Nardelli Silvia, Gioia Stefania, Pasquale Chiara, Pentassuglio Ilaria, Farcomeni Alessio, Merli Manuela, Salvatori Filippo Maria, Nikolli Leandra, Torrisi Sabrina, Greco Francesca, Nicoletti Valeria, Riggio Oliviero
Policlinico Umberto I-Department of Clinical Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, "Sapienza" University of Rome, Rome, Italy.
Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy.
Am J Gastroenterol. 2016 Apr;111(4):523-8. doi: 10.1038/ajg.2016.29. Epub 2016 Mar 1.
Hepatic encephalopathy (HE) is a major problem in patients treated with TIPS. The aim of the study was to establish whether pre-TIPS covert HE is an independent risk factor for the development of HE after TIPS.
Eighty-two consecutive cirrhotic patients submitted to TIPS were included. All patients underwent the PHES to identify those affected by covert HE before a TIPS. The incidence of the first episode of HE was estimated, taking into account the nature of the competing risks in the data (death or liver transplantation).
Thirty-five (43%) patients developed overt HE. The difference of post-TIPS HE was highly significant (P=0.0003) among patients with or without covert HE before a TIPS. Seventy-seven percent of patients with post-TIPS HE were classified as affected by covert HE before TIPS. Age: (sHR 1.05, CI 1.02-1.08, P=0.002); Child-Pugh score: (sHR 1.29, CI 1.06-1.56, P=0.01); and covert HE: (sHR 3.16, CI: 1.43-6.99 P=0.004) were associated with post-TIPS HE. Taking into consideration only the results of PHES evaluation, the negative predicting value was 0.80 for all patients and 0.88 for the patients submitted to TIPS because of refractory ascites. Thus, a patient with refractory ascites, without covert HE before a TIPS, has almost 90% probability of being free of HE after TIPS.
Psychometric evaluation before TIPS is able to identify most of the patients who will develop HE after a TIPS and can be used to select patients in order to have the lowest incidence of this important complication.
肝性脑病（HE）是经颈静脉肝内门体分流术（TIPS）治疗患者的一个主要问题。本研究的目的是确定TIPS术前隐匿性HE是否是TIPS术后发生HE的独立危险因素。
纳入82例连续接受TIPS治疗的肝硬化患者。所有患者在TIPS术前均接受了精神状态评分（PHES）以确定隐匿性HE患者。考虑到数据中的竞争风险（死亡或肝移植）的性质，估计了首次发生HE的发生率。
35例（43%）患者发生显性HE。TIPS术前有或无隐匿性HE的患者，TIPS术后HE的差异具有高度统计学意义（P = 0.0003）。TIPS术后发生HE的患者中，77%在TIPS术前被归类为隐匿性HE患者。年龄（标准化危险比1.05，95%置信区间1.02 - 1.08，P = 0.002）；Child-Pugh评分（标准化危险比1.29，95%置信区间1.06 - 1.56，P = 0.01）；以及隐匿性HE（标准化危险比3.16，95%置信区间1.43 - 6.99，P = 0.004）与TIPS术后HE相关。仅考虑PHES评估结果，所有患者的阴性预测值为0.80，因难治性腹水接受TIPS治疗的患者为0.88。因此，难治性腹水患者，在TIPS术前无隐匿性HE，TIPS术后发生HE的概率几乎为90%。
TIPS术前的心理测量评估能够识别出大多数TIPS术后将发生HE的患者，并可用于选择患者，以使这一重要并发症的发生率降至最低。
