Division of Gastroenterology and Hepatology, Department of MedicineUniversity of California-San FranciscoSan FranciscoCA.
Division of Gastroenterology and Hepatology, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIL.
Liver Transpl. 2021 Feb;27(3):329-340. doi: 10.1002/lt.25949. Epub 2021 Jan 2.
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for portal hypertensive complications, but its effect on renal function is not well characterized. Here we describe renal function and characteristics associated with renal dysfunction at 30 days post-TIPS. Adults with cirrhosis who underwent TIPS at 9 hospitals in the United States from 2010 to 2015 were included. We defined "post-TIPS renal dysfunction" as a change in estimated glomerular filtration rate (ΔeGFR) ≤-15 and eGFR ≤ 60 mL/min/1.73 m or new renal replacement therapy (RRT) at day 30. We identified the characteristics associated with post-TIPS renal dysfunction by logistic regression and evaluated survival using adjusted competing risk regressions. Of the 673 patients, the median age was 57 years, 38% of the patients were female, 26% had diabetes mellitus, and the median MELD-Na was 17. After 30 days post-TIPS, 66 (10%) had renal dysfunction, of which 23 (35%) required new RRT. Patients with post-TIPS renal dysfunction, compared with those with stable renal function, were more likely to have nonalcoholic fatty liver disease (NAFLD; 33% versus 17%; P = 0.01) and comorbid diabetes mellitus (42% versus 24%; P = 0.001). Multivariate logistic regressions showed NAFLD (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.00-4.17; P = 0.05), serum sodium (Na; OR, 1.06 per mEq/L; 95% CI, 1.01-1.12; P = 0.03), and diabetes mellitus (OR, 2.04; 95% CI, 1.16-3.61; P = 0.01) were associated with post-TIPS renal dysfunction. Competing risk regressions showed that those with post-TIPS renal dysfunction were at a higher subhazard of death (subhazard ratio, 1.74; 95% CI, 1.18-2.56; P = 0.01). In this large, multicenter cohort, we found NAFLD, diabetes mellitus, and baseline Na associated with post-TIPS renal dysfunction. This study suggests that patients with NAFLD and diabetes mellitus undergoing TIPS evaluation may require additional attention to cardiac and renal comorbidities before proceeding with the procedure.
经颈静脉肝内门体分流术（TIPS）是治疗门脉高压并发症的有效介入手段，但它对肾功能的影响尚未得到充分描述。本研究旨在描述 TIPS 术后 30 天肾功能及与肾功能障碍相关的特征。
我们纳入了 2010 年至 2015 年期间美国 9 家医院因肝硬化而行 TIPS 的成年患者。我们将“TIPS 术后肾功能障碍”定义为估算肾小球滤过率（eGFR）变化≤-15 且 eGFR≤60ml/min/1.73m 或术后 30 天需行肾脏替代治疗（RRT）。我们采用 logistic 回归识别与 TIPS 术后肾功能障碍相关的特征，并采用调整后的竞争风险回归评估生存情况。
在 673 例患者中，中位年龄为 57 岁，38%为女性，26%患有糖尿病，中位 MELD-Na 为 17。TIPS 术后 30 天，66 例（10%）发生肾功能障碍，其中 23 例（35%）需要新的 RRT。与肾功能稳定的患者相比，TIPS 术后发生肾功能障碍的患者更有可能患有非酒精性脂肪性肝病（NAFLD；33%比 17%；P=0.01）和合并糖尿病（42%比 24%；P=0.001）。多变量 logistic 回归显示，NAFLD（比值比[OR]，2.04；95%置信区间[CI]，1.00-4.17；P=0.05）、血清钠（Na；OR，每 mEq/L 增加 1.06；95%CI，1.01-1.12；P=0.03）和糖尿病（OR，2.04；95%CI，1.16-3.61；P=0.01）与 TIPS 术后肾功能障碍相关。竞争风险回归显示，TIPS 术后发生肾功能障碍的患者死亡亚风险更高（亚危险比，1.74；95%CI，1.18-2.56；P=0.01）。
在这项大型多中心队列研究中，我们发现 NAFLD、糖尿病和基线 Na 与 TIPS 术后肾功能障碍相关。本研究提示，行 TIPS 评估的 NAFLD 和糖尿病患者在接受该治疗前可能需要额外关注心脏和肾脏合并症。
