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Mu M, Zhou T, Guo H, Fu X, Chen Z, Jiang W, Li L, Qi H, Gao F. Utilizing a suture-constrained covered stent for shunt reduction to treat transjugular intrahepatic portosystemic shunt-related refractory hepatic encephalopathy: a retrospective study. Jpn J Radiol 2024:10.1007/s11604-024-01618-z. [PMID: 38922569 DOI: 10.1007/s11604-024-01618-z] [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: 12/13/2023] [Accepted: 06/18/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE Refractory hepatic encephalopathy (RHE) can occur as a consequence of excessive shunting following the creation of a transjugular intrahepatic portosystemic shunt (TIPS). We describe a technique that utilizes a suture-constrained covered stent for shunt reduction to treat TIPS-related RHE. MATERIALS AND METHODS Between January 2017 and September 2023, 25 patients with TIPS-related RHE who underwent shunt reduction utilizing a suture-constrained covered stent were reviewed. The procedure involved reducing the diameter of a polytetrafluoroethylene-covered stent from 8 to 5 mm with a non-absorbable suture and inserting it into the existing TIPS stent to reduce shunt flow. RESULTS Twelve of the 25 patients were evaluated. Shunt reduction was technically successful in all patients and no immediate complications related to the procedures were observed. Varying degrees of improvement in HE symptoms were observed after shunt reduction, with a mean increase in portosystemic gradient of 5 mmHg compared to pre-procedure, and complete disappearance of symptoms was observed in seven (58.3%) individuals. After a median follow-up of 8.3 months, HE recurred in 4 patients (33.3%) and TIPS indication recurred in 2 patients (16.7%) in the form of ascites and variceal bleeding, respectively. One patient (8.3%) developed shunt dysfunction detected by Doppler ultrasound and was accompanied by the presence of hepatic hydrothorax and ascites. At the end of the study, 5 patients (41.7%) were alive, 5 (41.7%) succumbed to liver failure, and 2 (16.7%) succumbed to pneumonia. CONCLUSIONS Constraining the stent diameter with a suture is feasible, and using this suture-constrained covered stent for shunt reduction can effectively improve TIPS-related RHE. Further investigations are warranted to precisely delineate the impact of the increased portosystemic gradient and to optimize patient survival.
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Affiliation(s)
- Maoyuan Mu
- Department of Minimally Invasive Intervention, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, China
| | - Tengchao Zhou
- Department of Interventional Radiology and Vascular Surgery, Hunan Provincial People's Hospital, Changsha, 410000, Hunan, China
| | - Huanqing Guo
- Department of Minimally Invasive Intervention, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, China
| | - Xiaobo Fu
- Department of Minimally Invasive Intervention, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, China
| | - Zixiong Chen
- Department of Minimally Invasive Intervention, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, China
| | - Weiwei Jiang
- Department of Interventional Radiology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510060, Guangdong, China
| | - Lixue Li
- Department of Minimally Invasive Intervention, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, China
| | - Han Qi
- Department of Minimally Invasive Intervention, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, China
| | - Fei Gao
- Department of Minimally Invasive Intervention, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, China.
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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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Wang LJ, Yao X, Qi Q, Qin JP. Prevention and treatment of hepatic encephalopathy during the perioperative period of transjugular intrahepatic portosystemic shunt. World J Gastrointest Surg 2023; 15:1564-1573. [PMID: 37701697 PMCID: PMC10494578 DOI: 10.4240/wjgs.v15.i8.1564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/09/2023] [Accepted: 05/22/2023] [Indexed: 08/25/2023] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for treating the complications of portal hypertension in liver cirrhosis. While the pathogenesis of postoperative TIPS-related hepatic encephalopathy (HE) has yet to be fully understood, intraoperative portosystemic shunts may provide a pathological basis for the occurrence of postoperative HE in patients with liver cirrhosis. Studies at home and abroad have expressed mixed opinions about TIPS-related HE. This study presents a literature review on the risk factors for and prevention and treatment of perioperative TIPS-related HE in patients with liver cirrhosis, aiming to optimize the procedure and reduce the incidence of postoperative HE.
