Liver and Bile
J Hepatol. 2024;80(4):596–602
Episodic overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt does not increase mortality in patients with cirrhosis
Background and aims: Overt hepatic encephalopathy (OHE) is a major complication of transjugular intrahepatic portosystemic shunt (TIPS) placement, given its high incidence and possibility of refractoriness to medical treatment. Nevertheless, the impact of post-TIPS OHE on mortality has not been investigated in a large population.
Methods: The authors designed a multicenter, non-inferiority, observational study to evaluate the mortality rate at 30 months in patients with and without OHE after TIPS. They analyzed a database of 614 patients who underwent TIPS in 3 Italian centers and estimated the cumulative incidence of OHE and mortality with competitive risk analyses, setting the non-inferiority limit at 0.12.
Results: During a median follow-up of 30 months (interquartile range, 12–30), 293 patients developed at least 1 episode of OHE. 27 (9.2%) of them experienced recurrent/persistent OHE. Patients with OHE were older (64 [57–71] vs. 59 [50–67] years, p < 0.001), had lower albumin (3.1 [2.8–3.5] vs. 3.25 [2.9–3.6] g/dl, p = 0.023), and had a higher prevalence of pre-TIPS OHE (15.4% vs. 9.0%, p = 0.023). Child-Pugh and Model for End-stage Liver Disease (MELD) scores were similar. The 30-month difference in mortality between patients with and without post-TIPS OHE was 0.03 (95% confidence interval [CI]: -0.042–0.102). Multivariable analysis showed that age (subdistribution hazard ratio [SHR] = 1.04, 95% CI: 1.02–1.05, p < 0.001) and MELD score (SHR = 1.09, 95% CI: 1.05–1.13, p < 0.001), but not post-TIPS OHE, were associated with a higher mortality rate. Similar results were obtained when patients undergoing TIPS for variceal rebleeding prophylaxis (n = 356) or refractory ascites (n = 258) were analyzed separately. The proportion of patients with persistent OHE after TIPS was significantly higher in the group of patients who died. The robustness of these results was increased following propensity score matching.
Conclusion: Episodic overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) is not associated with mortality in patients undergoing TIPS, regardless of the indication.