Association Between Portosystemic Shunts and Increased Complications and Mortality in Patients With Cirrhosis

Simón-Talero, Macarena; Roccarina, Davide; Martínez, Javier; Lampichler, Katharina; Baiges, Anna; Low, Gavin; Llop, Elba; Praktiknjo, Michael; Maurer, Martin; Zipprich, Alexander; Triolo, Michela; Vangrinsven, Guillaume; García-Martinez, Rita; Dam, Annette; Majumdar, Avik; Picón, Carmen; Tóth, Dániel; Darnell, Anna; Abraldes, Juan G.; López, Marta; Kukuk, Guido; Krag, Aleksander; Bañares, Rafael; Laleman, Wim; Mura, Vincenzo La; Ripoll, Cristina; Berzigotti, Annalisa; Trebicka, Jonel; Calleja, José Luís; Tandon, Puneeta; Hernández‐Gea, Virginia; Reiberger, Thomas; Albillos, Agustı́n; Tsochatzis, Emmanuel; Augustín, Salvador; Genescà, Joan; Quiroga, Sergi; Yu, Dominic; Téllez, Luís; Mandorfer, Mattias; García-Pagán, Juan Carlos; Berbel, Claudia; Ferrusquía, José; Blé, Michel; García-Criado, Ángeles; Belmonte, Ernest; Ney, Michael; Margini, Cristina; Casu, Stefania; Murgia, Giuseppe; Ludwig, Christiane; Rönsch, Martin; Stoevesandt, Dietrich; Carrión, L.; Botella, Enrique Ramón

doi:10.1053/j.gastro.2018.01.028

Cited by 165 publications

(226 citation statements)

References 35 publications

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“…As it would be expected, hepatic encephalopathy was more frequent in this population, confirming what has been described in prior reports . Similarly, ascites seemed to be more frequent in patient groups with SPSSs as described previously by Simón‐Talero et al In their cohort of patients, they found a more extensive plethora of portal hypertension–related signs and complications, including splenomegaly, gastroesophageal varices, gastrointestinal bleeding, ascites, acute kidney injury with hepatorenal physiology, and SBP. The widespread association was more limited in the present study, likely due to our limited and focused population.…”

Section: Discussionsupporting

confidence: 90%

“…To our knowledge, this is the biggest study that clinically correlates the presence of SPSSs prior to LT to outcomes in the post‐LT setting. Our results suggest that after LT surgery, the previously described clinical impact of SPSSs in the population with cirrhosis subsides …”

Section: Discussionsupporting

confidence: 56%

“…with expertise in intraabdominal diseases. The presence of SPSSs was documented and patients were classified according to the maximum diameter of the SPSS with a cutoff at 8 mm, which has been described in prior series . We arrived at 3 categories: SPSSs ≥8 mm were classified as large, SPSSs <8 mm as small, and patients without SPSSs as no SPSS.…”

Section: Methodsmentioning

confidence: 99%

“…Similarly, large SPSSs have been found to correlate with more advanced liver disease, as determined by a higher Child‐Turcotte‐Pugh score or an increased Model for End‐Stage Liver Disease (MELD‐Na) score. In patients with stable liver function, the presence of SPSSs was associated with lower transplant‐free survival . These results can therefore allow us to risk stratify patients in the pretransplantation period on the basis of the presence and size of SPSSs.…”

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confidence: 87%

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Clinical Outcomes of Portosystemic Shunts on the Outcome of Liver Transplantation

