Low Serum Cholinesterase Identifies Patients With Worse Outcome and Increased Mortality After TIPS

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension-related complications. However, careful selection of patients is crucial. The aim of this study was to evaluate the prognostic value of serum cholinesterase (CHE) for outcomes and mortality after TIPS insertion. In this multicenter study, 389 consecutive patients with cirrhosis receiving a TIPS at Hannover Medical School, University Hospital Essen, or Medical University of Vienna were included. The Hannover cohort (n = 200) was used to initially explore the role of CHE, whereas patients from Essen and Vienna served as a validation cohort (n = 189). Median age of the patients was 58 years and median Model for End-Stage Liver Disease (MELD) score was 12. Multivariable analysis identified MELD score (hazard ratio [HR]: 1.16; P < 0.001) and CHE (HR: 0.61; P = 0.008) as independent predictors for 1-year survival. Using the Youden Index, a CHE of 2.5 kU/L was identified as optimal threshold to predict post-TIPS survival in the Hannover cohort (P < 0.001), which was confirmed in the validation cohort (P = 0.010). CHE < 2.5 kU/L was significantly associated with development of acute-on-chronic liver failure (P < 0.001) and hepatic encephalopathy (P = 0.006). Of note, CHE was also significantly linked to mortality in the subgroup of patients with refractory ascites (P = 0.001) as well as in patients with high MELD scores (P = 0.012) and with high-risk FIPS scores (P = 0.004). After propensity score matching, mortality was similar in patients with ascites and CHE < 2.5 kU/L if treated by TIPS or by paracentesis. Contrarily, in patients with CHE ≥ 2.5 kU/L survival was significantly improved by TIPS as compared to treatment with paracentesis (P < 0.001). Conclusion: CHE is significantly associated with mortality and complications after TIPS insertion. Therefore, we suggest that CHE should be evaluated as an additional parameter for selecting patients for TIPS implantation. (Hepatology Communications 2022;6:621-632).A n effective and established treatment option for patients with decompensated liver cirrhosis is the insertion of a transjugular intrahepatic portosystemic shunt (TIPS). (1) TIPS placement reduces the need for large volume paracentesis and decreases bleeding-related mortality and the risk for further variceal bleedings. (1,2) In patients with refractory ascites (RA), overall survival was superior compared with repetitive paracentesis in some studies. (3,4) However, proper selection of patients eligible for TIPS

Hepatic encephalopathy post-TIPS: Current status and prospects in predictive assessment

“…Research by Stockhoff et al found a significant association between reduced CHE levels and increased mortality within one year of HE diagnosis, highlighting its relevance in both acute and chronic liver failure scenarios. This finding underscores the importance of monitoring CHE levels in clinical settings, particularly for post-operative care and prognostication [68] , [69] . Despite its demonstrated utility, the broader applicability and validation of CHE as a biomarker in different patient demographics requires further investigation.…”

Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy—A Review of the Past Decade’s Literature Focusing on Incidence, Risk Factors, and Prophylaxis

“…Both substances act directly in the brain, suggesting that post-TIPS HE risk may be related to cognitive effects of liver exocrine patterns [ 117 ]. Also, low serum cholinesterase, which is almost exclusively synthesised in hepatocytes and, in this context, may be seen as a proxy measure of liver function, was associated with post-TIPS HE risk in a large German cohort study [ 118 ].…”

A comprehensive review of prognostic scoring systems to predict survival after transjugular intrahepatic portosystemic shunt placement

“…Moreover, the diversion of portal blood flow into the systemic circulation decreases hepatic perfusion and deteriorates hepatic function. As such, biomarkers reflecting hepatic synthetic capacities, such as serum cholesterol and cholinesterase, were identified as predictors of post‐TIPS mortality, independent of the MELD score 90,91 . Another major consequence of portal‐systemic diversion is the increase in cardiac preload and the development of cardiac decompensation and pulmonary hypertension 92,93 .…”

“…As such, biomarkers reflecting hepatic synthetic capacities, such as serum cholesterol and cholinesterase, were identified as predictors of post-TIPS mortality, independent of the MELD score. 90,91 Another major consequence of portal-systemic diversion is the increase in cardiac preload and the development of cardiac decompensation and pulmonary hypertension. 92,93 Billey et al 94 identified several parameters that were significantly associated with cardiac decompensation after TIPS placement, including laboratory results (BNP and NT-pro BNP) and echocardiographic indices (E/A, E/e' ratio, and left ventricular ejection fraction).…”