Race and Gradient Difference Are Associated with Increased Risk of Hepatic Encephalopathy Hospital Admission After Transjugular Intrahepatic Portosystemic Shunt Placement

Abstract

Background/Aims: Hepatic encephalopathy (HE) is a well-recognized complication of transjugular intrahepatic portosystemic shunt (TIPS) placement. The aim of this investigation was to evaluate incidence and predictors of post-TIPS HE necessitating hospital admission in a non-clinical trial setting. Methods: We performed a retrospective cohort study identifying 273 consecutive patients undergoing TIPS from 2010 to 2015 for any indication; 210 met inclusion/exclusion criteria. The primary endpoint was incidence of post-TIPS HE defined as encephalopathy with no other identifiable cause requiring hospitalization within 90 days of TIPS. Clinical demographics and procedural variables were collected and analyzed to determine predictors of readmission for post-TIPS HE. Categorical variables were analyzed using Fisher's exact test; continuous variables were compared using Levene's t-test and student's t-test; P < 0.05, significant. Results: Forty-two of 210 patients (20%) developed post-TIPS HE requiring hospitalization within 90 days. On analysis of cohorts (post-TIPS HE vs. no post-TIPS HE): non-white race (31.0% vs. 17.5%, P = 0.022) and increased hepatic venous pressure gradient (HVPG) difference during TIPS (10.5 vs. 8.9 mmHg, P = 0.030) were associated with an increased incidence of HE requiring readmission within 90 days. Conclusions: HE remains a common complication of TIPS. Non-Caucasian race is a significant clinical demographic associated with increased risk for readmission. Independent of initial or final HVPG, HVPG difference appears to be a significant modifiable technical risk factor. In the absence of clear preventative strategies for post-TIPS encephalopathy, non-Caucasians with HVPG reductions >9 mmHg may require targeted follow up evaluation to prevent hospital readmission.

Case–control study: Proton pump inhibitor use is a major risk factor for hepatic encephalopathy after TIPS

“…Consistent with prior studies, a lower post‐TIPS portosystemic gradient, and higher MELD score were associated with a greater risk of developing HE 26,27 . Subjects in the post‐TIPS HE group had a higher grade of encephalopathy prior to TIPS (Grade I‐II encephalopathy, post‐TIPS HE: 62% vs No HE: 43%).…”

“…Consistent with prior studies, a lower post-TIPS portosystemic gradient, and higher MELD score were associated with a greater risk of developing HE. 26,27 Subjects in the post-TIPS HE group had a higher grade of encephalopathy prior to TIPS (Grade I-II encephalopathy, post-TIPS HE: 62% vs No HE: 43%). We found a strong association between baseline PPI use and HE development on both univariate (P = 3.808 × 10 −5 ) and multivariate regression (P = 0.00292): PPI use occurred in 86% of subjects in the post-TIPS HE group compared to 32% in the group that did not develop HE.…”

Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy—A Review of the Past Decade’s Literature Focusing on Incidence, Risk Factors, and Prophylaxis

“…Despite recent clinical and procedural advancements, there has been no overall trend towards a decrease in incidence over the years, as illustrated by Figure 2 , where studies are ordered according to the year when patient recruitment began ( Figure 2 ) [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ]. The studies are too few to conduct meaningful statistical calculations.…”

“…Hepatic venous pressure gradient (HVPG) and portal pressure gradient (PPG) reduction after TIPS placement: HVPG reduction of >9–10 mmHg or >60% by TIPS has been reported to increase the risk of post-TIPS HE [ 22 , 62 ]. However, a Swedish retrospective study of 131 TIPS patients found no difference in post-TIPS HE in groups with pressure gradients over or under five mmHg, but not all the patients had cirrhosis [ 97 ].…”

“…Accordingly, quantifying SPSS prior to TIPS and considering embolisation is increasingly being applied in clinical practice. Also, during TIPS procedures, the absolute and percentwise reduction of PPG should be monitored and kept below 60% as larger pressure gradient drops increase the risk of post-TIPS HE [ 22 , 62 ]. It has been suggested that in Child-Pugh class B cirrhosis patients, a PPG of 12 mmHg might have the best net benefit, while in Child-Pugh C patients, this was true for PPG < 14 mmHg [ 97 ].…”