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Affiliation(s)
- Lan-Jing Wang
- Department of Gastroenterology, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Xin Yao
- Department of Gastroenterology, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Qi Qi
- Department of Gastroenterology, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Jian-Ping Qin
- Department of Gastroenterology, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
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Trivedi S, Lam K, Ganesh A, Hasnain Y, Hassan W, Herren J, Gaba RC. Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation. Semin Intervent Radiol 2023; 40:9-14. [PMID: 37152788 PMCID: PMC10159723 DOI: 10.1055/s-0043-1764282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) creation is effective in treating the sequelae of decompensated liver cirrhosis-including medically refractory ascites and variceal bleeding-by decompressing the portal venous system through a manmade portosystemic conduit within the liver. However, the altered physiology in which splenomesenteric blood bypasses intrahepatic portal venous perfusion can precipitate varying degrees of hepatic encephalopathy (HE). While the majority of post-TIPS HE cases can be treated medically, some require escalated management strategies, including endovascular interventions to modify the indwelling TIPS and/or occlude competitive physiologic spontaneous portosystemic shunts. This review article details the epidemiology, risk factors, diagnosis, classification, and treatment of post-TIPS HE.
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Affiliation(s)
- Surbhi Trivedi
- Department of Radiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Katie Lam
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Ashwin Ganesh
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Yasir Hasnain
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Wassim Hassan
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Josi Herren
- Department of Radiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Ron C. Gaba
- Department of Radiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
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Nardelli S, Bellafante D, Ridola L, Faccioli J, Riggio O, Gioia S. Prevention of post-tips hepatic encephalopathy: The search of the ideal candidate. Metab Brain Dis 2022; 38:1729-1736. [PMID: 36445629 DOI: 10.1007/s11011-022-01131-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) has been used since more than 25 years to treat some of the complications of portal hypertension, especially variceal bleeding and ascites refractory to conventional therapy. TIPS establishes a communication between the portal and hepatic veins, inducing the blood to shift from the splanchnic circulation into the systemic vascular bed with the aim of decompressing the portal venous system, and avoids the major complications of portal hypertension. However, the shunt of the portal blood into the systemic circulation is the cause of one of the major complications of the procedure: the post-TIPS hepatic encephalopathy (HE). To date, few pharmacological treatment has been proven effective to prevent this complication and thus, the identification of patients at high risk of post-TIPS hepatic encephalopathy and the patients' carefully selection is the only way to prevent this frequent complication.
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Affiliation(s)
- Silvia Nardelli
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy.
| | - Daniele Bellafante
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Jessica Faccioli
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
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Fürschuß L, Rainer F, Effenberger M, Niederreiter M, Portugaller RH, Horvath A, Fickert P, Stadlbauer V. A novel score predicts mortality after transjugular intrahepatic portosystemic shunt: MOTS - Modified TIPS Score. Liver Int 2022; 42:1849-1860. [PMID: 35261130 PMCID: PMC9539997 DOI: 10.1111/liv.15236] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 02/04/2022] [Accepted: 03/02/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS The high risk for severe shunting-related post-interventional complications demands a stringent selection of candidates for transjugular intrahepatic portosystemic shunt (TIPS). We aimed to develop a simple and reliable tool to accurately predict early post-TIPS mortality. METHODS 144 cases of TIPS implantation were retrospectively analysed. Using univariate and multivariate Cox regression analysis of factors predicting mortality within 90 days after TIPS, a score integrating urea, international normalized ratio (INR) and bilirubin was developed. The Modified TIPS-Score (MOTS) ranges from 0 to 3 points: INR >1.6, urea >71 mg/dl and bilirubin >2.2 mg/dl account for one point each. Additionally, MOTS was tested in an external validation cohort (n = 187) and its performance was compared to existing models. RESULTS Modified TIPS-Score achieved a significant prognostic discrimination reflected by 90-day mortality of 8% in patients with MOTS 0-1 and 60% in patients with MOTS 2-3 (p < .001). Predictive performance (area under the curve) of MOTS was accurate (c = 0.845 [0.73-0.96], p < .001), also in patients with renal insufficiency (c = 0.830 [0.64-1.00], p = .02) and in patients with refractory ascites (c = 0.949 [0.88-1.00], p < .001), which are subgroups with particular room for improvement of post-TIPS mortality prediction. The results were reproducible in the validation cohort. CONCLUSIONS Modified TIPS-Score is a novel, practicable tool to predict post-TIPS mortality, that can significantly simplify clinical decision making. Its practical applicability should be further investigated.