et al. 2020

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Spontaneous portosystemic shunts (SPSSs) have been associated with worse clinical outcomes in the pre-liver transplantation (LT) setting, but little is known about their post-LT impacts. Our aim was to compare LT candidates with and withoutSPSSs and assess the impact of SPSSs on patient mortality and graft survival in the post-LT setting. Patients 18 years or older with abdominal imaging done prior to LT were included. Exclusion criteria were the presence of pre-LT surgical shunts, LT indications other than cirrhosis, and combined solid organ transplantations. SPSSs were classified as absent, small, or large according to their maximum diameter (8 mm). Multiple variables that could influence the post-LT course were extracted for analysis. Patient and graft survival were estimated using the Kaplan-Meier method and were compared between groups using a log-rank test. The project received institutional review board approval. We extracted data from 326 patients. After comparing patients without SPSS or with small or large SPSSs, no statistical difference was found for overall patient survival: no SPSS (n = 8/63), reference; small SPSS (n = 18/150), hazard ratio (HR), 1.05 (95% confidence interval [CI], 0.45-2.46); and large SPSS (n = 6/113), HR, 0.60 (95% CI, 0.20-1.78); P = 0.20. Also, no difference was found for graft survival: no SPSS (n = 11/63), reference; small SPSS (n = 21/150), HR, 0.80 (95% CI, 0.38-1.70); large SPSS (n = 11/113), HR, 0.59 (95% CI, 0.25-1.40); P = 0.48. Similarly, no statistical significance was found for these variables when comparing if the graft used was procured from a donation after circulatory death donor versus a donation after brain death donor. In conclusion, the previously described association between SPSSs and worse clinical outcomes in pre-LT patients seems not to persist once patients undergo LT. This study suggests that no steps to correct SPSS intraoperatively are necessary. Liver Transplantation 26 693-701 2020 AASLD.Portal hypertension is defined by a hepatic venous pressure gradient of 6 mmHg or more, and in the clinical scenario of cirrhosis, it is characterized by complications, such as ascites, variceal bleeding, and hepatic encephalopathy in advanced cases. (1) In cirrhosis, portal hypertension results from the increased collagen deposition and formation of regenerative nodules, which eventually lead to an increase in portal pressure. (2) These changes are followed by compensatory splanchnic vasodilation, which will further increase portal flow and continue to worsen portal pressure (as predicted by Ohm's law). The presence of these complications leads to clinical deterioration, with some series describing up to 80% 5-year mortality if 2 complications were present concomitantly, (3) which also results in cost increases due to frequent hospital admissions. (4) A complication in the setting of portal hypertension is the formation of spontaneous portosystemic shunts (SPSSs). These are channels that form as the portal rOdriguez et al.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionsupporting

confidence: 56%

Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 87%

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Clinical Outcomes of Portosystemic Shunts on the Outcome of Liver Transplantation

et al. 2020

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“…Moreover, SPSSs could be classified in large or small size according to its maximum diameter, with a cut-off of 8 mm; this value was chosen since it was the smallest size of a symptomatic shunt embolized reported in the literature. 9,10 SPSSs have been described in both patients with cirrhosis and in patients without significant alterations of liver function. 11 The presence of the shunt alters hepatic hemodynamics and increases the bioavailability of intestinally derived agents, such as ammonium, increasing the risk of HE.…”

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confidence: 99%

Radiological Intervention for Shunt Related Encephalopathy

Nardelli

Gioia

Riggio

2018

Journal of Clinical and Experimental Hepatology

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Hepatic Encephalopathy (HE) is a neuropsychiatric syndrome that occurs in up to 30% of patients with cirrhosis. HE may be a consequence of pure liver failure, as in patients with fulminant hepatitis, or of the combination of liver failure and portal-systemic shunting, as in patients with liver cirrhosis. Several clinical and pathophysiologic observations suggest the importance of portal-systemic shunts in the development of HE. Episodes of HE are usually related to precipitating events, such as infections or gastrointestinal bleeding; a minority of cirrhotic patients experienced a chronic HE, refractory to standard medical treatment. This latter type of HE should be related to spontaneous or radiological (such as Transjugular Intrahepatic Portosystemic Shunt (TIPS)) portal systemic shunts, that could be restricted or occluded in patients with chronic HE. Both TIPS reduction and shunt occlusion are radiological procedures, safe and effective to ameliorate neurological symptoms in patients with refractory HE. ( J CLIN EXP HEPATOL 2018;8:452-459) PORTOSYSTEMIC SHUNTS IN CIRRHOSIS-CLASSIFICATION, TYPES, CLINICAL IMPLICATIONS, NATURAL HISTORY SPSSs are, as the name implies, potential communications between the portal venous system and the systemic venous circulation than can open and grow when portal pressure increases. These SPSS act as "release valves" to reduce the portal pressure, but also act as bypasses to normal liver flow. At one point, the shunt becomes large enough that it starts contributing to the progression of the liver disease. 8 The main types of SPSSs are: paraumbilical vein, splenorenal, splenoiliac with internal hemorrhoids, esophageal varices and gastrocaval, indirect gastrocaval, gastrorenal associated with gastric varices. 8 SPSSs can be classified into left-sided and right-sided (central) shunts; the most frequent right-side shunt is represented by recanalization of paraumbilical vein, while the most common left-sided shunts are gastrorenal shunt, observed in 85% of patients with gastric varices, gastrocaval shunt and splenorenal shunt. The clinical manifestations of these latter shunts comprise gastric variceal bleeding, HE and portal vein

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