, clinicians must strictly adhere to the indications for PPI treatment in this population.
AIM To evaluate the pooled risk of HE in patients with advanced liver disease who use PPIs.
METHODS Three electronic databases (PubMed, EMBASE, and the Cochrane Library) were searched from the date of database inception through January 8, 2019 to identify comparative studies evaluating the association between PPI use and the risk of HE. Data from the included studies were extracted. The random-effects model was used for pooling risk estimates and the corresponding 95% confidence intervals (CIs). Subgroup and sensitivity analyses were also performed.
RESULTS In total, 4342 patients from five case-control studies and 188053 patients from four cohort studies were included in this analysis. In patients with advanced liver disease, PPI use was associated with an elevated risk of developing HE, with significant heterogeneity. The pooled odds ratio for case-control studies was 2.58 (95%CI: 1.68-3.94, I2 = 72%). The pooled RR for cohort studies was 1.67 (95%CI: 1.30-2.14, I2 = 67%). The results of the subgroup analyses suggested that the heterogeneity may be the result of differences in the study designs and the definitions of PPI use. The sensitivity and subgroup analyses did not alter our findings.
CONCLUSION In patients with advanced liver disease, PPI use is associated with an elevated risk of HE. Future large prospective studies are needed to confirm this association.
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Affiliation(s)
- Xin-Xing Tantai
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Long-Bao Yang
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Zhong-Cao Wei
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Cai-Lan Xiao
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Li-Rong Chen
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Jin-Hai Wang
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Na Liu
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
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Ma YJ, Cao ZX, Li Y, Feng SY. Proton pump inhibitor use increases hepatic encephalopathy risk: A systematic review and meta-analysis. World J Gastroenterol 2019; 25:2675-2682. [PMID: 31210718 PMCID: PMC6558435 DOI: 10.3748/wjg.v25.i21.2675] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/24/2019] [Accepted: 05/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Several studies have been conducted to explore the association between the use of proton pump inhibitors (PPIs) and hepatic encephalopathy (HE) risk in patients with liver cirrhosis. However, their results are controversial.
AIM To perform a systematic review and meta-analysis to evaluate the HE risk among PPI users.
METHODS A systematic search on PubMed, Web of Science, EMBase, and ScienceDirect databases was conducted up to December 31, 2018 for eligible studies involving PPI use and HE risk. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the fixed or random effects model. Publication bias was evaluated using Begg’s test, Egger’s test, and trim-and-fill method.
RESULTS Seven studies with 4574 patients were included in the present meta-analysis. The meta-analysis results indicated a significant association between the PPI use and HE risk (OR = 1.50; 95%CI: 1.25-1.75) with low heterogeneity (I2 = 14.2%, P = 0.321). Although publication bias existed when Egger’s tests were used (P = 0.005), the trim-and-fill method verified the stability of the pooled result. Sensitivity analyses suggested that the results of this meta-analysis were robust.
CONCLUSION The current evidence indicates that PPI use increases HE risk in patients with liver cirrhosis. Further studies with a large data set and well-designed models are needed to validate our findings.
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Affiliation(s)
- Yun-Jie Ma
- Emergency Department, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Zong-Xun Cao
- Emergency Department, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Yong Li
- Emergency Department, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Shun-Yi Feng
- Emergency Department, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
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Proton Pump Inhibitor Use Is Associated with an Increased Frequency of New or Worsening Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation. J Vasc Interv Radiol 2019; 30:163-169. [DOI: 10.1016/j.jvir.2018.10.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/10/2018] [Accepted: 10/13/2018] [Indexed: 12/22/2022] Open
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