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Affiliation(s)
- Luisa Fürschuß
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
| | - Florian Rainer
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
| | - Maria Effenberger
- Department of Internal Medicine I, Gastroenterology, Hepatology and Endocrinology & Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Niederreiter
- Department of Internal Medicine I, Gastroenterology, Hepatology and Endocrinology & Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert H Portugaller
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Angela Horvath
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
- Centre for Biomarker Research in Medicine (CBmed), Graz, Austria
| | - Peter Fickert
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
- Centre for Biomarker Research in Medicine (CBmed), Graz, Austria
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7
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Enomoto M, Takaya H, Namisaki T, Fujinaga Y, Nishimura N, Sawada Y, Kaji K, Kawaratani H, Moriya K, Akahane T, Inoue T, Matsumoto M, Yoshiji H. Ratio of von Willebrand factor antigen to ADAMTS13 activity is a useful biomarker for acute-on-chronic liver failure development and prognosis in patients with liver cirrhosis. Hepatol Res 2022; 52:390-400. [PMID: 34964539 DOI: 10.1111/hepr.13743] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/06/2021] [Accepted: 12/26/2021] [Indexed: 01/21/2023]
Abstract
AIM Acute-on-chronic liver failure (ACLF) is associated with a high risk of short-term mortality after progression to multiple organ failure. A disintegrin-like and metalloproteinase with thrombospondin type-1 motifs 13 (ADAMTS13) is a metalloproteinase that specifically cleaves multimeric von Willebrand factor (VWF). An imbalance between ADAMTS13 enzyme and VWF substrate is associated with liver cirrhosis progression that induces ACLF. This study examined the relationship between ADAMTS13 and VWF and ACLF development to determine whether ADAMTS13 and VWF are useful predictive biomarkers for ACLF development and prognosis of patients with liver cirrhosis. METHODS The study enrolled 67 patients with Child-Pugh class A and B liver cirrhosis. ADAMTS13 activity (ADAMTS13:AC) and VWF antigen (VWF:Ag) were measured using enzyme-linked immunosorbent assays. The ratio of VWF:Ag to ADAMTS13:AC (VWF:Ag/ADAMTS13:AC) was used to divide patients into two groups according to the classification and regression tree based on Gray model survival analysis. RESULTS Compared with patients with Child-Pugh class A liver cirrhosis, class B patients had a higher VWF:Ag/ADAMTS13:AC and a higher risk of ACLF development. Cumulative incidence of ACLF was significantly higher in patients with high (>7.9) versus low (≤7.9) VWF:Ag/ADAMTS13:AC (hazard ratio [HR], 6.50; 95% CI, 2.31-18.29; p < 0.001). Cumulative survival was significantly lower in cirrhotic patients with high versus low VWF:Ag/ADAMTS13:AC (HR 5.11; 95% CI, 1.85-14.14; p = 0.002). CONCLUSIONS For patients with liver cirrhosis, VWF:Ag/ADAMTS13:AC is associated with functional liver reserve and predicts the development of ACLF and the prognosis.
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Affiliation(s)
- Masahide Enomoto
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroaki Takaya
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Tadashi Namisaki
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Yukihisa Fujinaga
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Norihisa Nishimura
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Yasuhiko Sawada
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Kosuke Kaji
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Hideto Kawaratani
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Kei Moriya
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Takemi Akahane
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Takashi Inoue
- Institute for Clinical and Translational Science, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
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Khan A, Bailey CW. Unique Method of Transjugular Intrahepatic Portosystemic Shunt Reduction for Refractory Hepatic Encephalopathy. Cureus 2021; 13:e18838. [PMID: 34804693 PMCID: PMC8592787 DOI: 10.7759/cureus.18838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2021] [Indexed: 12/03/2022] Open
Abstract
We report the case of a 27-year-old female patient with a history of cryptogenic cirrhosis who was admitted to the hospital due to multiple episodes of hematemesis secondary to bleeding esophageal varices. The varices were persistent and refractory to endoscopic intervention, so an emergent transjugular intrahepatic portosystemic shunt (TIPS) was performed by interventional radiology (IR). Months later, the patient returned to the hospital unresponsive with acute intermittent hepatic encephalopathy which required a TIPS reduction by IR. Once the TIPS reduction was performed, the patient’s hepatic encephalopathy declined, and her symptoms improved. Here, we present a unique method of TIPS reduction utilizing a single Viabahn VBX balloon-expandable stent (W. L. Gore & Associates, Inc; Flagstaff, AZ) to constrain the existing TIPS stent.
