Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis.
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Praktiknjo Michael, Simón-Talero Macarena, Römer Julia, Roccarina Davide, Martínez Javier, Lampichler Katharina, Baiges Anna, Low Gavin, Llop Elba, Maurer Martin H, Zipprich Alexander, Triolo Michela, Maleux Geert, Fialla Annette Dam, Dam Claus, Vidal-González Judit, Majumdar Avik, Picón Carmen, Toth Daniel, Darnell Anna, Abraldes Juan G, López Marta, Jansen Christian, Chang Johannes, Schierwagen Robert, Uschner Frank, Kukuk Guido, Meyer Carsten, Thomas Daniel, Wolter Karsten, Strassburg Christian P, Laleman Wim, La Mura Vincenzo, Ripoll Cristina, Berzigotti Annalisa, Calleja José Luis, Tandon Puneeta, Hernandez-Gea Virginia, Reiberger Thomas, Albillos Agustín, Tsochatzis Emmanuel A, Krag Aleksander, Genescà Joan, Trebicka Jonel, Baveno VI-SPSS group of the Baveno Cooperation
Аннотация
METHODS: In this retrospective international multicentric study, CT scans of 908 cirrhotic patients with SPSS were evaluated for TSA. Clinical and laboratory data were recorded. Each detected SPSS radius was measured and TSA calculated. One-year survival was the primary endpoint and acute decompensation (oHE, variceal bleeding, ascites) was the secondary endpoint.
RESULTS: A total of 301 patients (169 male) were included in the training cohort. Thirty percent of all patients presented with >1 SPSS. A TSA cut-off of 83 mm2 was used to classify patients with small or large TSA (S-/L-TSA). Patients with L-TSA presented with higher model for end-stage liver disease score (11 vs. 14) and more commonly had a history of oHE (12% vs. 21%, p <0.05). During follow-up, patients with L-TSA experienced more oHE episodes (33% vs. 47%, p <0.05) and had lower 1-year survival than those with S-TSA (84% vs. 69%, p <0.001). Multivariate analysis identified L-TSA (hazard ratio 1.66; 95% CI 1.02-2.70, p <0.05) as an independent predictor of mortality. An independent multicentric validation cohort of 607 patients confirmed that patients with L-TSA had lower 1-year survival (77% vs. 64%, p <0.001) and more oHE development (35% vs. 49%, p <0.001) than those with S-TSA.
CONCLUSION: This study suggests that TSA >83 mm2 increases the risk for oHE and mortality in patients with cirrhosis. Our results support the clinical use of TSA/SPSS for risk stratification and decision-making in the management of patients with cirrhosis.
LAY SUMMARY: The prevalence of spontaneous portosystemic shunts (SPSS) is higher in patients with more advanced chronic liver disease. The presence of more than 1 SPSS is common in advanced chronic liver disease and is associated with the development of hepatic encephalopathy. This study shows that total cross-sectional SPSS area (rather than diameter of the single largest SPSS) predicts survival in patients with advanced chronic liver disease. Our results support the clinical use of total cross-sectional SPSS area for risk stratification and decision-making in the management of SPSS.