Pre-transjugular intrahepatic portosystemic shunts (TIPS) prediction of post-TIPS overt hepatic encephalopathy: The Critical Flicker Frequency is more accurate than psychometric tests

Abstract

Transjugular intrahepatic portosystemic shunts (TIPS) is a second-line treatment because of an increased incidence of overt hepatic encephalopathy (OHE). A better selection of patients to decrease this risk is needed and one promising approach could be the detection of minimal hepatic encephalopathy (MHE). The aim of the present prospective study was to determine whether pre-TIPS minimal hepatic encephalopathy was predictive of post-TIPS OHE and to compare Psychometric Hepatic Encephalopathy Sum Score (PHES) and the Critical Flicker Frequency (CFF) in this setting. From May 2008 to January 2011, 54 consecutive patients treated with TIPS were included. PHES and CFF were performed 1 to 7 days before and after TIPS at months 1, 3, 6, 9, and 12 or until liver transplantation or death. Before TIPS, MHE was detected by PHES and CFF in 33% and 39% of patients, respectively. After the TIPS procedure, 19 patients (35%) experienced a total of 64 episodes of OHE. OHE developed significantly more often in patients for whom an indication for TIPS had been refractory ascites, with a history of OHE or of renal failure, lower hemoglobin level, or MHE as diagnosed by CFF. Post-TIPS OHE was more accurately predicted by CFF than by PHES. Absence of MHE at CFF had a good negative predictive value (91%) for the risk of post-TIPS recurrent OHE, defined as the occurrence of three or more episodes of OHE or of one episode which lasted more than 15 days. The absence of pre-TIPS history of OHE and a CFF value equal to or greater than 39 Hz had a 100% negative predictive value for post-TIPS recurrent OHE. Conclusion: Aiming to decrease the rate of post-TIPS HE, the use of CFF could help selecting patients for TIPS. (HEPATOLOGY 2014;59:622-629) T ransjugular intrahepatic portosystemic shunts (TIPS) have been part of the armamentarium against the complications of portal hypertension for 20 years. As a whole, TIPS proved more effective than alternative treatments in controlling or preventing variceal bleeding and refractory ascites, although meta-analyses failed to show any improvement in survival and evidenced an increased incidence of hepatic encephalopathy (HE). 1-3 Consequently, in most situations TIPS is considered a second-line treatment. 4,5 Three risk factors for post-TIPS HE have been identified by a recent meta-analysis pooling more than 3,000 patients: age over 65 years, history of previous episodes of HE, and Child-Pugh score equal to or greater than 10. 6 A better selection of the patients based on those criteria should lessen the risk of post-TIPS HE. However, the incidence of post-TIPS overt HE (OHE) in patients fulfilling these criteria remains close to 30%, so that we clearly need new parameters. One of them could be minimal HE (MHE) which is

Qualifying and quantifying minimal hepatic encephalopathy

“…In a later study, by another group, a CFF cut-off of 38 Hz identified patients with minimal hepatic encephalopathy, diagnosed using the PHES test, with a sensitivity of 72.4 % and a specificity of 77.2 % and an observed agreement of 75 % (Romero-Gómez et al 2007). Low CFF readings predict the development of overt hepatic encephalopathy during follow-up (Romero-Gómez et al 2007); predict the development of overt hepatic encephalopathy following TIPS insertion more accurately than the PHES test (Berlioux et al 2014); and predict poor post-TIPS outcomes (Kircheis et al 2009). Variables such as gender, level of education and time of day do not appear to significantly affect CFF results (Kircheis et al 2002), although there is some evidence of differential effects in relation to age (Dhiman et al 2010;Goldbecker et al 2013) and the aetiology of the underlying liver disease (Kircheis et al 2002).…”

Consensus conference on TIPS management: Techniques, indications, contraindications

“…Bearing in mind these limitations, the incidence of overt episodic or recurrent HE post-TIPS varies between 15 and 67% in a 2-year follow-up. The incidence of persistent overt HE is around 8% [80] and that of de-novo, covert HE around 35% [14,26,[81][82][83][84][85][86][87][88]. [31,81,82,84] • Baseline arterial hypotension (1a) [4,83] • High serum creatinine and hyponatriemia (Na < 130) (1a) [4, 80,82] • Low serum albumin levels (1b) [80] • Bare vs. covered stent (2b) [85] • Very low porto-systemic pressure gradient after TIPS (<5 mmHg) (1a) [25,[78][79][80][81][82][83]87] a Child A risk of HE close to 0, in Child B up to 33%, in Child C up to 89%.…”

Longitudinal Monitoring of Hepatic Blood Flow before and after TIPS by Using 4D-Flow MR Imaging

“…The second major complication is recurrent portal hypertension secondary to development of in-stent stenosis, despite improved patency with the advent of covered stents (7,8). Therefore, comprehensive and longitudinal hemodynamic monitoring of the portal system and the TIPS is needed to monitor stent patency and the fraction of blood flow that is diverted from the liver (9,10). …”