Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt insertion: a decade of experience

Masson, Steven; Mardini, Hanan Al; Rose, James D.; Record, C. O.

doi:10.1093/qjmed/hcn037

Cited by 56 publications

(61 citation statements)

References 40 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Similar findings have been published before [17,25]. This finding is not surprising as the post-TIPS portal-pressure gradient in the patients with a covered stent did not differ from the patients with a non-covered stent.…”

Section: Discussionsupporting

confidence: 91%

“…Compared to other studies [15,16,17,18,21] the decrease of the portosystemic gradient following TIPS in our patients was similar. This makes a less aggressive reduction of the portal pressure gradient as a reason for the lower incidence of overt HE in our patients unlikely.…”

Section: Discussionsupporting

confidence: 79%

“…In contrast to the rate of overt HE, the rate of MHE did not increase after TIPS insertion. Masson et al [17] as well as Stefankova et al [18] published similar data. They described post-TIPS HE in 34.5 and 35.8% of patients, respectively.…”

Section: Discussionmentioning

confidence: 57%

See 2 more Smart Citations

Critical Flicker Frequency as a Marker of Hepatic Encephalopathy in Patients before and after Transjugular Intrahepatic Portosystemic Shunt

Biecker¹,

Hausdörfer²,

Grünhage³

et al. 2010

Digestion

View full text Add to dashboard Cite

Background: Overt hepatic encephalopathy (HE) following insertion of a transjugular intrahepatic portosystemic shunt (TIPS) is a problem in some patients. In contrast to overt HE, minimal HE (MHE) following TIPS is studied to a limited degree only. We therefore evaluated the incidence of MHE in patients following TIPS insertion by determination of the critical flicker frequency (CFF). Methods: 45 cirrhotic patients (Child A/B/C: 7/24/14; Child-Pugh score 8.5 ± 2.0) underwent TIPS because of recurrent esophageal bleeding (n = 15), refractory ascites (n = 25) or a combination of bleeding and refractory ascites (n = 5). Hemodynamic parameters were recorded during TIPS insertion. CFF was determined using a portable analyzer 2 days before and 3, 28 and 84 days after TIPS. At these time points the number connection test and biochemical markers were recorded as well. Results: TIPS led to a reduction of the portal pressure gradient from 19.1 ± 5.9 to 9.3 ± 6.1 mm Hg together with a slight but significant increase in bilirubin from 1.5 ± 0.9 to 2.2 ± 1.9 mg/dl and in the international normalized ratio from 1.2 ± 0.3 to 1.4 ± 0.5. Creatinine decreased from 1.3 ± 0.6 to 1.1 ± 0.5 mg/dl. Pre-TIPS, 27 patients had normal CFF (>38 Hz, CFF 41.1 ± 2.4 Hz) and 18 patients had altered CFF (≤38 Hz, CFF 34.4 ± 3.0 Hz): 3 had grade I and 15 MHE. Three days post-TIPS, 3 of the 27 patients (11.1%) with normal CFF deteriorated to MHE, 1 of the patients with grade I HE deteriorated to grade II HE, 1 maintained grade I HE and the other improved. No patient with MHE deteriorated to overt HE. Conclusions: Using the determination of the CFF, we were able to show that elective TIPS insertion in patients with preserved liver function causes a MHE in only the minority of patients. In addition, patients with preexisting MHE did not deteriorate to overt HE.

show abstract

Section: Discussionsupporting

confidence: 91%

Section: Discussionsupporting

confidence: 79%

See 1 more Smart Citation

Critical Flicker Frequency as a Marker of Hepatic Encephalopathy in Patients before and after Transjugular Intrahepatic Portosystemic Shunt

Biecker¹,

Hausdörfer²,

Grünhage³

et al. 2010

Digestion

View full text Add to dashboard Cite

show abstract

“…PCA shunts gut-derived ammonia from the portal vein to the systemic circulation (inferior vena cava) and results in hyperammonemia and HE, commonly seen in cirrhotic patients following a transjugular intrahepatic portosystemic shunt (Masson et al 2008). The present study demonstrates that a significant increase in arterial plasma and CSF ammonia levels in PCA rats does not lead to an increase in oxidative stress (HNE and carbonyl derivatives) in both arterial or CSF compared to sham-operated controls.…”

