Analysis of prognostic variables in the prediction of mortality, shunt failure, variceal rebleeding and encephalopathy following the transjugular intrahepatic protosystemic stent-shunt for variceal haemorrhage
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Abstract
The aim of this study was to analyse prognostic variables predicting mortality, shunt
insufficiency, variceal rebleeding and encephalopathy following transjugular intrahepatic
portosystemic stent-shunt for variceal haemorrhage.
Sixty-eight patients with cirrhosis who successfully underwent transjugular intrahepatic
portosystemic stent-shunt for variceal haemorrhage were studied. Mean age was 54.8
years (s.e. 1.5); 41 were males and 27 were females. Mean Child score was 8.3 (s.e.
0.3). Cirrhosis was alcohol related in 47. The patients have been followed up for
a mean of 10.8 (s.e. 1.1) months. The univariate association between 30 prognostic
variables and post-treatment encephalopathy was tested by the Chi-squared or Wilcoxon
rank-sum tests and multiple logistic regression was used to test the significance
of factors adjusted for one another. Cox's proportional hazard regression was used
to test the univariate and multivariate significance of the other three outcomes.
Transjugular intrahepatic portosystemic stent-shunt was performed successfully in
89.5% of patients. Twenty-two patients have died and eight have been transplanted.
Fourteen patients died within 30 days of transjugular intrahepatic portosystemic stent-shunt
and death was predicted independently by hyponatraemia (p < 0.001) and by severe liver
disease (Child C, p < 0.001). Eight patients died during follow up and survival in
the long term was predicted independently by the presence of encephalopathy (p < 0.001)
prior to transjugular intrahepatic portosystemic stent-shunt (p < 0.001). Shunt insufficiency
was predicted by an initial portal pressure gradient of greater than 18 mmHg (p <
0.01). None of the variables analysed predicted variceal rebleeding. Encephalopathy
following transjugular intrahepatic portosystemic stent-shunt was only predicted indepedently
by its presence prior to transjugular intrahepatic portosystemic stent-shunt (p <
0.001).
The results of this study suggest that patients with severe liver disease and hyponatraemia
are liable to die early, and the presence of encephalopathy prior to transjugular
intrahepatic portosystemic stent-shunt independently determines long-term survival.
Patients in these groups should be considered high risk and worked up for orthotopic
liver transplantation early. Shunt function in patients with an initial portal pressure
gradient of > 18 mmHg requires close supervision. Encephalopathic patients should
have smaller shunts and prophylactic measures to prevent worsening encephalopathy.