Early-Recurrent Overt Hepatic Encephalopathy Is Associated with Reduced Survival in Cirrhotic Patients after Transjugular Intrahepatic Portosystemic Shunt Creation 

Clinical question: How well does the presence of overt hepatic encephalopathy (OHE) occurring within 3 months of a transjugular intrahepatic portosystemic shunt (TIPS) placement predict survival?

Take-away point: Early recurrence of OHE was related to poorer long-term survival for cirrhotic patients who underwent the TIPS procedure.

Reference: Zuo L, Lv Y, Wang Q, et al. Early-Recurrent Overt Hepatic Encephalopathy Is Associated with Reduced Survival in Cirrhotic Patients after Transjugular Intrahepatic Portosystemic Shunt Creation. J Vasc Interv Radiol. 2019 Feb;30(2):148-153.e2. doi: 10.1016/j.jvir.2018.08.023. Epub 2019 Jan 9. PubMed PMID: 30638778.

Click here for abstract

Study design: Retrospective cohort study

Funding sources: Self-funded/NA

Setting: Single institution

Summary

Hepatic encephalopathy (HE) has been shown to have a major impact on survival in patients with decompensated cirrhosis, however the effect of HE following TIPS placement on survival has not been clearly delineated. 304 patients who underwent TIPS placement for variceal hemorrhage or refractory ascites were retrospectively analyzed for the development of OHE within 3 months of TIPS placement, as defined by grade 2-4 HE according to the West Haven Criteria. Multivariate, time-dependent models were applied to assess the impact of early OHE, early-single OHE, and early recurrent OHE. The cumulative rate of OHE occurring within 3 months of TIPS was 27.6% (n=84) with a total of 149 episodes of OHE occurring within this population. Early-recurrent OHE (64.9%) was associated with a statistically significant higher rate of mortality than those without early-recurrent OHE (20.6%) (HR = 4.31; 95% CI: 2.64–7.06; P < .001). In the multivariate analysis, early-recurrent OHE (HR = 2.81; 95% CI: 1.67–4.73; P < .001), MELD score (HR = 1.16; 95% CI: 1.06–1.26; P = .001), age (HR = 1.04; 95% CI: 1.02–1.06; P < .001), and ascites (HR = 1.91; 95% CI: 1.04–3.53, P =.037) were associated independently with survival. Landmark and propensity score analysis confirmed that early-recurrent OHE remained a significant predictor of survival.



Figure 1
(a) Cumulative probability of OHE and survival in 304 cirrhotic patients with TIPS. (b) Cumulative probability of secondary OHE in 304 cirrhotic patients with TIPS. (c) Cumulative probability of survival in 304 patients with cirrhosis undergoing TIPS.





Figure 2
(a) Probability of survival in patients with and without early OHE. (b) Probability of survival in patients with and without early-single OHE. (c) Probability of survival in patients with and without early-recurrent OHE.

Commentary

This study provides valuable insight into a patient’s prognosis following the development of HE after TIPS. Previous research has debated the association between HE and mortality following TIPS, however the results of the present study further supports the conclusion that HE following TIPS is associated with increased mortality. The large sample size coupled with rigorous statistical analyses bolsters the results of this study. Patient’s that develop recurrent OHE within 3 months of TIPS have significantly poorer survival than those with only one occurrence of OHE. Given that 44% of patients who had a first OHE episode after a TIPS would experience recurrent OHE within 3 months, intense surveillance and therapy should be pursued during this time period. It should be noted that a majority of the patients in this study developed cirrhosis secondary to Hepatitis B (84%), so the results may not be completely generalizable to patients with other chronic liver disease.

Post Author:
Jacob Bundy, MD, MPH
PGY-1
Department of Surgery
University of Michigan Health System
@JBundyRad