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Long-term Outcome And Predictors Of Mortality After Transjugular Intrahepatic Portosystemic Shunt (TIPS) For Variceal Hemorrhage And Refractory Ascites

Posted on:2012-05-06Degree:MasterType:Thesis
Country:ChinaCandidate:S S YuanFull Text:PDF
GTID:2234330338994528Subject:Internal Medicine
Abstract/Summary:PDF Full Text Request
【Background】Transjugular intrahepatic portosystemic shunt (TIPS) has been increasingly employed for the treatment of major complications of portal hypertension, namely esophageal varices bleeding (EVB) and refractory ascites (RA). Randomized controlled trails and Meta-analyses have failed to demonstrate a survival benefit of TIPS over standard treatments even if the rate of recurrence variceal bleeding could successfully be reduced by TIPS insertion. Hence, TIPS has not been recommended by American Association for the Study Liver Disease (AASLD) as primary therapy for portal hypertension. Recently, García-Pagán et al reported that early use of TIPS (within 72 hours after admission) could improve the survival in patients with acute variceal bleeding (AVB) compared with primary treatment, which may challenge the practice guideline of TIPS for AVB.Although the long-term outcome and predictors of mortality have been reported in previous studies, all findings were attributed on the large proportion of study patients with a diagnosis of alcoholic liver cirrhosis. HBV related cirrhosis is different from the alcoholic cirrhosis in histological changes, disease progression, and treatment options. To our knowledge, there is no data about the role of TIPS placement in the long-term management of complications of portal hypertension in HBV related cirrhosis. In addition, previous studies have not evaluated liver function through stratifying the severity of liver diseases. This study will be important to provide evidence for the management of portal hypertension in countries or areas with similar HBV infection. The present study represents the first retrospectively analysis addressing the long-term outcome and predictive factors after TIPS for portal hypertension at a single center in HBV epidemic area.Moreover, selecting appropriate patients and identifying predictors of mortality are crucial to optimize patient?s outcome for the TIPS procedure, which can stratify patients into those with a clear survival bene?t and others who should probably not undergo TIPS placement. At present, many predictors of mortality for patients with EVB and RA have been developed, but it still lacks an accurate selection criteria. This heterogeneity is confusing to clinicians and may affect future prognostic studies of survival after the TIPS placement. It is important to acquire reliable tools for prognostication of individual patients. In advanced liver disease prognostication may be of value particularly in the decision of therapeutic procedures. In this article, we also evaluate every study on predicting the poor outcome in patients with EVB and RA following TIPS placement and identify the most robust predictors of mortality. 【Method】1. Between January 2003 and July 2009, a total of 182 consecutive patients with cirrhosis were studied retrospectively. According to inclusion and exclusion criteria, 158 patients with HBV-related cirrhosis and portal hypertension were retrospectively analyzed in our study. Indications were EVB (n=136) and RA (n=22). Recurrent bleeding, shunt dysfunction, development of hepatic encephalopathy (HE), survival and prognostic factors were evaluated.2. We performed an electronic literature search of Medline database and ScienceDirect database via PUBMED. The final search was performed on November 30th, 2010 and no lower date limit was set on the search results. We select those studies which evaluating the prognostic factors of TIPS for the treatment of variceal hemorrhage and refractory ascites to identify the most robust predictors of mortality.【Results】1. K-M survival analysis shown that the cumulative shunt dysfunction rates at 1- and 5-years were 31.3% and 60%, respectively; the cumulative free of variceal rebleeding rates at 1- and 5-years were 85% and 65%, respectively; the cumulative 1- and 5-years survival rates were 85% and 54%, respectively.2. Univariate and multivariate analyses suggested that a history of pre-TIPS splenectomy was the only independent predictor for the development of shunt dysfunction in patients with HBV-related cirrhosis; pre-TIPS HE, serum albumin levels predicted development of HE; the independent predictors of survival were serum bilirubin, serum creatinine and serum albumin.3. ANOVA test demonstrated that the scores with Child B and C tend to improve from 7.92±1.17 at baseline to 12 months to 7.06±1.93 (P=0.008) while scores with Child A significantly increased (5.66±0.8 vs. 6.4±1.18, P=0.003).4. A total of 38 studies were included in our systematic review via PUBMED search, the number of variables found to be significant in multivariate analyses was 23.5. Description analysis found that Child-Pugh class, bilirubin and age were considered as the most robust predictors of mortality either in the 38 enrolled studies or in only ?good? quality studies.【Conclusion】1. TIPS was effective in the management of portal hypertension for patients with HBV related cirrhosis. These results would be expected to provide strong evidences for the treatment of complications of portal hypertension in patients with HBV related cirrhosis.2. The only independent predictor of shunt dysfunction was pre-TIPS splenectomy. TIPS improved Child-Pugh scores on patients with Child B and C diseases, which may affect future prognostic studies of survival after the TIPS placement.3. Higher Child-Pugh class, increased bilirubin and age were the most robust predictors of higher mortality for TIPS in patients with variceal hemorrhage and refractory ascites.
Keywords/Search Tags:TIPS, variceal bleeding, refractory ascites, Hepatiteis B, cirrhosis, predictor
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