Predictors of Occurrence and Risk of Hepatic Encephalopathy After TIPS Creation: A 15-Year Experience

Coronado, Wendy Melissa; Ju, Connie; Bullen, Jennifer; Kapoor, Baljendra

doi:10.1007/s00270-020-02512-7

Cited by 30 publications

(29 citation statements)

References 30 publications

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“…Despite the increased risk of developing HE or worsening it on the basis of chronic liver disease, TIPS has been well established in the therapy of refractory complications of portal hypertension such as variceal bleeding, ascites, hepatic hydrothorax and hepatorenal syndrome [1,2]. To ensure prevention and improve management of post-TIPS HE, careful patient selection for TIPS considering specific risk factors of HE is required [22][23][24]. Within this context, it is important to differentiate specific predictive risk factors of HE in cirrhosis and following TIPS placement.…”

Section: Risk Factors Of He In Cirrhosis and Following Tipsmentioning

confidence: 99%

“…Moreover, prevention and management of post-TIPS HE are still in need of improvement [1,22]. Correct patient selection for TIPS requires careful assessment of risk factors for HE to prevent complications which may weaken the improved hemodynamic results and worsen the patient's life quality or expectancy [22][23][24]. Furthermore, the history of HE with increased severity itself is one of the main risk factors for HE recurrence in cirrhosis, and also an important predictor of post-TIPS HE [25][26][27].…”

Section: Introductionmentioning

confidence: 99%

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Shunt-Induced Hepatic Encephalopathy in TIPS: Current Approaches and Clinical Challenges

Schindler

Heinzow

Trebicka

et al. 2020

JCM

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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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Section: Risk Factors Of He In Cirrhosis and Following Tipsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Shunt-Induced Hepatic Encephalopathy in TIPS: Current Approaches and Clinical Challenges

Schindler

Heinzow

Trebicka

et al. 2020

JCM

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“…In vivo studies have shown that VCX can assume and maintain the intended diameter on clinical follow-up[ 217 ]. VCX was associated with a good short term clinical success with a lower rate of HE and stent dysfunction[ 4 , 5 ]. Also, a reduced rate of readmission for sepsis and ascites was observed over a three-month follow-up[ 217 ].…”

Section: Update On the Technical Aspects Of Tipsmentioning

confidence: 99%

“…With the introduction of the novel controlled-expansion stent, options for modulation of the portosystemic gradient (PSPG) after placement of TIPS stent has evolved. Recent studies have demonstrated a reduction in the incidence of HE, stent dysfunction, readmission for sepsis, and ascites with the use of these stents[ 4 , 5 ]. In this review, we present an exhaustive update of current literature on the role of TIPS in the management of PH in patients with cirrhosis with emphasis on emerging indications of TIPS, evolving patient selection criteria, and technical aspects of the procedure.…”

Section: Introductionmentioning

confidence: 99%

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

Rajesh

George

Philips

et al. 2020

WJG

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More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

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“…With these limited evidence, underlying pre-TIPS HE has served as a relative contraindication to TIPS placement ( 3 , 10 ). Existing literature posits that TIPS may worsen or precipitate encephalopathy, with thorough emphasis currently placed on pre-TIPS screening ( 11 ).…”

Section: Introductionmentioning

confidence: 99%

History of Hepatic Encephalopathy Is Not a Contraindication to Transjugular Intrahepatic Portosystemic Shunt Placement for Refractory Ascites

Saab

Zhao

Asokan

et al. 2021

Clin Transl Gastroenterol

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INTRODUCTION: The outcomes of transjugular intrahepatic portosystemic shunt (TIPS) placement in patients with hepatic encephalopathy (HE) are controversial. We studied the relationship of pre-TIPS HE in patients undergoing TIPS for refractory ascites on all-cause mortality and development of post-TIPS HE. METHODS: A single-center retrospective comparison study was performed for patients undergoing TIPS for refractory ascites. Survival by history of pre-TIPS HE was demonstrated with Kaplan-Meier curves. Univariate and multivariate logistic regression analyses were performed to identify the predictors of post-TIPS clinical outcomes for patients with and without pre-TIPS HE. RESULTS: We identified 202 TIPS recipients (61% male, mean ± SD; age 59.1 ± 10.2 years; mean model for end-stage liver disease score 17.3 ± 6.9). Pre-TIPS HE did not predispose patients for increased all-cause mortality, increased risk of experiencing HE within 60 days, or increased risk of hospital admission for HE within 6 months. A multivariate analysis demonstrated that total bilirubin (odds ratio [OR] 1.03; P = 0.016) and blood urea nitrogen (OR 1.15; P = 0.002) were predictors for all-cause mortality within 6 months post-TIPS. Age ≥65 years (OR 3.92; P = 0.004), creatinine (OR 2.22; P = 0.014), and Child-Pugh score (OR 1.53; P = 0.006) were predictors for HE within 60 days post-TIPS. Predictors of intensive care admission for HE within 6 months post-TIPS included age ≥65 years (OR 8.84; P = 0.018), history of any admission for HE within 6 months pre-TIPS (OR 8.42; P = 0.017), and creatinine (OR 2.22; P = 0.015). DISCUSSION: If controlled, pre-TIPS HE does not adversely impact patient survival or clinical outcomes, such as development of HE within 60 days of TIPS or hospital admission for HE within 6 months. Patients may be able to undergo TIPS for refractory ascites despite a history of HE.

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Predictors of Occurrence and Risk of Hepatic Encephalopathy After TIPS Creation: A 15-Year Experience

Cited by 30 publications

References 30 publications

Shunt-Induced Hepatic Encephalopathy in TIPS: Current Approaches and Clinical Challenges

Shunt-Induced Hepatic Encephalopathy in TIPS: Current Approaches and Clinical Challenges

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

History of Hepatic Encephalopathy Is Not a Contraindication to Transjugular Intrahepatic Portosystemic Shunt Placement for Refractory Ascites

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