TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification.

Philipp Schindler,Leon Seifert,Hauke Heinzow,Michael Köhler,Moritz Wildgruber,Christian Wilms,Hartmut H Schmidt,Arne Riegel,Max Masthoff

doi:10.3390/jcm9020567

Abstract

Purpose: To evaluate predictive parameters for the development of Hepatic Encephalopathy (HE) after Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement and for success of shunt modification in the management of shunt-induced HE. Methods: A retrospective analysis of all patients with TIPS (n = 344) has been performed since 2011 in our university liver center. n = 45 patients with HE after TIPS were compared to n = 48 patients without HE after TIPS (case-control-matching). Of n = 45 patients with TIPS-induced HE, n = 20 patients received a reduction stent (n = 18) or TIPS occlusion (n = 2) and were differentiated into responders (improvement by at least one HE grade according to the West Haven classification) and non-responders (no improvement). Results: Older patient age, increased serum creatinine and elevated International Normalized Ratio (INR) immediately after TIPS placement were independent predictors for the development of HE. In 11/20 patients (responders, 55%) undergoing shunt modification, the HE grade was improved compared with nine non-responders (45%), with no relevant recurrence of refractory ascites or variceal bleeding. A high HE grade after TIPS insertion was the only positive predictor of treatment response (p = 0.019). A total of 10/11 responders (91%) survived the 6 months follow-up after modification but only 6/9 non-responders (67%) survived. Discussion: Older patient age as well as an increased serum creatinine and INR after TIPS are potential predictors for the development of HE. TIPS reduction for the treatment of TIPS-induced HE is safe, with particular benefit for patients with pronounced HE.

Highlights

Transjugular intrahepatic portosystemic shunt (TIPS) insertion is an established method in the management of decompensated liver cirrhosis [1,2]
A total of n = 48 patients without hepatic encephalopathy (HE) after TIPS were identified for the matched control group (median age, y: 54 (21–77); n = 33 male, n = 15 female)
It is of great clinical importance to identify predictive factors for the development of HE after TIPS, which allows patient selection based on a specific risk profile as well as targeting potential risk factors right after TIPS insertion

Summary

Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) insertion is an established method in the management of decompensated liver cirrhosis [1,2]. Hepatic encephalopathy (HE) is one of the most common complications with an incidence of 20% to 50% [4,5,6] It is based on a multifactorial mechanism of reduced hepatic filter function in liver dysfunction and splanchnic blood shunting into the systemic circulation, as well as an overproduction of intestinal neurotoxins and an increased permeability of the blood–brain barrier [7,8]. Refractory HE after TIPS is often associated with further deterioration of liver function and remains a clinical challenge [17]. In these cases, TIPS modification is the only therapeutic option besides liver transplantation [13,18,19]. There are only limited data available regarding the safety, effectiveness and outcome of TIPS modification [14,18,19]

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