TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
- Grade 0 (minimal)—normal state of consciousness, objectifiable only by neuropsychiatric tests;
- Grade 1—slight mental slowdown, disturbed fine motor skills;
- Grade 2—increased fatigue, apathy, flapping tremor/asterixis, ataxia, slurred speech;
- Grade 3—somnolence, marked disorientation, rigor, stupor;
- Grade 4—coma.
2.2. TIPS Placement and Modification Procedure
2.3. Definitions regarding HE
2.4. Statistics
3. Results
3.1. Patient Characteristics
3.2. Laboratory and Procedural Data Regarding TIPS Insertion
3.3. Logistic Regression Analysis of Predictors for Post-TIPS HE
3.4. Shunt Modification in Patients with HE
3.5. Comparison of Responders and Non-Responders to TIPS Modification
3.6. Analysis of Predictors for Response to Shunt Modification
4. Discussion
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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No HE | HE | |||
---|---|---|---|---|
Parameter | Total No. (%) | No. (%) | No. (%) | p-value |
Total | 93 (100) | 48 (51.6) | 45 (48.4) | |
Sex | 0.624 | |||
male | 65 (69.9) | 33 (68.8) | 32 (71.1) | |
female | 28 (30.1) | 15 (31.3) | 13 (28.9) | |
Median age (range), years | 59 (21–77) | 54 (21–77) | 56 (25–77) | 0.984 |
Aetiology of liver disease | 0.232 | |||
alcoholic | 47 (50.5) | 25 (52.1) | 22 (48.9) | |
PBC/autoimmune | 11 (11.8) | 6 (12.5) | 5 (11.1) | |
viral | 7 (7.5) | 5 (10.4) | 2 (4.4) | |
NASH | 9 (9.7) | 3 (6.3) | 6 (13.3) | |
other | 19 (20.4) | 9 (18.8) | 10 (22.2) | |
Child’s grade | 0.559 | |||
A | 17 (18.3) | 9 (18.8) | 8 (17.8) | |
B | 58 (62.4) | 31 (64.6) | 27 (60.0) | |
C | 18 (19.4) | 8 (16.7) | 10 (22.2) | |
Post-TIPS HE grade (West Haven criteria) | E | |||
0 | 48 (51.6) | 48 (100) | 0 (0) | |
1 | 19 (20.4) | 0 (0) | 19 (42.2) | |
2 | 12 (12.9) | 0 (0) | 12 (26.7) | |
3 | 9 (9.7) | 0 (0) | 9 (20.0) | |
4 | 5 (5.4) | 0 (0) | 5 (11.1) | |
Indication for TIPS insertion | 0.294 | |||
variceal bleeding | 23 (24.7) | 13 (27.1) | 10 (22.2) | |
refractory ascites | 64 (68.8) | 31 (64.6) | 33 (73.3) | |
other | 6 (6.5) | 4 (8.3) | 2 (4.4) |
No HE (n = 48) | HE (n = 45) | ||
---|---|---|---|
mean (SD) | mean (SD) | p-value | |
Before TIPS insertion | |||
Bilirubin, mg/dl | 2.1 (2.2) | 2.1 (3.6) | 0.664 |
Albumin, g/dl | 3.0 (1.1) | 2.6 (1.2) | 0.525 |
Creatinine, mg/dl | 1.2 (0.7) | 1.5 (1.2) | 0.125 |
INR | 1.4 (0.3) | 1.3 (0.3) | 0.475 |
MELD-score | 14.1 (5.5) | 14.8 (6.7) | 0.347 |
CLIF-c AD-score | 57.5 (8.8) | 56.7 (9.4) | 0.839 |
PPG, mmHg | 18.4 (5.8) | 18.8 (5.8) | 0.973 |
After TIPS insertion | |||
Bilirubin, mg/dl | 2.3 (1.5) | 2.6 (4.1) | 0.225 |
Albumin, g/dl | 3.1 (0.8) | 2.9 (0.6) | 0.304 |
Creatinine, mg/dl | 1.1 (0.9) | 1.3 (0.9) | 0.610 |
INR | 1.4 (0.3) | 1.4 (0.3) | 0.687 |
MELD-score | 12.1 (6.7) | 13.4 (7.0) | 0.668 |
CLIF-c AD-score | 48.4 (6.6) | 51.2 (5.9) | 0.441 |
PPG, mmHg | 9.0 (3.3) | 8.9 (3.4) | 0.249 |
PPG reduction, mmHg | 9.4 (4.5) | 9.9 (4.8) | 0.654 |
post-TIPS HE | |||
---|---|---|---|
Variable | Regression Coefficient | Standard Effort | p-Value |
Age | 0.120 | 0.044 | 0.007 |
Post-TIPS Creatinine | 4.934 | 2.099 | 0.019 |
Post-TIPS INR | 4.000 | 1.943 | 0.040 |
post-TIPS HE | post-TIPS HE | ||
---|---|---|---|
no Shunt Modification | Shunt Modification | ||
n = 25 | n = 20 | ||