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Affiliation(s)
- Ayub Khan
- Medicine, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| | - Christopher W Bailey
- Interventional Radiology, Virginia Commonwealth University School of Medicine, Richmond, USA
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Seifert LL, Schindler P, Schoster M, Weller JF, Wilms C, Schmidt HH, Maschmeier M, Masthoff M, Köhler M, Heinzow H, Wildgruber M. Recurrence of Hepatic Encephalopathy after TIPS: Effective Prophylaxis with Combination of Lactulose and Rifaximin. J Clin Med 2021; 10:jcm10204763. [PMID: 34682886 PMCID: PMC8537523 DOI: 10.3390/jcm10204763] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/26/2021] [Accepted: 10/13/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) implantation is an established procedure to treat portal hypertension with hepatic encephalopathy (HE) as a common complication. There is lack of evidence concerning HE prophylaxis after TIPS. METHODS N = 233 patients receiving TIPS between 2011 and 2018 at a German tertiary care center were included. Of them, 21% (n = 49) had a history of HE. The follow-up period was 12 months. The risk factors of post-TIPS HE were analyzed via multivariate analysis. The efficacy of prophylactic medication regimens was studied. The results show that 35.6% (n = 83) received no medication (NM), 36.5% (n = 85) received lactulose monoprophylaxis (LM), 2.6% (n = 6) rifaximin monoprophylaxis (RM) and 25.3% (n = 59) lactulose and rifaximin (LR) of which 64.4% received l-ornithin-l-aspartate (LOLA) additionally (LR + LOLA) and 36.6% did not (LRonly). RESULTS Multivariate analysis revealed higher age (p = 0.003) and HE episodes prior to TIPS (p = 0.004) as risk factors for HE after TIPS. LM has no prophylactic effect. LR prevents HE recurrence at 1, 3 and 12 months after TIPS (p = 0.003, p = 0.003, p = 0.006) but does not prevent HE in patients with no history of HE (p = 0.234, p = 0.483, p = 0.121). LR prevents HE recurrence compared with LM/NM (25.0% vs. 64.7%, p = 0.007) within 12 months after TIPS, whereas de novo occurrence is unaffected (p = 0.098). The additional administration of LOLA to LR has no benefit (LRonly: 25.0%, LR + LOLA: 29.7%, p = 0.780). CONCLUSIONS Higher age and previous HE are risk factors post-TIPS HE. In patients with HE prior to TIPS, effective prophylaxis of HE is feasible via combination of lactulose and rifaximin with no additional benefit from LOLA.
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Affiliation(s)
- Leon Louis Seifert
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, 48149 Muenster, Germany; (L.L.S.); (M.S.); (C.W.); (H.H.S.); (M.M.); (H.H.)
| | - Philipp Schindler
- Clinic for Radiology, University Hospital Muenster, 48149 Muenster, Germany; (P.S.); (M.M.); (M.K.)
| | - Martin Schoster
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, 48149 Muenster, Germany; (L.L.S.); (M.S.); (C.W.); (H.H.S.); (M.M.); (H.H.)
| | - Jan Frederic Weller
- Department of Hematology, University Hospital Tuebingen, 72076 Tuebingen, Germany;
| | - Christian Wilms
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, 48149 Muenster, Germany; (L.L.S.); (M.S.); (C.W.); (H.H.S.); (M.M.); (H.H.)
| | - Hartmut H. Schmidt
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, 48149 Muenster, Germany; (L.L.S.); (M.S.); (C.W.); (H.H.S.); (M.M.); (H.H.)
- Department of Gastroenterology and Hepatology, University Hospital Duisburg-Essen, 45147 Essen, Germany
| | - Miriam Maschmeier
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, 48149 Muenster, Germany; (L.L.S.); (M.S.); (C.W.); (H.H.S.); (M.M.); (H.H.)
