Hyponatremia: A Risk Factor for Early Overt Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation

Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis

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.

Encephalopathy in Cirrhosis: Prevention and Management

Hepatic encephalopathy (HE) is a major neuropsychiatric complication of cirrhosis. The clinical manifestations of HE ranges from mild confusion, disorientation to altered behaviour and coma in advanced stages. HE is an important cause of recurrent admissions in liver cirrhosis patients. HE is the most common cause of altered mentation in a patient of liver cirrhosis. Lactulose and rifaximin are approved treatment options for the treatment of HE. In patients who have localised neurological signs or are not improving with lactulose and rifaximin should be investigated for other causes of altered sensorium.

The combination of Child-Pugh score and quantitative CT-based spleen volume could predict the risk of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation

PURPOSE

Hepatic encephalopathy (HE) is a common complication in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). The objective of this study was to assess the prognostic factors and make risk stratification of post-TIPS HE.

METHODS

This was a retrospective cohort study consisting of cirrhotic patients who had undergone TIPS creation at our center from November 2015 to August 2020. The baseline characteristics including spleen volume (SVol) and other markers were collected. The univariate and multivariate Cox regression analyses were used to identify independent predictors of post-TIPS overt HE (OHE).

RESULTS

Higher Child-Pugh (CP) score (HR 1.334, 95% CI 1.090-1.632, P = 0.005) and smaller SVol (HR 0.999, 95% CI 0.997-1.000, P = 0.004) were identified as the independent risk factors for post-TIPS OHE. And a time-dependent ROC analysis was used to determine the cutoff values of CP score and SVol, which were respectively 6.5 and 773 cm³. Subsequently, the CP-SVol grading system was developed to divide patients into three risk grades according to the above two cutoff values. Kaplan-Meier analysis showed that the cumulative rates of patients free of OHE in Grade 1, 2 and 3 were respectively 96.4% ± 3.5%, 82.1 ± 4.7%, and 59.3% ± 6.4%, which were in descending order (Log rank P < 0.001).

CONCLUSION

SVol might be a novel marker to predict the prognosis of post-TIPS OHE, and the proposed CP-SVol grading system composed of CP score and SVol achieved a superior predictive performance.

Risk factors for overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation in patients with liver cirrhosis

OBJECTIVE

This study aimed to determine the risk factors and establish a risk score for post-transjugular intrahepatic portosystemic shunt (TIPS) overt hepatic encephalopathy (OHE).

METHODS

Altogether 299 and 62 cirrhotic patients receiving TIPS from January 2015 to March 2018 were divided into the derivation and validation cohorts, respectively. The data of the derivation cohort were analyzed for risk factors of post-TIPS OHE. A risk score was established from the derivation cohort and verified by the validation cohort.

RESULTS

During a median follow-up of 112.6 weeks, 52 (17.4%) patients in the derivation cohort experienced post-TIPS OHE. Logistic regression showed that alcoholic cirrhosis (odds ratio [OR] 3.068, 95% confidence interval [CI] 1.423-6.613, P = 0.004), stent diameter of 10 mm (OR 12.046 [95% CI 2.308-62.862], P = 0.003), portal pressure gradient (PPG) decrement ≥60% (OR 3.548 [95% CI 1.741-7.230], P < 0.001), model for end-stage liver disease (MELD) score ≥10 (OR 2.695 [95% CI 1.203-6.035], P = 0.016), blood ammonia (OR 1.009 [95% CI 1.000-1.018], P = 0.043) and notable hydrothorax (OR 4.393 [95% CI 1.554-12.415], P = 0.005) were associated with an increased risk of post-TIPS OHE. The risk score reached a promising risk evaluation of post-TIPS OHE when verified by the validation cohort (sensitivity 71.4%, specificity 70.7%, accuracy 71.0%).

CONCLUSIONS

Alcoholic cirrhosis and notable hydrothorax are independent risk factors for post-TIPS OHE in liver cirrhosis, together with the stent diameter of 10 mm, PPG decrement ≥60%, MELD score ≥10 and blood ammonia. The established risk score is reliable to identify high-risk individuals of developing post-TIPS OHE.

A nomogram to predict the risk of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in Cirrhotic Patients

BACKGROUND AND AIM

Hepatic encephalopathy (HE) is a serious complication of decompensated liver cirrhosis, affecting the prognosis of patients underwent transjugular intrahepatic portosystemic shunts (TIPS). We aim to create a nomogram to predict hepatic encephalopathy- free survivals (HEFS) after TIPS in cirrhotic patients and select appropriate candidates for TIPS.

