Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis

JOURNAL OF HEPATOLOGY

卷:72

Article

Praktiknjo, Michael¹  Simon-Talero, Macarena²  Roemer, Julia¹  Roccarina, Davide^3,4,5  Martinez, Javier⁶  Lampichler, Katharina⁷  Baiges, Anna⁸  Low, Gavin⁹  Llop, Elba¹⁰  Maurer, Martin H.¹¹  Zipprich, Alexander¹²  Triolo, Michela¹³  Maleux, Geert¹⁴  Fialla, Annette Dam¹⁵  Dam, Claus¹⁵  Vidal-Gonzalez, Judit²  Majumdar, Avik^3,4,5  Picon, Carmen¹⁶  Toth, Daniel⁷  Darnell, Anna¹⁷  Abraldes, Juan G.¹⁸  Lopez, Marta¹⁰  Jansen, Christian¹  Chang, Johannes¹  Schierwagen, Robert²⁶  Uschner, Frank²⁶  Kukuk, Guido¹⁹  Meyer, Carsten¹⁹  Thomas, Daniel¹⁹  Wolter, Karsten¹⁹  Strassburg, Christian P.¹  Laleman, Wim²⁰  La Mura, Vincenzo^21,22,23  Ripoll, Cristina¹²  Berzigotti, Annalisa²⁴  Luis Calleja, Jose¹⁰  Tandon, Puneeta¹⁸  Hernandez-Gea, Virginia⁸  Reiberger, Thomas²⁵  Albillos, Agustin⁶  Tsochatzis, Emmanuel A.^3,4,5  Krag, Aleksander¹⁵  Genesca, Joan²  Trebicka, Jonel^15,26,27,28 

[1] Univ Bonn, Dept Internal Med 1, Bonn, Germany

[2] Univ Autonoma Barcelona, Hosp Univ Vall Hebron, CIBERehd, Dept Internal Med,Liver Unit,VHIR, Barcelona, Spain

[3] Royal Free Hosp, Sheila Sherlock Liver Unit, London, England

[4] Royal Free Hosp, UCL Inst Liver & Digest Hlth, London, England

[5] UCL, London, England

[6] Univ Alcala, Hosp Univ Ramon y Cajal, Dept Gastroenterol & Hepatol, IRICYS,CIBERehd, Madrid, Spain

[7] Med Univ Vienna, Dept Biomed Imaging & Image Guided Therapy, Vienna, Austria

[8] Univ Barcelona, Hepat Hemodynam Lab, CIBERehd, Liver Unit,Hosp Clin,IDIBAPS, Barcelona, Spain

[9] Univ Alberta, Dept Radiol, Edmonton, AB, Canada

[10] Univ Autonoma Madrid, Hosp Univ Puerta Hierro, Liver Unit, Madrid, Spain

[11] Univ Bern, Inselspital, Dept Radiol, Bern, Switzerland

[12] Martin Luther Univ Halle Wittenberg, Dept Internal Med 1, Halle, Saale, Germany

[13] Univ Milan, IRCCS, Med Interna, San Donato Milanese, MI, Italy

[14] Katholieke Univ Leuven, Univ Hosp Leuven, Dept Intervent Radiol, Leuven, Belgium

[15] Odense Univ Hosp, Dept Gastroenterol & Hepatol, Odense, Denmark

[16] Univ Alcala, Hosp Univ Ramon y Cajal, Dept Radiol, IRICYS,CIBERehd, Madrid, Spain

[17] Univ Barcelona, Hosp Clin, Dept Radiol, IDIBAPS, Barcelona, Spain

[18] Univ Alberta, Cirrhosis Care Clin, Edmonton, AB, Canada

[19] Univ Bonn, Dept Radiol, Bonn, Germany

[20] Univ Hosp Leuven, Dept Gastroenterol & Hepatol, Leuven, Belgium

[21] UOC Med Gen Emostasi & Trombosi, Osped Maggiore Policlin, Fdn IRCCS Ca Granda, Milan, Italy

[22] Univ Milan, Dipartimento Sci Biomed Salute, Milan, Italy

[23] Univ Milan, Ctr Ric Coordinata AMeA Migliavacca Studio & Cura, Milan, Italy

[24] Univ Bern, Inselspital, Hepatol, Bern, Switzerland

[25] Med Univ Vienna, Div Gastroenterol & Hepatol, Vienna Hepat Hemodynam Lab, Vienna, Austria

[26] Goethe Univ Frankfurt, Dept Internal Med 1, Theodor Stern Kai 7, D-60590 Frankfurt, Germany

[27] European Fdn Study Chron Liver Failure EF CLIF, Barcelona, Spain

[28] Inst Bioengn Catalonia, Barcelona, Spain

关键词: Spontaneous portosystemic shunt;    Ascites;    TIPS;    SPSS;    Computed tomography;    Cirrhosis;    Liver;    Acute decompensation;    Portal hypertension;    Hepaticencephalopathy;    Acute-on-chronic liver failure;    ACLF;   

DOI  :  10.1016/j.jhep.2019.12.021

来源: Elsevier

【 摘 要 】

Background & Aims: Spontaneous portosystemic shunts (SPSS) frequently develop in liver cirrhosis. Recent data suggested that the presence of a single large SPSS is associated with complications, especially overt hepatic encephalopathy (oHE). However, the presence of >1 SPSS is common. This study evaluates the impact of total cross-sectional SPSS area (TSA) on outcomes in patients with liver cirrhosis. Methods: In this retrospective international multicentric study, CT scans of 908 cirrhotic patients with SPSS were evaluated for TSA. Clinical and laboratory data were recorded. Each detected SPSS radius was measured and TSA calculated. One-year survival was the primary endpoint and acute decompensation (oHE, variceal bleeding, ascites) was the secondary endpoint. Results: A total of 301 patients (169 male) were included in the training cohort. Thirty percent of all patients presented with >1 SPSS. A TSA cut-off of 83 mm(2) was used to classify patients with small or large TSA (S-/L-TSA). Patients with L-TSA presented with higher model for end-stage liver disease score (11 vs. 14) and more commonly had a history of oHE (12% vs. 21%, p<0.05). During follow-up, patients with L-TSA experienced more oHE episodes (33% vs. 47%, p<0.05) and had lower 1-year survival than those with S-TSA (84% vs. 69%, p<0.001). Multivariate analysis identified L-TSA (hazard ratio 1.66; 95% CI 1.02-2.70, p<0.05) as an independent predictor of mortality. An independent multicentric validation cohort of 607 patients confirmed that patients with L-TSA had lower 1-year survival (77% vs. 64%, p<0.001) and more oHE development (35% vs. 49%, p<0.001) than those with S-TSA. Conclusion: This study suggests that TSA >83 mm(2) increases the risk for oHE and mortality in patients with cirrhosis. Our results support the clinical use of TSA/SPSS for risk stratification and decision-making in the management of patients with cirrhosis. Lay summary: The prevalence of spontaneous portosystemic shunts (SPSS) is higher in patients with more advanced chronic liver disease. The presence of more than 1 SPSS is common in advanced chronic liver disease and is associated with the development of hepatic encephalopathy. This study shows that total cross-sectional SPSS area (rather than diameter of the single largest SPSS) predicts survival in patients with advanced chronic liver disease. Our results support the clinical use of total cross-sectional SPSS area for risk stratification and decision-making in the management of SPSS. (C) 2020 European Association for the Study of the Liver. Published by Elsevier B.V.

【 授权许可】

Free