- Department of Medicine I, Krankenhaus der Barmherzigen Brüder, 54292 Trier, Germany
| | - Max Masthoff
- Clinic for Radiology, University Hospital Muenster, 48149 Muenster, Germany; (P.S.); (M.M.); (M.K.)
| | - Michael Köhler
- Clinic for Radiology, University Hospital Muenster, 48149 Muenster, Germany; (P.S.); (M.M.); (M.K.)
| | - Hauke Heinzow
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, 48149 Muenster, Germany; (L.L.S.); (M.S.); (C.W.); (H.H.S.); (M.M.); (H.H.)
- Department of Medicine I, Krankenhaus der Barmherzigen Brüder, 54292 Trier, Germany
| | - Moritz Wildgruber
- Clinic for Radiology, University Hospital Muenster, 48149 Muenster, Germany; (P.S.); (M.M.); (M.K.)
- Department of Radiology, University Hospital LMU Munich, 81377 Munich, Germany
- Correspondence:
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10
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Ballester MP, Lluch P, Gómez C, Capilla M, Tosca J, Martí-Aguado D, Guijarro J, Mínguez M. Transjugular intrahepatic portosystemic shunt reduces hospital care burden in patients with decompensated cirrhosis. Intern Emerg Med 2021; 16:1519-1527. [PMID: 33400160 DOI: 10.1007/s11739-020-02602-x] [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: 04/20/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIMS Patients with decompensated cirrhosis frequently require hospital admissions, which are associated with worse prognosis. The aim of this study was to analyze the effect of TIPS on the need for hospital care. Secondary objectives were to assess the clinical and biological impact of TIPS and to identify predictors of post-TIPS hospital care. METHODS An observational, retrospective study of patients with decompensated cirrhosis treated with TIPS from January 2008 until March 2019. Exclusion criteria were TIPS placed for non-cirrhotic portal hypertension (PH) and patients referred from another hospital without prior or subsequent follow-up at our Unit. Hospital care, PH-related complications, and laboratory data were compared before and after TIPS. RESULTS The final cohort comprised 104 patients (72% male) with a mean age of 60 (± 10) years. Follow-up from first decompensation until TIPS and that from procedure to study completion were 7 (4.2-9.8) and 20 (4.6-35.4) months, respectively. TIPS was indicated mainly for refractory ascites (50%) and variceal bleeding (39%). Hemodynamic and clinical success rates were 97% and 92%, respectively. The number of emergency department visits and hospital admissions decreased after the procedure (p < 0.001). Improvement was seen in MELD and Child-Pugh scores, renal function, hyponatremia, and anemia after TIPS. Variceal bleeding as the indication for TIPS (OR 0.047; 95 CI 0.006-0,39; p < 0.05) together with early creation of the shunt (stage 3 vs 5; p < 0.05) were associated with a reduction in risk of post-TIPS hospital care. CONCLUSION TIPS is a safe and effective procedure that reduces hospital care burden by improving PH-related complications, hepatic, renal function, hyponatremia, and anemia. Variceal bleeding as the indication and early placement of the device were associated with a reduction in post-TIPS hospital care. These findings support a role for this treatment, predominantly in the early stages of cirrhosis.
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Affiliation(s)
- Maria Pilar Ballester
- Digestive Disease Department, Clinic University Hospital of Valencia, Blasco Ibañez 17, 46010, Valencia, Spain.
- Neurological Impairment Research Unit, INCLIVA Biomedical Research Institute of Clinic University Hospital of Valencia, Valencia, Spain.
