Transjugular intrahepatic portosystemic shunt (TIPS) is a widely used non-surgical interventional radiologic procedure that has become an established treatment for patients with complications of portal hypertension, mainly for the treatment of variceal rebleeding and recurrent or refractory ascites. Overt hepatic encephalopathy (OHE) is a major shunt-related complication after TIPS insertion. The incidence of OHE in patients with cirrhosis is as high as 35-50% within the first year after TIPS, and persistent OHE may occur in up to 8% of patients treated with TIPS. It is not clear whether OHE after TIPS will increase the mortality rate of TIPS patients, and a recent multicenter, non-inferiority, observational study compared the mortality rate of OHE after TIPS in a large sample of TIPS patients.
Research Methods:
A multicenter, non-inferiority observational study to assess mortality at 30 months in patients with/without OHE after TIPS. The study analysed a database of 614 patients who received TIPS at three centers in Italy and estimated the cumulative incidence of OHE and death using a competitive risk analysis, setting the non-inferiority limit at 0.12.
Findings:
1. Occurrence of OHE
A total of 614 patients treated with TIPS were included, and the cumulative incidence of OHE was 47% (95% CI 43-51) at 30 months follow-up. The mean time to TIPS placement and OHE was 2.4±4.7 months, and the mean duration of episodes was 3.3±2.5 days. Grade 2 OHE was detected in 61% of patients, 34% in 34% and 4 in 5%.
Of the 293 patients who had at least one OHE experience, 58 (19.7%) had multiple OHEs, of which 48% had two OHEs, 42% had three times, 5% had four times, and 5% had five or more OHEs. The main causes of OHE were dehydration (40%), infection (31%), constipation (13%), gastrointestinal bleeding not related to portal hypertension (5%), use of benzodiazepines (5%), or other causes (6%).
2. Circumstances of death
A total of 168 (27%) patients died within a median follow-up period of 30 months, of which 64 (10%) received transplantation. The leading causes of death included: acute-on-chronic liver failure (36%), infection and sepsis (32%), heart failure (15%), hepatocellular carcinoma (7%), and other causes unrelated to liver disease (10%).
Estimates of mortality after TIPS were similar in patients with and without OHE after TIPS, taking into account liver transplantation (LT) as a competitive risk (Figure 1). Mortality at 30 months was 0.34 (0.28–0.40) and 0.31 (0.25–0.37), respectively, in patients with and without OHE. The difference in mortality at 30 months between patients with and without OHE was 0.03 (-0.042 to 0.102). Thus, the upper limit of the CI (0.102) was lower than the prespecified confidence limit for non-inferiority of 0.12. On this basis, it can be considered that the mortality rate of patients with OHE after TIPS is not inferior to that of patients without OHE.
Figure 1 Estimated mortality in patients with or without OHE after TIPS
Conclusions of the study
Regardless of the indication for shunting, OHE after TIPS does not increase patient mortality. However, OHE can adversely affect patients' quality of life and morbidity, so it remains a significant problem for patients receiving selective TIPS. Persistent OHE, although uncommon after TIPS, is still an important complication associated with increased mortality. Therefore, in-depth research to improve patient selection and risk stratification remains critical.
Source:
Nardelli S, Riggio O, Marra F, Gioia S, Saltini D, Bellafante D, Adotti V, Guasconi T, Ridola L, Rosi M, Caporali C, Fanelli F, Roccarina D, Bianchini M, Indulti F, Spagnoli A, Merli M, Vizzutti F, Schepis F. Episodic overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt does not increase mortality in patients with cirrhosis. J Hepatol. 2024 Apr; 80(4):596-602. doi: 10.1016/j.jhep.2023.11.033. Epub 2023 Dec 13. PMID: 38097113.
Source: Yimaitong Hepatology