Queck Alexander, Schwierz Louise, Gu Wenyi, Ferstl Philip G, Jansen Christian, Uschner Frank E, Praktiknjo Michael, Chang Johannes, Brol Maximilian J, Schepis Filippo, Merli Manuela, Strassburg Christian P, Lehmann Jennifer, Meyer Carsten, Trebicka Jonel
Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany.
Department of Internal Medicine I , University Hospital Bonn , Bonn , Germany.
Hepatology. 2023 Feb 1;77(2):466-475. doi: 10.1002/hep.32676. Epub 2022 Aug 12.
Ascites is a definitive sign of decompensated liver cirrhosis driven by portal hypertension. Although transjugular intrahepatic portosystemic shunt insertion (TIPS) is indicated for therapy of recurrent and refractory ascites, there is no evidence-based recommendation for a specific target of portal hepatic pressure gradient (PPG) decrease.
In this single-center, retrospective trial, we investigated the decrease of PPG in 341 patients undergoing TIPS insertion for therapy of refractory or recurrent ascites until 2015. During each procedure, portal and inferior vena cava pressures were invasively measured and correlated with patients' outcome and ascites progression over time, according to the prespecified Noninvasive Evaluation Program for TIPS and Follow-Up Network protocol (NCT03628807).
Patients without ascites at 6 weeks after TIPS had significantly greater PPG reduction immediately after TIPS, compared to the patients with refractory ascites (median reduction 65% vs. 55% of pre-TIPS PPG; p = 0.001). Survival was significantly better if ascites was controlled, compared to patients with need for paracentesis 6 weeks after TIPS (median survival: 185 vs. 41 weeks; HR 2.0 [1.3-2.9]; p < 0.001). Therefore, higher PPG reduction by TIPS ( p = 0.005) and lower PPG after TIPS ( p = 0.02) correlated with resolution of severe ascites 6 weeks after TIPS. Multivariable analyses demonstrated that higher Child-Pugh score before TIPS (OR 1.3 [1.0-1.7]; p = 0.03) and lower serum sodium levels (OR 0.9 [0.9-1.0]; p = 0.004) were independently associated with ascites persistence 6 weeks after TIPS, whereas PPG reduction (OR 0.98 [0.97-1.00]; p = 0.02) was associated with resolution of ascites 6 weeks after TIPS.
Extent of PPG reduction and/or lowering of target PPG immediately after TIPS placement is associated with improved ascites control in the short term and with survival in the long term. A structured follow-up visit for patients should assess persistence of ascites at 6 weeks after TIPS.
腹水是由门静脉高压驱动的失代偿期肝硬化的明确体征。尽管经颈静脉肝内门体分流术（TIPS）适用于复发性和难治性腹水的治疗，但对于门静脉肝压梯度（PPG）降低的具体目标尚无循证推荐。
在这项单中心回顾性试验中，我们调查了截至2015年接受TIPS治疗难治性或复发性腹水的341例患者的PPG降低情况。在每次手术过程中，根据预先指定的TIPS无创评估计划和随访网络协议（NCT03628807），通过有创测量门静脉和下腔静脉压力，并将其与患者的预后及腹水随时间的进展情况相关联。
与难治性腹水患者相比，TIPS术后6周无腹水的患者在TIPS术后即刻PPG降低幅度明显更大（PPG降低中位数：术前PPG的65% 对55%；p = 0.001）。与TIPS术后6周仍需进行腹腔穿刺术的患者相比，腹水得到控制的患者生存率明显更高（中位生存期：185周对41周；风险比2.0 [1.3 - 2.9]；p < 0.001）。因此，TIPS术后PPG降低幅度更大（p = 0.005）以及TIPS术后PPG更低（p = 0.02）与TIPS术后6周严重腹水的消退相关。多变量分析表明，TIPS术前Child-Pugh评分更高（比值比1.3 [1.0 - 1.7]；p = 0.03）以及血清钠水平更低（比值比0.9 [0.9 - 1.0]；p = 0.004）与TIPS术后6周腹水持续存在独立相关，而PPG降低（比值比0.98 [0.97 - 1.00]；p = 0.02）与TIPS术后6周腹水消退相关。
TIPS术后即刻PPG降低的程度和/或目标PPG的降低与短期内腹水控制改善及长期生存率相关。应为患者安排结构化的随访，以评估TIPS术后6周腹水是否持续存在。