| | - Paloma Lluch
- Digestive Disease Department, Clinic University Hospital of Valencia, Blasco Ibañez 17, 46010, Valencia, Spain
- Department of Medicine. Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
| | - Concepción Gómez
- Digestive Disease Department, Clinic University Hospital of Valencia, Blasco Ibañez 17, 46010, Valencia, Spain
| | - Maria Capilla
- Digestive Disease Department, Clinic University Hospital of Valencia, Blasco Ibañez 17, 46010, Valencia, Spain
| | - Joan Tosca
- Digestive Disease Department, Clinic University Hospital of Valencia, Blasco Ibañez 17, 46010, Valencia, Spain
| | - David Martí-Aguado
- Digestive Disease Department, Clinic University Hospital of Valencia, Blasco Ibañez 17, 46010, Valencia, Spain
- Biomedical Imaging Research Group (GIBI230), La Fe Health Research Institute, Valencia, Spain
| | - Jorge Guijarro
- Interventional Radiology Department, Clinic University Hospital of Valencia, Valencia, Spain
| | - Miguel Mínguez
- Digestive Disease Department, Clinic University Hospital of Valencia, Blasco Ibañez 17, 46010, Valencia, Spain
- Department of Medicine. Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
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Krishnamurthy P, Ahmad A. Successful treatment of recurrent hepatic encephalopathy with revision of transjugular intrahepatic portasystemic shunt and embolisation of splenorenal shunt. BMJ Case Rep 2021; 14:14/6/e242368. [PMID: 34167979 DOI: 10.1136/bcr-2021-242368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of 64-year-old US veteran who developed recurrent hepatic encephalopathy (HE) following transjugular intrahepatic portasystemic shunt (TIPSS) procedure. The patient had a history of metabolic syndrome and cirrhosis due to non-alcoholic steatohepatitis. He had undergone sleeve gastrectomy 1 year earlier with preoperative TIPSS placement. He developed recurrent symptoms of HE despite optimising his medications, resulting in poor quality of life and multiple hospitalisations. A liver Doppler ultrasound and CT scan of the abdomen was obtained which showed a patent TIPSS and a prominent shunt between the splenic vein and left renal vein via the left gonadal vein. This was treated with reduction of TIPSS, by placement of a covered stent in an hourglass configuration within the existing TIPSS stent and simultaneous embolisation of the splenorenal shunt by interventional radiology. The patient had complete resolution of symptoms following the procedure without any recurrence of HE.
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Affiliation(s)
- Padmini Krishnamurthy
- Department of Medicine, Wright State University, Dayton, Ohio, USA .,Gastroenterology, Dayton VA Medical Center, Dayton, Ohio, USA
| | - Ammar Ahmad
- Internal Medicine, Wright State University, Dayton, Ohio, USA
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12
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Praktiknjo M, Abu-Omar J, Chang J, Thomas D, Jansen C, Kupczyk P, Schepis F, Garcia-Pagan JC, Merli M, Meyer C, Strassburg CP, Pieper CC, Trebicka J. Controlled underdilation using novel VIATORR® controlled expansion stents improves survival after transjugular intrahepatic portosystemic shunt implantation. JHEP Rep 2021; 3:100264. [PMID: 34013182 PMCID: PMC8113713 DOI: 10.1016/j.jhepr.2021.100264] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 12/11/2022] Open
Abstract
Background & Aims Smaller 8-mm diameter transjugular intrahepatic portosystemic shunts (TIPS) appear to be more beneficial than larger 10-mm TIPS stent-grafts, but lack the ability for secondary dilation in cases of clinical ineffectiveness. Underdilated VIATORR® TIPS stent grafts (VTS) expand passively, whereas novel VIATORR Controlled Expansion (VCX) stent grafts do not. This study evaluated the impact on survival of underdilated VCX compared with VTS in patients with decompensated cirrhosis. Methods This was a prospective case-control study including patients with cirrhosis receiving TIPS using 10-mm VCX underdilated to 8 mm. Patients with cirrhosis receiving 10-mm VTS underdilated to 8 mm were matched for age, sex, indication for TIPS, and liver function. Results A total of 114 patients (47 VCX, 47 VTS, and 20 fully dilated VCX/VTS) were included. After TIPS implantation, underdilated VCX diameter was 8.0 (7.8-9.2) mm at a median time of 359 (87-450) days, compared with VTS at 9.9 (9.7-10.0) mm (p <0.001). The portosystemic pressure gradient immediately after TIPS procedure and after 7 days did not change significantly in VCX [mean 9.4 (± 0.8) vs. 10.4 (± 0.7) mmHg, p = 0.115). Hospital readmission rates for hepatic encephalopathy were 23% (n = 11) vs 51% (n = 24) for VCX and VTS (p <0.001), respectively. Patients with VCX had significantly lower rates of large-volume paracentesis (n = 5 [11%] vs. n = 10 [21%], p = 0.017) and heart failure (n = 1 [2%] vs. n = 7 [15%], p = 0.015). One-year mortality for underdilated VCX and VTS was 15% (n = 7) and 30% (n = 14) and, for fully dilated VCX/VTS, was 45% (n = 9) (log-rank p = 0.008), respectively. Conclusions This study demonstrated that VCX stent grafts underdilated to 8 mm do not passively expand to nominal diameter and suggests reduced hospital readmissions because of hepatic encephalopathy, uncontrolled ascites, and heart failure, and improved 1-year survival compared with underdilated VTS. Lay summary Transjugular intrahepatic portosystemic shunt (TIPS) improves survival in selected patients with liver cirrhosis and acute variceal bleeding or refractory ascites. Smaller 8-mm diameter TIPS stent grafts appear to improve patient outcome compared with larger 10-mm diameter stent grafts. Novel VIATORR® Controlled Expansion (VCX) stent grafts facilitate safe and stable underdilation to 8 mm of large 10-mm diameter stent grafts with improved patient outcome (survival, hepatic encephalopathy, ascites and heart failure) compared with legacy VIATORR TIPS stent graft (VTS). Thus, the use of underdilated VCX could preserve heart function. Clinical Trials Registration The study is registered at Clinicaltrials.govNCT03628807.