Section: Discussionsupporting

confidence: 46%

Portacaval anastomosis-induced hyperammonemia does not lead to oxidative stress

et al. 2010

View full text Add to dashboard Cite

Yang, X. et al., 2010. Portacaval anastomosis-induced hyperammonemia does not lead to oxidative stress. Metabolic Brain Disease, 25(1), ABSTRACTAmmonia is neurotoxic and believed to play a major role in the pathogenesis of hepatic encephalopathy (HE). It has been demonstrated, in vitro and in vivo, that acute and high ammonia treatment induces oxidative stress. Reactive oxygen species (ROS) are highly reactive and can lead to oxidization of proteins resulting in protein damage. The present study was aimed to assess oxidative status of proteins in plasma and brain (frontal cortex) of rats with 4-week portacaval anastomosis (PCA). Markers of oxidative stress, 4-hydroxy-2-nonenal (HNE) and carbonylation were evaluated by immunoblotting in plasma and frontal cortex. Western blot analysis did not demonstrate a significant difference in either HNE-linked or carbonyl derivatives on proteins between PCA and sham-operated control rats in both plasma and frontal cortex. The present study suggests PCA-induced hyperammonemia does not lead to systemic or central oxidative stress.

show abstract

“…Despite these objective benefits, adverse sequelae of TIPS, such as hepatic encephalopathy, may temper its utility, and predictive factors for clinical outcomes, such as ascites control, remain unclear (8). Mortality after TIPS creation has been associated with a variety of factors, including persistent refractory ascites, patient age, procedural urgency, various laboratory parameters, various liver disease scoring systems, and the occurrence of hepatic encephalopathy (7,(9)(10)(11). However, an ideal prognostic tool remains to be found.…”

Section: Methodsmentioning

confidence: 99%

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Parvinian¹,

Bui²,

Knuttinen³

et al. 2013

Diagn Interv Radiol

View full text Add to dashboard Cite

ORIGINAL ARTICLE PURPOSE This study was performed to assess the safety, efficacy, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation for treatment of medically refractory ascites and to identify prognostic factors for clinical response, morbidity, and mortality. MATERIALS AND METHODSIn this retrospective study, 80 patients (male:female, 52:28; mean age, 56 years; mean Model for End-Stage Liver Disease [MELD] score, 15.1) who underwent elective TIPS creation for refractory ascites between 1999-2012 were studied. A medical record review was performed to identify data on demographics, liver disease, procedures, and outcome. The influence of these parameters on 30-day, 90-day, and oneyear mortality was assessed using binary logistic regression. Overall survival was analyzed with Kaplan-Meier statistics. RESULTS TIPS was successfully created using covered (n=70) or bare metal (n=10) stents. Hemodynamic success was achieved in all cases. The mean final portosystemic pressure gradient (PSG) was 6.8 mmHg. Thirty-day complications included mild encephalopathy in 35% of patients. Clinical improvement in ascites occurred in 78% of patients, with complete resolution or a ≥50% decrease in 66% of patients. No predictors of response or optimal PSG threshold were identified. The 30-day, 90-day, and one-year mortality rates were 14%, 23%, and 33%, respectively. Patient age (P = 0.026) was associated with 30-day mortality, while final PSG was associated with 90-day (P = 0.020) and one year (P = 0.032) mortality. No predictors of overall survival were identified. CONCLUSION TIPS creation effectively treats medically refractory ascites with nearly 80% efficacy. The incidence of mild encephalopathy is nontrivial. Older age and final PSG are associated with mortality, and these factors should be considered in patient selection and procedure performance.T he development of medically refractory ascites is associated with a grave prognosis in patients with liver cirrhosis. One-year survival in this population is less than 50%, and there is an increased risk of complications such as spontaneous bacterial peritonitis, hepatorenal syndrome, and dilutional hyponatremia (1). Moreover, these patients typically have low Model for End-Stage Liver Disease (MELD) scores despite their high mortality rate, and thus hold low positions on national transplant listings (2, 3). Transjugular intrahepatic portosystemic shunt (TIPS) creation, an established treatment for complications of portal hypertension, has demonstrated utility in patients with refractory ascites (4). By diverting blood from the portal venous system to the systemic circulation, TIPS acts to lower hepatic sinusoidal pressure and increase effective circulatory flow, thereby reducing excess sodium retention and achieving ascites recurrence rates as low as 30% (5). Two recent studies revealed reduced mortality in patients undergoing TIPS placement, compared with those receiving serial large-volume paracentesis procedures, with one-year survival rates ra...

show abstract

Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt insertion: a decade of experience

Abstract: Although, HE is relatively common after TIPS insertion, with careful selection of patients it is usually short-lived and easily managed. Minimal HE is no more prevalent than expected in a cirrhotic population without TIPS.

Cited by 56 publications

References 40 publications

Critical Flicker Frequency as a Marker of Hepatic Encephalopathy in Patients before and after Transjugular Intrahepatic Portosystemic Shunt

Critical Flicker Frequency as a Marker of Hepatic Encephalopathy in Patients before and after Transjugular Intrahepatic Portosystemic Shunt

Portacaval anastomosis-induced hyperammonemia does not lead to oxidative stress

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Contact Info

Product

Resources

About