Michael Praktiknjo1, Macarena Simón-Talero2, Julia Römer1, Davide Roccarina3, Javier Martínez4, Katharina Lampichler5, Anna Baiges6, Gavin Low7, Elba Llop8, Martin H Maurer9, Alexander Zipprich10, Michela Triolo11, Geert Maleux12, Annette Dam Fialla13, Claus Dam13, Judit Vidal-González2, Avik Majumdar3, Carmen Picón14, Daniel Toth5, Anna Darnell15, Juan G Abraldes16, Marta López8, Christian Jansen1, Johannes Chang1, Robert Schierwagen17, Frank Uschner17, Guido Kukuk18, Carsten Meyer18, Daniel Thomas18, Karsten Wolter18, Christian P Strassburg1, Wim Laleman19, Vincenzo La Mura20, Cristina Ripoll10, Annalisa Berzigotti21, José Luis Calleja8, Puneeta Tandon16, Virginia Hernandez-Gea6, Thomas Reiberger22, Agustín Albillos4, Emmanuel A Tsochatzis3, Aleksander Krag13, Joan Genescà23, Jonel Trebicka24. 1. Department of Internal Medicine I, University of Bonn, Bonn, Germany. 2. Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain. 3. Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom. 4. Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRICYS, Universidad de Alcalá, CIBERehd, Spain. 5. Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria. 6. Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS, Universitat de Barcelona, CIBERehd, Spain. 7. Department of Radiology, University of Alberta, Edmonton, Canada. 8. Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain. 9. Department of Radiology, Inselspital, University of Berne, Berne, Switzerland. 10. First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany. 11. Medicina Interna, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Donato, Università Degli Studi di Milano, San Donato Milanese (MI), Italy. 12. Department of Interventional Radiology, University Hospitals Leuven, KU Leuven, Belgium. 13. Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark. 14. Department of Radiology, Hospital Universitario Ramón y Cajal, IRICYS, Universidad de Alcalá, CIBERehd, Spain. 15. Department of Radiology, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain. 16. Cirrhosis Care Clinic, University of Alberta, Edmonton, Canada. 17. Department of Internal Medicine I, University of Frankfurt, Frankfurt, Germany. 18. Department of Radiology, University of Bonn, Bonn, Germany. 19. Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium. 20. Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, U.O.C. Medicina Generale-Emostasi e Trombosi, Milano, Italy; Dipartimento di Scienze biomediche per la Salute and Centro di Ricerca Coordinata "A. M. e A. Migliavacca" per lo Studio e la Cura delle Malattie del Fegato, Università degli Studi di Milano, Milano, Italy. 21. Hepatology, Inselspital, University of Berne, Berne, Switzerland. 22. Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria. 23. Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain. Electronic address: jgenesca@vhebron.net. 24. Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department of Internal Medicine I, University of Frankfurt, Frankfurt, Germany; European Foundation for the Study of Chronic Liver Failure - EF CLIF, Barcelona, Spain; Institute for Bioengineering of Catalonia, Barcelona, Spain. Electronic address: jonel.trebicka@kgu.de.
Abstract
BACKGROUND & AIMS: Spontaneous portosystemic shunts (SPSS) frequently develop in liver cirrhosis. Recent data suggested that the presence of a single large SPSS is associated with complications, especially overt hepatic encephalopathy (oHE). However, the presence of >1 SPSS is common. This study evaluates the impact of total cross-sectional SPSS area (TSA) on outcomes in patients with liver cirrhosis. 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.
BACKGROUND & AIMS: Spontaneous portosystemic shunts (SPSS) frequently develop in liver cirrhosis. Recent data suggested that the presence of a single large SPSS is associated with complications, especially overt hepatic encephalopathy (oHE). However, the presence of >1 SPSS is common. This study evaluates the impact of total cross-sectional SPSS area (TSA) on outcomes in patients with liver cirrhosis. 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.
Authors: Johannes Chang; Avend Bamarni; Nina Böhling; Xin Zhou; Leah-Marie Klein; Jonathan Meinke; Georg Daniel Duerr; Philipp Lingohr; Sven Wehner; Maximilian J Brol; Jürgen K Rockstroh; Jörg C Kalff; Steffen Manekeller; Carsten Meyer; Ulrich Spengler; Christian Jansen; Vicente Arroyo; Christian P Strassburg; Jonel Trebicka; Michael Praktiknjo Journal: Hepatol Commun Date: 2021-03-26
Authors: Justin R Boike; Bartley G Thornburg; Sumeet K Asrani; Michael B Fallon; Brett E Fortune; Manhal J Izzy; Elizabeth C Verna; Juan G Abraldes; Andrew S Allegretti; Jasmohan S Bajaj; Scott W Biggins; Michael D Darcy; Maryjane A Farr; Khashayar Farsad; Guadalupe Garcia-Tsao; Shelley A Hall; Caroline C Jadlowiec; Michael J Krowka; Jeanne Laberge; Edward W Lee; David C Mulligan; Mitra K Nadim; Patrick G Northup; Riad Salem; Joseph J Shatzel; Cathryn J Shaw; Douglas A Simonetto; Jonathan Susman; K Pallav Kolli; Lisa B VanWagner Journal: Clin Gastroenterol Hepatol Date: 2021-07-15 Impact factor: 13.576