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Key Words
- Acute decompensation
- Ascites
- CT, computed tomography
- Cirrhosis
- HE, hepatic encephalopathy
- HF, heart failure
- Hepatic encephalopathy
- LV, left ventricular
- LV-GLS, LV global longitudinal strain
- LVP, large-volume paracentesis
- Liver
- MELD, model of end-stage liver disease
- NEPTUN, Non-invasive Evaluation Program for TIPS and follow Up Network
- PSPG, portosystemic pressure gradient
- PTFE, polytetrafluorethylene
- RA, recurrent/refractory ascites
- RAAS, renin-angiotensin-aldosterone system
- SPSS, spontaneous portosystemic shunt
- TIPS
- TIPS, transjugular intrahepatic portosystemic shunt
- TTE, transthoracic echocardiography
- Transjugular intrahepatic portosystemic shunt
- VB, variceal bleeding
- VCX, VIATORR controlled expansion
- VTS, VIATORR TIPS stent
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Affiliation(s)
- Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Jasmin Abu-Omar
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Daniel Thomas
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Patrick Kupczyk
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Filippo Schepis
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Juan Carlos Garcia-Pagan
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Carsten Meyer
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | | | - Claus C Pieper
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Frankfurt, Frankfurt, Germany.,European Foundation for the Study of Chronic Liver Failure - EF CLIF, Barcelona, Spain
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Evaluation of impact of elective invasive examinations in patients with transjugular intrahepatic portosystemic shunt in the long-term follow up. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:24-34. [PMID: 33429447 DOI: 10.1055/a-1330-9867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In the management of patients with decompensated liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) insertion is well-established but common recommendations in the follow up management are inconsistent. Doppler sonography is commonly used for detection for TIPS dysfunction whilst data on the impact of elective invasive examinations are scarce. AIM The aim of this retrospective analysis is to evaluate potential benefits of elective invasive examinations in the follow up management of patients after TIPS insertion METHODS: Data of all patients receiving TIPS at the university hospitals of Muenster and Bonn between 2013 and 2018 (n = 534) were collected. The impact of performance of elective invasive examinations at 12 months after TIPS insertion on the occurrence of liver related events (LREs) and frequency of TIPS revisions within 24 months after TIPS insertion was analyzed. RESULTS No significant differences were found concerning occurrence of liver related events after 24 months depending on whether an elective invasive examination was performed. Occurrence of hepatic encephalopathy, relapse of initial indication for TIPS, as well as death or liver transplantation all did not differ. These findings were verified by a subgroup analysis including only patients who did not experience a LRE or TIPS revision within the first 12 months after TIPS procedure. CONCLUSION The analyzed data suggest no evidence for a beneficial impact due to implementation of an elective invasive examination program after TIPS insertion. Invasive examinations should remain reserved to patients with suspected TIPS dysfunction.
