Early occurrence of hepatic encephalopathy following TIPS-insertion is linked to impaired survival: a multicenter cohort study.

Abstract

Background and aims: Hepatic encephalopathy (HE) is a common complication following transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, the prognostic significance of overt HE post-TIPS remains controversial.

Methods: We screened 2137 patients who underwent TIPS insertion at eight German tertiary care centers between 2004 and 2021. Patients with pre-emptive TIPS placement, hepatocellular carcinoma, missing data, and non-PTFE covered stents were excluded. Competing risk analysis was performed, considering liver transplantation as a competing event. To correct for immortal time bias, landmark analyses were conducted, with the landmark being set at 30 and 90-days post-TIPS. Outcome data were assessed for up to 30 months post-TIPS insertion.

Results: A total of 1356 patients (median MELD: 13 (IQR 10-17), age: 60 (IQR 54-67), 64% male, 12% HE before TIPS), were included. Overall, HE post-TIPS was linked to impaired survival (p<0.001, sHR: 1.41 [1.15-1.73]). However, this was only confirmed if HE occurred within the first 30 days post-TIPS (early HE; p<0.001, sHR: 2.02 [1.59-2.57]). Additionally, patients with a history of HE (p<0.001, sHR: 1.59 [1.21-2.07]) and history of HE and early HE post-TIPS (p<0.001, sHR: 3.44 [2.34-5.04]) showed impaired survival. These findings were confirmed in the landmark and multivariable analyses.

Conclusion: Early HE post-TIPS is associated with significantly reduced survival. Therefore, patients who experience early HE or have a history of HE should be closely monitored by physicians, as they constitute a particularly vulnerable group with impaired survival.