METHODS

Cirrhotic patients underwent TIPS from 2015 to 2018 in our department were included. Multivariable Cox regression was conducted to estimate the predictors of overt HE (OHE) after TIPS within one year. A nomogram based on the Cox proportional hazard model using data from a retrospective training cohort (70% of the patients) was developed. Then the prediction model was validated in the remaining 30% patients by Harrell's C-indexes, ROC curves and calibration plots.

RESULTS

Of 373 patients, 117 developed postoperative OHE (31.4%). The training and validation groups comprised 83 (31.4%) and 34 (31.2%) patients, respectively. The cumulative survival rates of patients with HE at 1, 2 and 3 years were 90%, 83% and 76%, respectively. The nomogram included the following variables: age, Child-Turcotte-Pugh class (CTP class), diabetes mellitus (DM), serum creatinine and serum sodium (C-index = 0.772). The C-index for HEFS prediction was 0.773 for the validation cohort. The ROC for predicting HEFS was 0.809 and 0.783, respectively.

CONCLUSIONS

We created a nomogram of predicting postoperative HEFS in cirrhotic patients received TIPS. This nomogram could be an important tool of HE risk prediction before TIPS to guide the therapeutic strategy in cirrhotic patients.

Predictors of Occurrence and Risk of Hepatic Encephalopathy After TIPS Creation: A 15-Year Experience

PURPOSE

To identify clinical variables, including use of newer Viatorr TIPS endoprosthesis with controlled expansion (VCX) that may affect the occurrence and risk of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) creation.

METHODS

A total of 376 patients who underwent TIPS creation at our institution between 2003 and 2018 were retrospectively identified. Of these patients, 71 received a Viatorr controlled expansion endoprosthesis and 305 received a Viatorr TIPS endoprosthesis (older version without controlled expansion). Multivariate regression analysis was used to identify factors predicting the occurrence of hepatic encephalopathy after TIPS creation; a Cox proportional hazard model was used to assess risk of HE through time to HE onset RESULTS: A total of 194 patients (52%) developed hepatic encephalopathy after TIPS creation, including 28 of 71 patients (39%) who received a VCX endoprosthesis. Older patient age and the use of Viatorr endoprosthesis without controlled expansion were significantly associated with the development of hepatic encephalopathy overall. Pre-TIPS pressure variables, patient age, plasma international normalized ratio, and model for end-stage liver disease score were risk factors for time to hepatic encephalopathy.

CONCLUSION

Several variables are mild predictors of early hepatic encephalopathy development after TIPS creation, and the use of VCX endoprosthesis in TIPS creation is associated with a modest lower risk of hepatic encephalopathy. These preliminary findings should be considered in regard to patient selection, endoprosthesis selection, and post-transjugular intrahepatic portosystemic shunt creation monitoring for the development of hepatic encephalopathy.

TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification

Purpose: To evaluate predictive parameters for the development of Hepatic Encephalopathy (HE) after Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement and for success of shunt modification in the management of shunt-induced HE. Methods: A retrospective analysis of all patients with TIPS (n = 344) has been performed since 2011 in our university liver center. n = 45 patients with HE after TIPS were compared to n = 48 patients without HE after TIPS (case-control-matching). Of n = 45 patients with TIPS-induced HE, n = 20 patients received a reduction stent (n = 18) or TIPS occlusion (n = 2) and were differentiated into responders (improvement by at least one HE grade according to the West Haven classification) and non-responders (no improvement). Results: Older patient age, increased serum creatinine and elevated International Normalized Ratio (INR) immediately after TIPS placement were independent predictors for the development of HE. In 11/20 patients (responders, 55%) undergoing shunt modification, the HE grade was improved compared with nine non-responders (45%), with no relevant recurrence of refractory ascites or variceal bleeding. A high HE grade after TIPS insertion was the only positive predictor of treatment response (p = 0.019). A total of 10/11 responders (91%) survived the 6 months follow-up after modification but only 6/9 non-responders (67%) survived. Discussion: Older patient age as well as an increased serum creatinine and INR after TIPS are potential predictors for the development of HE. TIPS reduction for the treatment of TIPS-induced HE is safe, with particular benefit for patients with pronounced HE.

