Hyponatremia: A Risk Factor for Early Overt Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation

Abstract

Hepatic encephalopathy (HE) is a frequent complication in cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). Hyponatremia (HN) is a known contributing risk factor for the development of HE. Predictive factors, especially the effect of HN, for the development of overt HE within one week of TIPS placement were assessed. A single-center, retrospective chart review of 71 patients with cirrhosis who underwent TIPS creation from 2006–2011 for non-variceal bleeding indications was conducted. Baseline clinical and laboratory characteristics were collected. Factors associated with overt HE within one week were identified, and a multivariate model was constructed. Seventy one patients who underwent 81 TIPS procedures were evaluated. Fifteen patients developed overt HE within one week. Factors predictive of overt HE within one week included pre-TIPS Na, total bilirubin and Model for End-stage Liver Disease (MELD)-Na. The odds ratio for developing HE with pre-TIPS Na <135 mEq/L was 8.6. Among patients with pre-TIPS Na <125 mEq/L, 125–129.9 mEq/L, 130–134.9 mEq/L and ≥135 mEq/L, the incidence of HE within one week was 37.5%, 25%, 25% and 3.4%, respectively. Lower pre-TIPS Na, higher total bilirubin and higher MELD-Na values were associated with the development of overt HE post-TIPS within one week. TIPS in hyponatremic patients should be undertaken with caution.

Pathological Predictors of Shunt Stenosis and Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt

“…Merola et al showed that higher MELD scores, hyponatremia, and higher total bilirubin level were associated with the development of overt HE post-TIPS [18]. Other studies demonstrated that the risk of post-TIPS HE was higher in the patients with increased age, preexisting HE, and higher Child-Pugh score [19, 20].…”

Aktualisierte S2k-Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) „Komplikationen der Leberzirrhose“

“…Bei modernen gecoverten Stents führt das Unterschreiten einer unteren Grenze des portosystemischen Druckgradienten < 5 mm zu einem deutlich erhöhten Risiko für eine HE oder ein Leberversagen [702]. Vorhersageparameter für eine HE sind: Alter über 65 Jahre [703,704], frühere HE [673,705], Child-Pugh-Score > 10, MELD-Score > 14 [706], niedriges Serumnatrium [576] und eine Hyperbilirubinämie [698]. Neben dem MELD-Score stellte auch das Vorliegen einer Sarkopenie einen unabhängigen Risikofaktor für das Auftreten einer HE nach TIPS-Anlage dar [213].…”

Predictors and Management of Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt: The Current State of Literature

“…5,8,11,14 A prospective study by Angeli et al 15 determined a strong association between hyponatremia, defined as serum Na <135, and increased frequency of HE among a cohort of 997 patients. Another retrospective review of 71 patients by Merola et al 11 also found hyponatremia to be a predictor of post-TIPS HE. Although the pathophysiology regarding the effects of hyponatremia and HE remains unclear, the prevailing physiological hypothesis suggests that low serum Na potentiates the effects of serum ammonia and encourages further depletion of cerebral osmolytes.…”

“…Though pre-TIPS HE has been noted extensively in the literature to increase the risk of post-TIPS HE, it should be mentioned that many frequently cited studies do not elucidate their method of diagnosing HE or the severity of HE in their patient sample. 8,[11][12][13] The study by Kircheis et al 4 and Berlioux et al 13 demonstrated that the West Haven scale, a psychometric assessment commonly used to diagnose HE, was insensitive to post-TIPS changes when compared with critical flicker frequency. This critique of the West Haven scale in addition to the heterogeneity of diagnostic methods in the existing literature calls into question what is the actual incidence of post-TIPS HE.…”

“…Numerous studies have affirmed the predictive value of elevated total bilirubin on developing post-TIPS HE, and serum levels > 3mg/dL have become a relative contraindication to the TIPS procedure. 1, 7,8,11 Creatinine is a metabolic product of creatine phosphate cleared by the renal system, so elevated levels in the serum may be indicative of renal dysfunction. However, unlike bilirubin, there is less evidence to conclude significance in the predictive value of serum creatinine on post-TIPS HE, with many studies reaching discordant conclusions.…”