Transjugular Intrahepatic Portosystemic Shunt Outcomes in the Elderly Population: A Systematic Review and Meta-Analysis

Abstract

Background: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure typically utilized to treat refractory ascites and variceal bleeding. However, TIPS can lead to significant complications, most commonly hepatic encephalopathy (HE). Advanced age has been described as a risk factor for HE, as the elderly population tends to have decreased cognitive reserve and increased sarcopenia. We conducted a systematic review and meta-analysis of the available literature to summarize the association between advanced age and risk of adverse events after undergoing TIPS. Methods:A comprehensive search strategy to identify reports of specific outcomes (HE, 30-day and 90-day mortality, and 30-day readmission due to HE) in elderly patients after undergoing TIPS was developed in Embase (Embase.com, Elsevier). We compared outcomes and performed separate data analyses for patients aged < 70 vs. > 70 years and patients aged < 65 vs. > 65 years.Results: Six studies with a total of 1,591 patients met our inclusion criteria and were included in the final meta-analysis. Three studies divided patients by age < 65 vs. > 65 years, with a total of 816 patients who were 54% male. The remaining three studies divided patients by age < 70 vs. > 70 years, with a total of 775 patients who were 63% male. Results demonstrated a significantly lower risk of post-TIPS HE (risk ratio (RR): 0.42, confidence interval (CI): 0.185 -0.953, P = 0.03, I 2 = 49%), 30-day mortality (RR: 0.37, CI: 0.188 -0.74, P = 0.005, I 2 = 0%), and 90-day mortality (RR: 0.35, CI: 0.24 -0.49, P = 0.001, I 2 = 0%) in patients aged > 70 vs. < 70 years, as well as a trend towards lower risk of 30-day readmission due to HE. There was no significant difference in post-TIPS HE, 30-day or 90-day mortality, or 30-day readmission due to HE between patients aged < 65 vs. > 65 years. Conclusion:Age > 70 years is associated with significantly higher rates of HE and 30-day and 90-day mortality rates in patients after undergoing TIPS, as well as a trend towards higher 30-day readmission due to HE.

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

“…Age: Older age has repeatedly been shown to be a predictor for post-TIPS HE, and particularly at ages >70 years the incidence rises considerably [ 54 ]. The liver maintains functionality at high ages, so the risk likely rests in changes in the aging brain, making it less resistant to neurotoxins and inflammation.…”

“…Age-related sarcopenia with less ammonia-clearing capacity contributes [ 17 , 19 , 55 , 56 , 57 , 58 ]. A meta-analysis indicated an age threshold: age >70 but not >65 was associated with an increased post-TIPS HE incidence [ 54 ]. Still, high age alone should not exclude patients from TIPS, but particular attention to markers of other organ functions is necessary, e.g., sodium and creatinine [ 59 ].…”