经颈静脉肝内门体分流术（TIPS）后确定控制腹水同时使肝性脑病（HE）风险降至最低的最佳门静脉压力降低值：一项多中心研究
Identification of optimal portal pressure decrease to control ascites while minimizing HE after TIPS: A multicenter study.
作者信息
Kabelitz Martin A, Hartl Lukas, Schaub Golda, Tiede Anja, Rieland Hannah, Kornfehl Andrea, Hübener Peter, Jachs Mathias, Hinrichs Jan, Schütte Sarah L, Riedel Christoph, Mauz Jim B, Tergast Tammo L, Meyer Bernhard C, Bannas Peter, Kappel Julia, Wedemeyer Heiner, Kluwe Johannes, Piecha Felix, Reiberger Thomas, Sandmann Lisa, Maasoumy Benjamin
机构信息
Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany.
Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
出版信息
Hepatology. 2025 Jan 3. doi: 10.1097/HEP.0000000000001219.
BACKGROUND AND AIMS
Clinically significant portal hypertension in patients with liver cirrhosis can lead to refractory ascites. A TIPS treats clinically significant portal hypertension but may cause overt hepatic encephalopathy (oHE). Our aim was to determine the optimal reduction of the portal pressure gradient (PPG) through TIPS to control ascites without raising oHE risk.
APPROACH AND RESULTS
This multicenter study screened 1509 patients from 3 European centers (Hannover, Vienna, and Hamburg) undergoing TIPS implantation between 2000 and 2023. Patients with TIPS indications other than refractory ascites/hepatic hydrothorax, vascular liver disease, HCC, or insufficient PPG data were excluded. PPG was measured before and after TIPS insertion. Outcome data were assessed up to 1 year after TIPS insertion. Analyses were conducted utilizing a modern machine learning model, namely a competing-risk random survival forest, partial dependence plots, and competing risk analyses with liver transplantation/death as competitors. The cohort was divided into a 60% derivation and 40% validation cohort. Overall, 729 patients (median MELD: 13 [IQR 10-16], 66% male, 23% oHE before TIPS) were analyzed. The derivation cohort comprised 438 patients, and the validation cohort comprised 291 patients. The optimal PPG reduction, determined by maximally selected Gray statistic and PDP of the random survival forest, was 60%-80%. In this range, patients showed significantly fewer hepatic decompensations due to ascites (HDA) (subdistribution hazard ratio [sHR]: 0.7 [0.52-0.96]) with similar oHE incidences (sHR: 0.92 [0.67-1.27]). The PPG range was confirmed in the validation cohort (HDA: sHR: 0.66 [0.46-0.96]; oHE: sHR: 0.89 [0.61-1.32]).
CONCLUSIONS
A targeted PPG reduction of 60%-80% showed significantly reduced HDA without increased oHE risk. Therefore, PPG reduction within this range could be a valid reduction target.
背景与目的
肝硬化患者临床上显著的门静脉高压可导致顽固性腹水。经颈静脉肝内门体分流术（TIPS）可治疗临床上显著的门静脉高压，但可能会引起明显肝性脑病（oHE）。我们的目的是确定通过TIPS降低门静脉压力梯度（PPG）的最佳幅度，以控制腹水且不增加oHE风险。
方法与结果
这项多中心研究筛选了2000年至2023年间在3个欧洲中心（汉诺威、维也纳和汉堡）接受TIPS植入的1509例患者。排除有顽固性腹水/肝性胸水、肝脏血管疾病、肝癌等TIPS适应症以外的患者，以及PPG数据不足的患者。在TIPS植入前后测量PPG。在TIPS植入后长达1年的时间里评估结局数据。采用现代机器学习模型进行分析，即竞争风险随机生存森林模型、偏倚依赖图以及以肝移植/死亡作为竞争风险的竞争风险分析。将队列分为60%的推导队列和40%的验证队列。总体而言，分析了729例患者（中位终末期肝病模型评分[MELD]：13[四分位间距10 - 16]，66%为男性，23%在TIPS术前有oHE）。推导队列包括438例患者，验证队列包括291例患者。通过随机生存森林模型的最大选择Gray统计量和PDP确定的最佳PPG降低幅度为60% - 80%。在此范围内，患者因腹水导致的肝脏失代偿（HDA）显著减少（亚分布风险比[sHR]：0.7[0.52 - 0.96]），而oHE发生率相似（sHR：0.92[0.67 - 1.27]）。在验证队列中也证实了该PPG范围（HDA：sHR：0.66[0.46 - 0.96]；oHE：sHR：0.89[0.61 - 1.32]）。
结论
将PPG有针对性地降低60% - 80%可显著减少HDA，且不增加oHE风险。因此，在此范围内降低PPG可能是一个有效的降低目标。
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