Kumar Rahul, Kerbert Annarein J C, Sheikh M Faisal, Roth Noam, Calvao Joana A F, Mesquita Monica D, Barreira Ana I, Gurm Haqeeqat S, Ramsahye Komal, Mookerjee Rajeshwar P, Yu Dominic, Davies Neil H, Mehta Gautam, Agarwal Banwari, Patch David, Jalan Rajiv
Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK; Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Duke-NUS Academic Medical Centre, CGH Campus, Singapore.
Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK.
J Hepatol. 2021 Jan;74(1):66-79. doi: 10.1016/j.jhep.2020.06.010. Epub 2020 Jun 16.
BACKGROUND & AIMS: Failure to control oesophago-gastric variceal bleeding (OGVB) and acute-on-chronic liver failure (ACLF) are both important prognostic factors in cirrhosis. The aims of this study were to determine whether ACLF and its severity define the risk of death in OGVB and whether insertion of rescue transjugular intrahepatic shunt (TIPS) improves survival in patients with failure to control OGVB and ACLF.
Data on 174 consecutive eligible patients, with failure to control OGVB between 2005 and 2015, were collected from a prospectively maintained intensive care unit registry. Rescue TIPS was defined as technically successful TIPS within 72 hours of presentation with failure to control OGVB. Cox-proportional hazards regression analyses were applied to explore the impact of ACLF and TIPS on survival in patients with failure to control OGVB.
Patients with ACLF (n = 119) were significantly older, had organ failures and higher white cell count than patients with acute decompensation (AD, n = 55). Mortality at 42-days and 1-year was significantly higher in patients with ACLF (47.9% and 61.3%) than in those with AD (9.1% and 12.7%, p <0.001), whereas there was no difference in the number of endoscopies and transfusion requirements between these groups. TIPS was inserted in 78 patients (AD 21 [38.2%]; ACLF 57 [47.8%]; p = 0.41). In ACLF, rescue TIPS insertion was an independent favourable prognostic factor for 42-day mortality. In contrast, rescue TIPS did not impact on the outcome of patients with AD.
This study shows that in patients with failure to control OGVB, the presence and severity of ACLF determines the risk of 42-day and 1-year mortality. Rescue TIPS is associated with improved survival in patients with ACLF.
Variceal bleeding that is not controlled by initial endoscopy is associated with high risk of death. The results of this study showed that in the occurrence of failure of the liver and other organs defines the risk of death. In these patients, insertion of a shunt inside the liver to drain the portal vein improves survival.
食管胃静脉曲张破裂出血（OGVB）控制不佳和慢加急性肝衰竭（ACLF）都是肝硬化重要的预后因素。本研究旨在确定ACLF及其严重程度是否决定OGVB患者的死亡风险，以及置入挽救性经颈静脉肝内门体分流术（TIPS）是否能提高OGVB控制不佳合并ACLF患者的生存率。
从一个前瞻性维护的重症监护病房登记处收集了2005年至2015年间174例连续符合条件的OGVB控制不佳患者的数据。挽救性TIPS定义为在出现OGVB控制不佳后72小时内技术成功的TIPS。应用Cox比例风险回归分析来探讨ACLF和TIPS对OGVB控制不佳患者生存的影响。
ACLF患者（n = 119）比急性失代偿（AD，n = 55）患者年龄显著更大，有器官功能衰竭且白细胞计数更高。ACLF患者42天和1年时的死亡率（47.9%和61.3%）显著高于AD患者（9.1%和12.7%，p <0.001），而两组之间的内镜检查次数和输血需求数量没有差异。78例患者接受了TIPS置入（AD组21例[38.2%]；ACLF组57例[47.8%]；p = 0.41）。在ACLF患者中，置入挽救性TIPS是42天死亡率的独立有利预后因素。相比之下，挽救性TIPS对AD患者的结局没有影响。
本研究表明，在OGVB控制不佳的患者中，ACLF的存在及其严重程度决定了42天和1年死亡率的风险。挽救性TIPS与ACLF患者生存率提高相关。
初次内镜检查未能控制的静脉曲张出血与高死亡风险相关。本研究结果表明，肝脏和其他器官功能衰竭的发生决定了死亡风险。在这些患者中，在肝脏内置入分流装置以引流门静脉可提高生存率。
