3 years ago

Association Between Portosystemic Shunts and Increased Complications and Mortality in Patients With Cirrhosis

Spontaneous portosystemic shunts (SPSSs) have been associated with hepatic encephalopathy (HE). Little is known about their prevalence among patients with cirrhosis or clinical effects. We investigated the prevalence and characteristics of SPSSs in patients with cirrhosis and their outcomes. Methods We performed a retrospective study of 1729 patients with cirrhosis who underwent abdominal computed tomography or magnetic resonance imaging analysis from 2010 through 2015 at 14 centers in Canada and Europe. We collected data on demographic features, etiology of liver disease, comorbidities, complications, treatments, laboratory and clinical parameters, model for end-stage liver disease (MELD) score, and endoscopy findings. Abdominal images were reviewed by a radiologist (or a hepatologist trained by a radiologist) and searched for the presence of SPSS, defined as spontaneous communications between the portal venous system or splanchnic veins and the systemic venous system, excluding gastroesophageal varices. Patients were assigned to groups with large SPSSs (L-SPSSs, ≥8 mm), small SPSSs (S-SPSSs, <8 mm), or without SPSS (W-SPSS). The main outcomes were the incidence of complications of cirrhosis and mortality according to the presence of SPSS. Secondary measurements were the prevalence of SPSSs in patients with cirrhosis and their radiologic features. Results L-SPSS were identified in 488 patients (28%), S-SPSS in 548 patients (32%), and no shunt (W-SPSS) in 693 patients (40%). The most common L-SPSS was spleno–renal (46% of L-SPSSs). The presence and size of SPSS increased with liver dysfunction: among patients with MELD scores of 6–9, 14% had L-SPSSs and 28% had S-SPSSs; among patients with MELD scores of 10–13, 30% had L-SPSSs and 34% had S-SPSSs; among patients with MELD scores of 14 or more, 40% had L-SPSSs and 32% had S-SPSSs (P<.001 for multiple comparison among MELD groups). HE was reported in 48% of patients with L-SPSSs, 34% of patients with S-SPSSs, and 20% of patients W-SPSSs (P<.001 for multiple comparison among SPSS groups). Recurrent or persistent HE was reported in 52% of patients with L-SPSSs, 44% of patients with S-SPSSs, and 37% of patients W-SPSSs (P=.007 for multiple comparison among SPSS groups). Patients with SPSSs also had a larger number of portal hypertension-related complications (bleeding or ascites) than those W-SPSSs. Quality of life and transplant-free survival were lower in patients with SPSSs vs without. SPSSs were an independent factor associated with death or liver transplantation (hazard ratio, 1.26; 95% CI, 1.06–1.49) (P=.008) in multivariate analysis. When patients were stratified by MELD score, SPSSs were associated with HE independently of liver function: among patients with MELD scores of 6–9, HE was reported in 23% with L-SPSSs, 12% with S-SPSSs, and 5% with W-SPSSs (P<.001 for multiple comparison among SPSS groups); among those with MELD scores of 10–13, HE was reported in 48% with L-SPSSs, 33% with S-SPSSs, and 23% with W-SPSS (P<.001 for multiple comparison among SPSS groups); among patients with MELD scores of 14 or more, HE was reported in 59% with L-SPSSs, 57% with S-SPSSs, and 48% with W-SPSS (P=.043 for multiple comparison among SPSS groups). Patients with SPSS and MELD scores of 6–9 were at higher risk for ascites (40.5% vs 23%; P<.001) and bleeding (15% vs 9%; P=0.038) than patients W-SPSS and had lower odds of transplant-free survival (hazard ratio 1.71; 95% CI, 1.16-2.51) (P=.006). Conclusions In a retrospective analysis of almost 2000 patients, we found 60% to have SPSSs; prevalence increases with deterioration of liver function. SPSSs increase risk for HE and chronic course. In patients with preserved liver function, SPSSs increase risk for complications and death. ClincialTrials.gov no: NCT02692430.

Publisher URL: www.sciencedirect.com/science

DOI: S0016508518300696

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