Influencing Factors And Prognosis Analysis Of Portal Hypertension Related Complications In Cirrhosis

Part Ⅰ:Risk factors and prediction of portal hypertension gastropathy due to cirrhosisIn 1985,McCormack et al.reported that had gastric mucosal lesions,such as small white reticular structures of the mucosa looks like snake skin signs and even diffuse erythema hemorrhage were popular in patients with liver cirrhosis.Pathological biopsy of these lesions showed irregular dilation and distortion of the small blood vessels in the mucosa or submucosa,while the inflammation was relatively mild.Subsequently,the gastric mucosal lesions due to portal hypertension were defined as portal hypertensive gastropathy(PHG)People gradually pay more and more attention to the upper gastrointestinal bleeding caused by PHG.PHG accounts for 2%-12%of acute upper gastrointestinal bleeding in patients with cirrhosis,1%-8%of initial upper gastrointestinal bleeding,and up to 30%-60%of recurrent upper gastrointestinal bleedingAt present,gastroscope is still the gold standard for diagnosing PHG and identifying the risk of bleeding.However,in clinical practice,the compliance of endoscopic screening in patients with cirrhosis is poor.Besides,patients with cirrhosis often have both PHG and varices leading to high risk of bleeding during gastroscopy.Simple and effective method for PHG screening is encouraged.This study aims to explore the risk factors related to PHG,the effect of PHG on the prognosis of cirrhosis,and to develop a non-invasive prediction model for PHGThe main contents:1.Gastroscopy characteristics and related factor analysis of portal hypertensive gastropathy with cirrhosisRetrospective analysis of 867 patients with liver cirrhosis,and their gastroesophageal varices,PHG and ulcers were recorded.Meanwhile,the data of spontaneous bacterial peritonitis(SBP),hepatic encephalopathy(HE)and hepatocellular carcinoma(HCC)were collected 2.Effect of PHG on prognosis of patients with cirrhosisA retrospective database of Daping Hospital was reviewed.A total of 700 cirrhotic patients undergoing gastroscopy between August 2012 and June 2018 were screened.Regular outpatient follow-up or a telephone follow-up in July 2019 to survey survival time and hepatocarcinogenesis time were conducted.Survival analysis was conducted via the Kaplan-Meier method based on log-rank test,as well as the development of HCC.The Cox proportional hazard model was applied for the detection of independent prognostic factors for survival.Hazard ratios with 95%confidence interval were calculated3.A nomogram predicting PHG constructed based on logistic regressionA total of 700 patients were split into 70%and 30%cases.The former was used as training cohort for nomogram construction.Univariate and multivariate logistic regression was used to determine the associated factors with the presence of PHG at diagnosis.The independent risk factors associated with PHG stem from multivariate logistic regression were incorporated into the nomogram.Discrimination,calibration,and clinical usefulness of the predicting nomogram were assessed using the C-index,calibration plot,and decision curve analysis.Internal validation was assessed based on a bootstrapping method,and further validation was assessed using the remaining 208 patientsThe main results:1.Gastroscopy characteristics and related factor analysis of portal hypertensive gastropathy with cirrhosisThe incidence of PHG in cirrhosis patients was 66.2%(574/867),and its incidence and severity are closely related to the aggravation of gastroesophageal varices,the mucosal lesions and presence of HCC.Patients with PHG have a high risk of upper gastrointestinal bleeding,which accounts for the second most common cause of upper gastrointestinal bleeding in cirrhosis.Ulcers are not associated with PHG.Futhermore,the incidence of HE and SBP have no correlation with PHG2.Effect of PHG on prognosis of patients with cirrhosisPatients with PHG showed a poorer prognosis than those without(P=0.01).Although severe PHG tended to have worse prognosis than mild PHG,there was no statistical difference(P=0.398).The mean survival time was 68.2 months in non-PHG cases.When PHG was present,it was reduced to 59 months,even shrink to 52.2 months for severe cases Similarly,the 1-year or 5-year survival rate of patients with cirrhosis decrease gradually with the occurrence and aggravation of PHG.In the cox regression survival analysis,age,PHG,hemoglobin,and MELD score were independently associated with overall survivalDuring the follow-up,we also observed the occurrence of HCC.HCC occurred in 16,23 and 5 cirrhosis with no,mild,and severe PHG,respectively.The HCC-free survival was not significantly correlated with the presence or severity of PHG based on log-rank test3.A nomogram predicting PHG constructed based on logistic regressionA nomogram was constructed using clinical parameters age,hemoglobin,platelet count and Child-Pugh class of training cohort based on logistic regression.The C-index was 0.773(95%CI:0.730 to 0.816)in training cohort and 0.761 after a bootstrapping.It was 0.745(95%CI:0.673 to 0.817)calculated in external validation.The AUC values were 0.767,0.724 and 0.756 in training,validation and total groups,respectively.Well-fitted calibration curves were observed in both cohorts.Decision curve analysis demonstrated that the nomogram was clinically useful when an intervention was decided at a threshold of 15%-93%The main conclusions:1.PHG,an important