Predictors of hepatic encephalopathy in cirrhotic patients undergoing elective transjugular intrahepatic portosystemic shunt
Mendiratta V, Kumssa F, and Venkat D. Predictors of hepatic encephalopathy in cirrhotic patients undergoing elective transjugular intrahepatic portosystemic shunt. Hepatology 2018; 68:1177A-1178A.
Background: Transjugular Intrahepatic Portosystemic Shunt (TIPS) is used for the management of patients with complications related to portal hypertension. A significant post-TIPS complication is new or worsening hepatic encephalopathy (HE), occurring in up to 35% of patients; thus, appropriate patient selection is critical. Previous studies suggest age, prior HE, Child-Pugh (CPS) and MELD scores to be predictive of post-TIPS HE. The purpose of this study was to identify significant predictors of HE development in patients undergoing elective TIPS procedure and develop a model to risk stratify potential candidates. Methods: Cirrhotic patients who underwent elective TIPS placement between 1/2004-6/2016 with at least 1-year follow-up were included, yielding 95 patients. Relevant data collected retrospectively included: patient demographics, TIPS indication, etiology of cirrhosis, albumin, platelets, creatinine, bilirubin, INR, sodium, pre-TIPS MELD, MELD-Na, CPS, pre-and post-TIPS portosystemic gradient, pre-TIPS benzodiazepine or opiate use (BZDO), pre-TIPS HE occurrence, and post-TIPS HE frequency, as well as severity by West Haven criteria. T-test analysis was used for continuous variables and Chi-square tests for categorical variables, while multiple logistic regression model was performed using stepwise variable selection. Results: 95 elective TIPS were performed in 38 females and 57 males with a mean age of 55. HE occurred in 39% (37/95) of patients within 1-year post-procedure, 9% (9/95) of whom had clinically severe HE (defined as grade III or IV). Univariate analysis showed albumin <2.5 (p<.004, OR: 0.35, CI: 0.17-0.75), MELD >13 (p<.004, OR: 1.16, CI: 1.04-1.29), MELDNa > 17 (p<.015, OR: 1.11, CI: 1.02-1.20), Child-Pugh Score >10 (p<.001, OR: 1.89, CI: 1.31-2.71) and pre-TIPS BZDO use (OR: 2.57, CI: 1.07-6.16) to be significant predictors of HE occurrence within 1-year. Multivariate analysis showed age (p<.04, OR: 1.06, CI: 1.00-1.21), MELD (p<.04, OR: 1.13, CI: 1.01-1.27) Child-Pugh (p<.003, OR: 1.81, CI: 1.23-2.67), and Pre-TIPS BZDO use (p<.01, OR: 4.16, CI: 1.41-12.28) to be predictive for development of HE post-TIPS. These four variables were used to create a predictive model with AUC found to be .81 (.73-.90). Conclusion: Our analysis was able to refine data from prior studies by establishing predictive cutoffs for MELD (13), MELD-Na (17) and CPS (10) for the development of post TIPS HE. We also found that pre-TIPS benzodiazepine/opiate use was a novel and strong predictor of post TIPS HE. Finally, we were able to create a model from this data using age, MELD, CPS and pre-TIPS BZDO use that reliably risk stratifies patients for the development of post TIPS HE.