S1267 The Use of Prophylactic Treatment in the Prevention of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt

Abstract

Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) procedures are indicated in the treatment of refractory ascites or variceal bleeding in patients with end-stage liver disease. Hepatic encephalopathy (HE) is a major complication of the procedure as ammonia is able to bypass the liver. Previous studies have shown prophylactic use of rifaximin to have significant benefit in primary prevention of HE. The purpose of our study was to evaluate how frequently primary HE prophylaxis medications were prescribed and to assess if this led to decreased incidence of HE. Methods: We performed a retrospective chart review of 231 patients who received TIPS over the past 10 years at our institution that also had at least one follow up visit. Patient demographics were recorded including age, race, cirrhosis etiology, cirrhotic decompensations, MELDNa, BMI, pre/post TIPS gradients, and use of HE prophylaxis medications. Diagnosis of hepatic encephalopathy was performed through chart review by reviewing both Hepatology clinic notes and all hospital admissions. Variables were analyzed using Chi-Squared test, two sample T test, and multivariate analysis for incidence of hepatic encephalopathy. Results: Our cohort included 231 patients with 95 females (41.1%) and the majority being elective cases (62.8%). Common indications for TIPS included esophageal varices (51.9%), ascites (35.5%), and hepatic hydrothorax (7.8%). There were 111 patients that were discharged with lactulose, 9 patients discharged with rifaximin, 55 patients discharged with a combination of lactulose and rifaximin, and 57 patients were discharged without HE prophylaxis. Multivariate analysis showed the incidence of HE was significantly reduced in the group of patients discharged with lactulose [Adjusted Odds Ratio (OR): 0.48, 95% CI (0.23-0.99), p=0.049] and a near significant difference in patients discharged with a combination of lactulose and rifaximin [Odds Ratio (OR): 0.48, 95% CI (0.20-1.15), p=0.100]. (Table) Conclusion: Lactulose as prophylaxis following TIPS procedure was associated with significantly decreased likelihood of developing HE. Lactulose provides a cost effective alternative to rifaximin. Table 1. - Variable Unadjusted OR 95% CI p-value Adjusted OR 95% CI p-value Age 1.019 0.993, 1.045 0.1482 1.027 0.997, 1.058 0.0781 BMI 0.994 0.959, 1.030 0.7428 0.998 0.959, 1.038 0.9097 Pre-TIPS Gradient 1.009 0.954, 1.068 0.7515 0.977 0.906, 1.053 0.5428 Post-TIPS Gradient 1.079 0.970, 1.200 0.1616 1.076 0.937, 1.236 0.2967 Gradient Change 1.016 0.953, 1.082 0.6283 NA Gender Female ref ref Male 1.459 0.854, 2.493 0.1664 1.300 0.700, 2.413 0.4066 Ethnicity White ref ref Black 0.491 0.169, 1.426 0.1908 0.373 0.105, , 1.322 0.1265 Other 0.510 0.097, 2.689 0.4274 0.388 0.0622.428 0.3115 TIPS Indication EV ref ref Ascites 0.692 0.388, 1.234 0.2118 0.599 0.285, 1.261 0.1775 Hydrothorax 1.011 0.373, 2.741 0.9823 1.130 0.369, 3.462 0.8301 Volume Overload NC Prior HE No ref ref Yes 0.810 0.4411.489 0.4971 1.380 0.636, 2.992 0.4147 Unknown 0.634 0.1832.190 0.4710 0.804 0.186, 3.469 0.7699 Prior Hep Visit No ref ref Yes 1.103 0.619, 1.966 0.7390 1.064 0.5042.245 0.8701 HE Prophylaxis Meds None ref ref Lactulose 0.491 0.257, 0.939 0.0316 0.484 0.235, 0.996 0.0486 Rifaximin 1.048 0.255, 4.313 0.9478 1.326 0.234, 7.503 0.7495 Both 0.518 0.244, 1.100 0.0871 0.476 0.197, 1.153 0.1000 Surgery Elective ref ref Emergent 1.483 0.867, 2.538 0.1503 1.523 0.729, 3.180 0.2632