| Aims: Ascites is one of the most common complications in decompensated cirrhotic patients.Refractory ascites may occur in approximately 10% of decompensated cirrhotic patients with ascites each year,with low survival rates and poor living qualities.Transjugular intrahepatic portosystemic shunt(TIPS)can be used as a common treatment to decrease portal vein pressure in order to treat portal hypertension-related ascites in decompensated cirrhotic patients.Pyrrolizidine alkaloid-induced hepatic sinusoidal obstruction syndrome(PA-HSOS)is a hepatic vascular disease characterized by liver injury and acute sinus portal hypertension,leading to sinusoidal congestion due to the swelling and necrosis of sinusoidal endothelial cells in zone 3 of the hepatic acini.It is caused by the use of drugs containing pyrrolidine alkaloids.According to ‘Expert consensus on diagnosis and treatment of pyrrolizidine alkaloids-induced sinusoidal obstruction syndrome’ published in 2017,the ‘anticoagulationTIPS’ therapy is recommended.However,the efficacy of TIPS treatment in refractory ascites patients caused by PA-HSOS remains controversial.The aim of this study was to compare the clinical characteristics and survival prognosis between PA-HSOS and decompensated cirrhosis-related refractory ascites patients treated by TIPS,and also to investigate the possible predictors for TIPS efficacy.Methods: The clinical data of patients with refractory ascites caused by PA-HSOS or decompensated cirrhosis between August 2008 and September 2020 in Drum Tower Hospital affiliated with Nanjing University School of Medicine were reviewed retrospectively.Baseline indicators such as laboratory parameters(blood tests,coagulation function,liver and kidney function),occurrence of complications and portal pressure changes during TIPS were collected and analyzed.The cumulative survival rates in two groups after TIPS were calculated using the Kaplan-Meier analysis.In addition,the propensity score matching(PSM)was generated at 1:1 ratio based on subjects’ age,end-stage model of liver disease(MELD)score,preoperative hepatic encephalopathy,preoperative portal venous thrombosis and portal venous blood flow velocity with a caliper value of 0.2.the Kaplan-Meier analysis was also performed after PSM.Cox regression was used for the investigation of risk factors for poor prognosis after TIPS in two groups respectively.Results: Finally,141 PA-HSOS patients with refractory ascites and 42 decompensated cirrhosis-related refractory ascites patients were enrolled.The follow-up time was16.63(10.67-26.60)months in PA-HSOS patients and 16.47(9.40-41.53)in decompensated cirrhosis patients.The preoperative Child-Pugh grade(A/B/C:3/74/64 vs 8/33/1,P=0.000)and MELD score(14.25±6.62 vs 11.05±3.82,P=0.003)in PA-HSOS patients were significantly higher than those in decompensated cirrhosis patients.During the follow-up period,18(12.77%)patients died in PA-HSOS group and 10(23.81%)patients died in decompensated cirrhosis group.There was no statistical significance in cumulative mortality rates after TIPS between two groups(X~2=1.737,P=0.188).In PA-HSOS patients,multivariate Cox analysis indicated aspartate aminotransferase,serum total bilirubin,serum creatinine serum levels and pre-TIPS portal vein velocity were independent risk factors influencing postoperative cumulative mortality rates.In decompensated cirrhosis patients,no independent risk factors were found.After PSM,24 PA-HSOS patients were matched to 24 decompensated cirrhosis patients.The cumulative mortality rate was significantly lower in PA-HSOS group than that in decompensated cirrhosis group(X~2=6.594,P=0.010).Conclusions: TIPS can treat refractory ascites patients caused by PA-HSOS or decompensated cirrhosis.Although the former has poorer preoperative liver function and portal hemodynamics,the PA-HSOS patients do not have worse postoperative survival compared with the decompensated cirrhosis-related refractory ascites patients. |
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