Introduction Transjugular intrahepatic portosystemic shunt (TIPS) insertion has been used for over twenty years to treat the complications of portal hypertension. TIPS insertion provides better control of refractory ascites than large volume paracentesis but with a higher risk of developing hepatic encephalopathy (HE). In addition, a survival benefit has only been found in carefully selected patients. The aims of this study were to review the use of TIPS for the treatment of refractory ascites, in a single centre, over a twenty-year period with the aim of identifying factors predictive of the development of HE and survival.
Methods All patients who underwent TIPS for refractory ascites in the Royal Free Hospital, London, between 1992 and 2012 were reviewed. All non-transplanted patients still alive in 2012 were recalled for assessment of their neuropsychiatric status using clinical, neuropsychometric and neurophysiological criteria. The factors associated with the development of post–TIPS HE were determined by multivariate analysis using the Cox proportional regression model. Differences in survival were determined by Kaplan-Meier analysis.
Results Of the 169 patients identified, 96 (56.8%) had died, 22 (13.1%) had been transplanted while the remaining 51 were alive. The median survival time was 18.8 months. The factors predictive of death were a higher serum AST (p < 0.04), ALP (p < 0.02), and sodium (p < 0.02) and an increased INR (p < 0.01). Survival rates were higher in patients of non-British white ethnic origin (p < 0.00). Of the 27 patients available for review, 21 (78%) had some degree of HE although less than 30% were on anti-encephalopathy treatment. The factors predictive of HE were older age (p < 0.01), with the risk increasing by 6.5% for every year of age, and white British ethnicity (p < 0.01).
Conclusion Older patients and those of white British origin are particularly at risk for developing HE and should be monitored carefully following the TIPS procedure. The finding that patients with hypernatraemia have significantly reduced survival rates is novel; it most likely reflects overdiuresis and should be corrected pre-procedure. Thus, careful assessment and selection of candidates for TIPS insertion for refractory ascites as well as closer and longer-term monitoring may help prevent the development of HE and lead to improved outcomes.
Disclosure of Interest None Declared.
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