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14
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Huang Z, Yao Q, Zhu J, He Y, Chen Y, Wu F, Hua T. Efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) created using covered stents of different diameters: A systematic review and meta-analysis. Diagn Interv Imaging 2020; 102:279-285. [PMID: 33303394 DOI: 10.1016/j.diii.2020.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this study was to make a systematic review and meta-analysis to determine the stent diameter (8mm vs. 10mm) that conveys better safety and clinical efficacy for transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS Four databases were used to identify clinical trials published from inception until March 2020. Data were extracted to estimate and compare one-year and three-year overall survivals, hepatic encephalopathy, variceal rebleeding, and shunt dysfunction rates between patients with 8mm covered stents and those with 10mm covered stents. RESULTS Five eligible studies were selected, which included 489 patients (316 men, 173 women). The 8mm covered stent group had higher efficacy regarding one-year or three-year overall survival (odds ratio [OR], 2.88; P=0.003) and (OR, 1.81; P=0.04) and lower hepatic encephalopathy (OR, 0.69; P=0.04) compared with 10mm covered stent group. There were no significant differences in variceal rebleeding rate (OR 0.80; P=0.67). However, shunt dysfunction was lower in 10mm covered stent group (OR, 2.26; P=0.003). CONCLUSIONS Our results suggest that the use of 8mm covered stents should be preferred to that of 10mm covered stents for TIPS placement when portal pressure is frequently monitored.
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Affiliation(s)
- Zongzhang Huang
- Department of Radiology, Ningbo Yinzhou No. 2 Hospital, 315000 Ningbo, Zhejiang, China
| | - Qigu Yao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 310058 Hangzhou, China
| | - Jianping Zhu
- Department of Radiology, Ningbo Yinzhou No. 2 Hospital, 315000 Ningbo, Zhejiang, China
| | - Ying He
- Zhejiang Chinese Medical University, 310053 Hangzhou, Zhejiang, China
| | - Yanghao Chen
- Department of Cardiology, The Key Lab of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, 325035 Wenzhou, China
| | - Feng Wu
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, 315000 Ningbo, Zhejiang, China
| | - Teng Hua
- Department of Radiology, Ningbo Yinzhou No. 2 Hospital, 315000 Ningbo, Zhejiang, China.
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15
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Shunt-Induced Hepatic Encephalopathy in TIPS: Current Approaches and Clinical Challenges. J Clin Med 2020; 9:jcm9113784. [PMID: 33238576 PMCID: PMC7700586 DOI: 10.3390/jcm9113784] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/11/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment tool in decompensated liver cirrhosis that has been shown to prolong transplant-free survival. Hepatic encephalopathy (HE) is a frequent complication of decompensated cirrhosis, eventually induced and/or aggravated by TIPS, that remains a clinical challenge especially in these patients. Therefore, patient selection for TIPS requires careful assessment of risk factors for HE. TIPS procedural parameters regarding stent size and invasive portosystemic pressure gradient measurements thereby have an important role. Endovascular shunt modification, in combination with a conservative medical approach, often results in a significant reduction of symptoms. This review summarizes HE molecular mechanisms and pathophysiology as well as diagnostic and therapeutic approaches targeting shunt-induced HE.
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16
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Takaya H, Namisaki T, Sato S, Kaji K, Tsuji Y, Kaya D, Fujinaga Y, Sawada Y, Shimozato N, Kawaratani H, Moriya K, Akahane T, Mitoro A, Yoshiji H. Increased Endotoxin Activity Is Associated with the Risk of Developing Acute-on-Chronic Liver Failure. J Clin Med 2020; 9:jcm9051467. [PMID: 32422875 PMCID: PMC7290888 DOI: 10.3390/jcm9051467] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) leads to systematic inflammatory response syndrome and multiple organ failure. This study investigated the relationship between endotoxin (Et) and ACLF with the aim of determining whether Et activity (EA) is useful as a predictive biomarker of ACLF development and whether rifaximin treatment decreased the risk of ACLF development. Two hundred forty-nine patients with liver cirrhosis were enrolled in this study. Et concentration was determined in the whole blood by a semiquantitative EA assay. Predictive factors of ACLF development and the risk of ACLF development with and without rifaximin treatment were identified by univariate and multivariate analysis using Fine and Gray’s proportional subhazards model. EA level was higher in Child-Pugh class B than in class A patients, and class B patients had an increased risk of ACLF development compared with class A patients. Multivariate analysis showed that EA level was a predictive factor independently associated with ACLF development. Rifaximin decreased EA level and the risk of ACLF development in Child-Pugh class B patients. Et levels were associated with functional liver capacity and were predictive of ACLF development in cirrhotic patients. Rifaximin decreased Et level and the risk of ACLF development in advanced cirrhotic patients.
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