The correlation between sarcopaenia and post-transjugular intrahepatic portosystemic shunt hepatic encephalopathy: a single-institution review

Introduction

Sarcopaenia, or muscle wasting, can be used to objectively quantify malnutrition in cirrhotic patients.

Material and methods

In this retrospective study, a list of all patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) procedure at Westchester Medical Centre from September 2009 to July 2018 was obtained, and individual chart reviews were performed.

Results

In total, 90 charts were reviewed. Fifty-six patients satisfied our inclusion criteria. Using PMA cut-off values determined in prior studies, we found that 50 of the 56 patients in our study were sarcopaenic. The majority of the patients were male (n = 45). The most common aetiology of cirrhosis was alcoholic cirrhosis (n = 27), followed by viral hepatitis (n = 10), and the most common indication for TIPS was refractory ascites (n = 34). The mean age in the sarcopaenic group was 60.1 years compared to 57.4 years in the non-sarcopaenic group. Mean MELD-Na scores and albumin levels were comparable in both groups. Only one patient was deceased at 6 months post-TIPS. Of the 56 patients included, 18 developed clinically significant hepatic encephalopathy within 6 months of their TIPS procedure. All 18 patients belonged to the sarcopaenic group; 6 patients were not sarcopaenic, and none of them were noted to develop HE within 6 months of their TIPS (p = 0.074)

Conclusions

Based on our results, we concluded that sarcopaenia correlates with the development of hepatic encephalopathy within 6 months of a TIPS procedure; however, the results did not reach statistical significance.

Transjugular intrahepatic portosystemic shunt creation for cirrhotic portal hypertension is well tolerated among patients with portal vein thrombosis

BACKGROUND

Portal vein thrombosis (PVT) develops in cirrhotic patients because of stagnation of blood flow. Transjugular intrahepatic portosystemic shunt (TIPS) creates a low-resistance conduit that restores portal venous patency and blood flow.

AIM

The effect of PVT on transplant-free survival in cirrhotic patients undergoing TIPS creation was evaluated.

PATIENTS AND METHODS

A multicenter, retrospective cohort study of patients who underwent TIPS creation for cirrhotic portal hypertension was carried out. A Cox model with propensity score adjustment was developed to evaluate the effect of PVT on 90-day and 3-year transplant-free survival. A subgroup analysis examining mortality of those with superior and inferior PVT was also carried out.

RESULTS

A total of 252 consecutive TIPS creations were assessed, including 65 in patients with PVT. Survival of patients with high Model for End-stage Liver Disease scores (≥18) and PVT was not statistically different compared with patients with low Model for End-stage Liver Disease scores (<18) and no PVT at 90 days (P=0.46) and 3 years (P=0.42). Those with superior PVT had improved 90-day and 3-year survival both compared with patients with a inferior PVT and those without a PVT (P<0.01, all cases).

CONCLUSION

The presence of PVT does not impair the prognosis of patients following TIPS creation, particularly in patients with superior portal occlusion.

Pathological Predictors of Shunt Stenosis and Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt

Background. Transjugular intrahepatic portosystemic shunt (TIPS) is an artificial channel from the portal vein to the hepatic vein or vena cava for controlling portal vein hypertension. The major drawbacks of TIPS are shunt stenosis and hepatic encephalopathy (HE); previous studies showed that post-TIPS shunt stenosis and HE might be correlated with the pathological features of the liver tissues. Therefore, we analyzed the pathological predictors for clinical outcome, to determine the risk factors for shunt stenosis and HE after TIPS. Methods. We recruited 361 patients who suffered from portal hypertension symptoms and were treated with TIPS from January 2009 to December 2012. Results. Multivariate logistic regression analysis showed that the risk of shunt stenosis was increased with more severe inflammation in the liver tissue (OR, 2.864; 95% CI: 1.466–5.592; P = 0.002), HE comorbidity (OR, 6.266; 95% CI, 3.141–12.501; P < 0.001), or higher MELD score (95% CI, 1.298–1.731; P < 0.001). Higher risk of HE was associated with shunt stenosis comorbidity (OR, 6.266; 95% CI, 3.141–12.501; P < 0.001), higher stage of the liver fibrosis (OR, 2.431; 95% CI, 1.355–4.359; P = 0.003), and higher MELD score (95% CI, 1.711–2.406; P < 0.001). Conclusion. The pathological features can predict individual susceptibility to shunt stenosis and HE.