Spengler Erin K, Hunsicker Lawrence G, Zarei Sanam, Zimmerman M Bridget, Voigt Michael D
Division of Gastroenterology and Hepatology Department of Internal Medicine, The University of Iowa Hospitals and Clinics Iowa City IA.
University of Wisconsin, School of Medicine and Public Health Madison WI.
Hepatol Commun. 2017 Jun 7;1(5):460-468. doi: 10.1002/hep4.1053. eCollection 2017 Jul.
Physicians often exclude patients with a model for end-stage liver disease (MELD) score ≥ 18 from a transjugular intrahepatic portosystemic shunt (TIPS) procedure due to the concern for higher risk of death. We aimed to determine if TIPS increased the risk of death in these patients. We analyzed the interaction between TIPS and MELD in 106 patients with TIPS and 79 with intractable ascites without TIPS. We performed Cox proportional hazard regression, including both TIPS and MELD as time-dependent covariates together with their interaction, to calculate the impact of TIPS on the risk of death associated with a high MELD score. We found a negative interaction between a high MELD score and a history of TIPS, with potentially important effect sizes. Patients with MELD scores ≥18 had a 51% lower incremental risk of death (lower risk than would be expected from the combined independent risks of MELD and needing/receiving TIPS) associated with TIPS than patients with MELD scores <18 (hazard ratio for TIPS, 0.49; 95% confidence interval, 0.10-2.45) in the first 6 months following TIPS. There was an 80% lower incremental risk of death among patients with a MELD score ≥18 (hazard ratio for TIPS, 0.20; 95% confidence interval, 0.03-1.23) 6 months after the TIPS procedure. : Risk of death is associated with underlying disease severity as shown by the MELD score and the need for TIPS, and both history of TIPS and high MELD score independently increased the risk of mortality. However, the risk of death after TIPS was progressively lower than expected as the MELD score increased. ( 2017;1:460-468).
由于担心死亡风险较高，医生通常会将终末期肝病模型（MELD）评分≥18的患者排除在经颈静脉肝内门体分流术（TIPS）之外。我们旨在确定TIPS是否会增加这些患者的死亡风险。我们分析了106例行TIPS的患者和79例有顽固性腹水但未行TIPS的患者中TIPS与MELD之间的相互作用。我们进行了Cox比例风险回归分析，将TIPS和MELD作为时间依赖性协变量及其相互作用纳入分析，以计算TIPS对与高MELD评分相关的死亡风险的影响。我们发现高MELD评分与TIPS病史之间存在负向相互作用，且效应量可能具有重要意义。与MELD评分<18的患者相比，MELD评分≥18的患者在TIPS术后的前6个月内，与TIPS相关的死亡增量风险降低了51%（低于MELD和需要/接受TIPS的联合独立风险预期值）（TIPS的风险比为0.49；95%置信区间为0.10 - 2.45）。在TIPS术后6个月，MELD评分≥18的患者死亡增量风险降低了80%（TIPS的风险比为0.20；95%置信区间为0.03 - 1.23）。死亡风险与MELD评分所示的潜在疾病严重程度以及对TIPS的需求相关，TIPS病史和高MELD评分均独立增加了死亡风险。然而，随着MELD评分的增加，TIPS术后的死亡风险逐渐低于预期。（2017；1：460 - 468）