cause of gastrointestinal bleeding in cirrhosis,is closely related to the severity and location of varices.PHG should be actively treated to reduce the risk of bleeding and other complications2.PHG is an independent prognostic factor in patients with liver cirrhosis,but has no correlation with the occurrence of HCC3.The risk of PHG nomogram achieved an optimal prediction based on strong concordance performance and perfect calibrationPart Ⅱ:Medical burden of transjugular intrahepatic portosystemic shunt in cirrhosisEsophagogastric varices are serious complication of portal hypertension in cirrhosis Fatal upper gastrointestinal bleeding may occur in about 1/3 of patients with esophagogastric varices can cause.In patients with cirrhosis who have suffered from bleeding of esophagogastric varices,the rate of rebleeding within 1 year is more than 60%and the mortality rate is close to 20%,which seriously threatens the safety of patientsTransjugular intrahepatic portosystemic shunt(TIPS)was proposed in 1988 and applied in the clinical to relieve portal hypertension.It has gradually been accepted by clinicians,and became an important measure for the treatment of esophagogastric varices.With the development and optimization of technology,TIPS is now widely used in the treatment of esophagogastric varices bleeding in cirrhosis,intractable pleural or abdominal fluid,budd-chiari syndrome and hepatic sinus obstruction syndrome,etc.In addition,TIPS can also be used as a bridge therapy for patients with decompensated cirrhosis waiting for liver transplantation.It is generally accepted that the most effective treatment for patients with terminal hepatic disease is liver transplantation.In clinical practice,TIPS has become the most important end-stage treatment for patients with end-stage cirrhosis due to the extremely limited source of liverChild-pugh and model for end-stage liver disease(MELD)scores have been widely used to predict the mortality of varices bleeding and surgical outcomes associated with cirrhosis However,there were seldom reports on the prognosis of decompensated cirrhosis patients treated with TIPS.The purpose of this study is to explore the influencing factors by analyzing the prognostic data of cirrhosis underwent TIPS,such as the in-hospital operation expenses and postoperative readmission,so as to guide clinical practiceThe main contents:1.The effect of preoperative liver function on the medical burden of patients with liver cirrhosis undergoing TIPSA retrospective study of medical expenses,in-hospital time and daily expenses was conducted on 252 patients with decompensated cirrhosis who underwent TIPS during hospitalization.Subsequently,follow-up was also conducted to observe the rehospitalization within 6 months after surgery.Finally,the influence of preoperative liver function on the factors mentioned above was analyzed2.Factors influencing rehospitalization in cirrhosis after TIPSThe information of 252 cirrhosis patients who underwent TIPS was retrospectively analyzed.Using rehospitalization within half a year after TIPS as the endpoint,the patients were divided into rehospitalization group and non-rehospitalization group.Logistic univariate and multivariate regression analysis were used to explore the independent risk factors influencing the occurrence of the endpoint,and the Area Under Curve(AUC)was used to evaluate the predicting accuracyThe main results:1.The effect of preoperative liver function on the medical burden of patients with liver cirrhosis undergoing TIPSThere were 108 patients with Child A,131 with Child B and 13 with Child C before TIPS.The median hospitalization expenses were 9.10,10.07 and 10.83 wan yuan,the median hospitalization period was 10.0,11.0 and 13.0 days,the median daily expenses were 0.94,0.90 and 0.71 wan yuan,and the re-hospitalization rate within 6 months after TIPS was 22.2%,36.6%and 53.8%,respectively.The differences were all statistically significant(P<0.05)except for daily expenses.Child and iMELD scores of preoperative liver function were positively correlated with medical expenses during hospitalization(P<0.05),while MELD,MELD-Na and MESO scores were not(P>0.05)2.Factors influencing rehospitalization in cirrhosis after TIPSOf the 252 decompensated patients included in the analysis,79 were readmitted to hospital within six months after TIPS.The age,AST,Child and MELD-Na scores of the patients in the rehospitalization group were significantly higher than those in the non-rehospitalization group(P<0.05).Four factors including age(OR=1.029,95%CI:1.004-1.054),AST(OR=1.007,95%CI:1.001-1.014),Child score(OR=1.373,95%CI:1.145-1.647)and iMELD score(OR=1.080,95%CI:1.031-1.132)were screened out by univariate logistic analysis.Multivariate logistic analysis showed that Child score was an independent risk factor for rehospitalization(OR=1.255,95%CI:1.028-1.531,P<0.05),with an AUC of 0.630.The main conclusions:1.Hospitalization expenses,period,and rehospitalization rate within six months were different in cirrhosis underwent TIPS with different Child grading of liver function.However,there was no difference in the daily expenses of hospitalization.Child and iMELD scores of preoperative liver function can reflect the hospitalization costs of TIPS in a certain extent,while MELD,MELD-Na and MESO scores could not2.The Child score for liver function was an independent risk factor for rehospitalization within six months after TIPS in decompensated cirrhosis,with a predictive accuracy of 63%.