Transjugular Intrahepatic Portosystemic Shunt And Traditional Chinese Medicine In The Treatment Of Hepatorenal Syndrome: A Systematic Review And Meta-analysis

Purpose: To systematically review the efficacy and safety of transjugular intrahepatic portosystemic shunt(TIPS)and traditional Chinese medicine(TCM)for the treatment of hepatorenal syndrome(HRS).Material and method: First study: Publications were searched via Pub Med and EMBASE databases.The meta-analyses were performed by the Stats Direct Statistical Package software version 2.7.8(Stats Direct Ltd,Sale,Cheshire,UK).We employed the random-effect model alone.As for the proportion data,we calculated the pooled proportion as the effect size.Second study: Publications were searched electronically from China National Knowledge Infrastructure(CNKI),Wan Fang,VIP,Pub Med,and EMBASE databases.The meta-analyses were performed by the Review Manager 5.3,(Copenhagen: The Nordic Cochrane Centre,The Cochrane Collaboration,Copenhagen,Denmark)and Stata version 12(Stata Corp,College Station,Texas,USA).Random-effect model was employed.Odds ratio(OR)with 95% confidence interval(CI)was calculated for binary variables.Standardized mean difference(SMD)with 95%CI was calculated for continuous variables.Heterogeneity was quantified using the Cochrane Q-test and the ?~2 statistics.Results: First study: Nine publications were included,in which 128 patients with HRS were treated with TIPS.The pooled short-term and 1-year survival rates were 72% and 47% in HRS-1 and 86% and 64% in HRS-2.No lethal procedure-related complications were observed.The pooled rate of hepatic encephalopathy(HE)after TIPS was 49%.The pooled rate of renal function improvement after TIPS was 93% in HRS-1 and 83% in any type of HRS.After TIPS,serum creatinine,blood urea nitrogen,serum sodium,sodium excretion,and urine volume were significantly improved;by comparison,serum bilirubin slightly increased,but the difference was not statistically significant.Second study: Fourteen randomized controlled trials involving 788 patients with HRS were included.Random generation sequence was reported in only two studies.Blinding was not used in any study.Compared to conventional treatment without traditional Chinese medicine(TCM),TCM led to a significant survival benefit during hospitalization(OR: 0.18;95% CI: 0.08-0.39;P<0.0001),a significantly higher complete response(OR: 3.2;95% CI: 2.06-4.97;P<0.00001),and a significantly lower no response(OR: 0.2;95% CI: 0.14-0.3;P<0.00001).Partial response was not significantly different between the two groups(OR: 1.39;95% CI: 0.9-2.15;P=0.14).Regardless of TCM,blood urea nitrogen and abdominal circumference were significantly decreased,and urine volume was significantly increased after treatment.Compared to conventional treatment without TCM,TCM led to a significantly lower serum creatinine,blood urea nitrogen,bilirubin,plasma ammonia,and abdominal circumference and significantly higher urine volume after treatment.There was significant heterogeneity.Conclusion: The conclusions of the two studies were as follows:(1)Limited evidence suggested a potential survival benefit of TIPS in patients with HRS but with a high incidence of HE;(2)TCM might have a better survival and a higher complete response in patients with HRS.However,the quality of published studies was unsatisfactory.