mean (SD) | mean (SD) | p-value | |
Before TIPS insertion | |||
Bilirubin, mg/dl | 2.5 (4.5) | 2.0 (1.2) | 0.944 |
Albumin, g/dl | 2.2 (1.2) | 3.2 (0.9) | 0.014 |
Creatinine, mg/dl | 1.7 (1.5) | 1.2 (0.6) | 0.251 |
INR | 1.3 (0.3) | 1.4 (0.3) | 0.929 |
MELD-score | 14.3 (1.8) | 13.5 (4.7) | 0.802 |
PPG, mmHg | 20.8 (5.3) | 16.0 (5.5) | 0.016 |
After TIPS insertion | |||
Bilirubin, mg/dl | 2.6 (5.0) | 2.6 (1.6) | 0.985 |
Albumin, g/dl | 3.0 (0.7) | 3.1 (0.3) | 0.878 |
Creatinine, mg/dl | 1.6 (1.0) | 0.9 (0.4) | 0.112 |
INR | 1.3 (0.2) | 1.5 (0.4) | 0.059 |
MELD-score | 13.7 (7.7) | 13.0 (5.8) | 0.766 |
PPG, mmHg | 9.9 (3.3) | 7.4 (3.0) | 0.027 |
PPG reduction, mmHg | 10.9 (4.9) | 8.6 (4.4) | 0.297 |
Responder | Non-Responder | ||
---|---|---|---|
n = 11 | n = 9 | ||
Sex (m:f) | 9:2 | 3:6 | |
Median Age (range), y | 64 (56–77) | 65 (26-76) | |
Aetiology (ALD/non-ALD) | 5/6 | 4/5 | |
Child’s grade (A/B/C) | 5/4/2 | 2/5/2 | |
post-TIPS HE | |||
West Haven criteria (1–2/3–4) | 1/11 | 9/0 | |
early (< 6 months) / late (> 6 months) | 8/3 | 4/5 | |
TIPS reduction / occlusion | 11/0 | 7/2 | |
Recurrence of primary TIPS indication | n = 1 | n = 2 | |
mean (SD) | mean (SD) | p-value | |
Before TIPS modification | |||
Bilirubin, mg/dl | 1.9 (1.3) | 3.4 (3.2) | 0.149 |
Albumin, g/dl | 3.1 (0.5) | 2.9 (0.5) | 0.746 |
Creatinine, mg/dl | 1.5 (0.7) | 1.8 (1.9) | 0.111 |
INR | 1.4 (0.4) | 1.6 (0.5) | 0.839 |
MELD-score | 15.4 (5.6) | 18.3 (6.3) | 0.928 |
CLIF-c AD-score | 52.7 (5.6) | 55.2 (8.7) | 0.565 |
PPG, mmHg | 7.3 (3.1) | 8.2 (5.1) | 0.182 |
After TIPS modification | |||
Bilirubin, mg/dl | 1.9 (1.7) | 2.0 (1.0) | 0.215 |
Albumin, g/dl | 3.3 (0.6) | 3.1 (0.5) | 0.559 |
Creatinine, mg/dl | 1.6 (1.2) | 1.5 (1.4) | 0.714 |
INR | 1.4 (0.4) | 1.5 (0.3) | 0.490 |
MELD-score | 15.6 (6.5) | 17.1 (6.7) | 0.864 |
CLIF-c AD-score | 53.0 (5.1) | 54.3 (8.4) | 0.299 |
PPG, mmHg | 11.8 (4.2) | 12.6 (4.9) | 0.660 |
PPG increase, mmHg | 3.8 (4.3) | 5.6 (4.9) | 0.862 |
XA time, min | 4.0 (2.7) | 6.8 (3.5) | 0.457 |
Variable | Regression Coefficient | Standard Effort | p-Value |
---|---|---|---|
HE grade (West Haven) | 2.634 | 1.125 | 0.019 |
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Schindler, P.; Seifert, L.; Masthoff, M.; Riegel, A.; Köhler, M.; Wilms, C.; Schmidt, H.H.; Heinzow, H.; Wildgruber, M. TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification. J. Clin. Med. 2020, 9, 567. https://doi.org/10.3390/jcm9020567
Schindler P, Seifert L, Masthoff M, Riegel A, Köhler M, Wilms C, Schmidt HH, Heinzow H, Wildgruber M. TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification. Journal of Clinical Medicine. 2020; 9(2):567. https://doi.org/10.3390/jcm9020567
Chicago/Turabian StyleSchindler, Philipp, Leon Seifert, Max Masthoff, Arne Riegel, Michael Köhler, Christian Wilms, Hartmut H. Schmidt, Hauke Heinzow, and Moritz Wildgruber. 2020. "TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification" Journal of Clinical Medicine 9, no. 2: 567. https://doi.org/10.3390/jcm9020567
APA StyleSchindler, P., Seifert, L., Masthoff, M., Riegel, A., Köhler, M., Wilms, C., Schmidt, H. H., Heinzow, H., & Wildgruber, M. (2020). TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification. Journal of Clinical Medicine, 9(2), 567. https://doi.org/10.3390/jcm9020567