Jalan R, Elton R A, Redhead D N, Finlayson N D, Hayes P C
Department of Medicine, Royal Infirmary of Edinburgh, Scotland, UK.
J Hepatol. 1995 Aug;23(2):123-8. doi: 10.1016/0168-8278(95)80325-4.
BACKGROUND/AIMS: The aim of this study was to analyse prognostic variables predicting mortality, shunt insufficiency, variceal rebleeding and encephalopathy following transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage.
Sixty-eight patients with cirrhosis who successfully underwent transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage were studied. Mean age was 54.8 years (s.e. 1.5); 41 were males and 27 were females. Mean Child score was 8.3 (s.e. 0.3). Cirrhosis was alcohol related in 47. The patients have been followed up for a mean of 10.8 (s.e. 1.1) months. The univariate association between 30 prognostic variables and post-treatment encephalopathy was tested by the Chi-squared or Wilcoxon rank-sum tests and multiple logistic regression was used to test the significance of factors adjusted for one another. Cox's proportional hazard regression was used to test the univariate and multivariate significance of the other three outcomes.
Transjugular intrahepatic portosystemic stent-shunt was performed successfully in 89.5% of patients. Twenty-two patients have died and eight have been transplanted. Fourteen patients died within 30 days of transjugular intrahepatic portosystemic stent-shunt and death was predicted independently by hyponatraemia (p < 0.001) and by severe liver disease (Child C, p < 0.001). Eight patients died during follow up and survival in the long term was predicted independently by the presence of encephalopathy (p < 0.001) prior to transjugular intrahepatic portosystemic stent-shunt (p < 0.001). Shunt insufficiency was predicted by an initial portal pressure gradient of greater than 18 mmHg (p < 0.01). None of the variables analysed predicted variceal rebleeding. Encephalopathy following transjugular intrahepatic portosystemic stent-shunt was only predicted indepedently by its presence prior to transjugular intrahepatic portosystemic stent-shunt (p < 0.001).
The results of this study suggest that patients with severe liver disease and hyponatraemia are liable to die early, and the presence of encephalopathy prior to transjugular intrahepatic portosystemic stent-shunt independently determines long-term survival. Patients in these groups should be considered high risk and worked up for orthotopic liver transplantation early. Shunt function in patients with an initial portal pressure gradient of > 18 mmHg requires close supervision. Encephalopathic patients should have smaller shunts and prophylactic measures to prevent worsening encephalopathy.
背景/目的：本研究旨在分析经颈静脉肝内门体分流术（TIPS）治疗静脉曲张出血后预测死亡率、分流功能不全、静脉曲张再出血和肝性脑病的预后变量。
对68例成功接受TIPS治疗静脉曲张出血的肝硬化患者进行研究。平均年龄为54.8岁（标准误1.5）；男性41例，女性27例。平均Child评分8.3（标准误0.3）。47例肝硬化与酒精有关。患者平均随访10.8（标准误1.1）个月。采用卡方检验或Wilcoxon秩和检验对30个预后变量与治疗后肝性脑病之间的单变量关联进行检验，并采用多元逻辑回归检验相互调整因素的显著性。采用Cox比例风险回归检验其他三个结局的单变量和多变量显著性。
89.5%的患者成功进行了TIPS。22例患者死亡，8例患者接受了肝移植。14例患者在TIPS术后30天内死亡，低钠血症（p<0.001）和严重肝病（Child C级，p<0.001）可独立预测死亡。8例患者在随访期间死亡，TIPS术前存在肝性脑病（p<0.001）可独立预测长期生存（p<0.001）。初始门静脉压力梯度大于18 mmHg可预测分流功能不全（p<0.01）。分析的变量均不能预测静脉曲张再出血。TIPS术后肝性脑病仅由TIPS术前存在肝性脑病独立预测（p<0.001）。
本研究结果表明，严重肝病和低钠血症患者易早期死亡，TIPS术前存在肝性脑病可独立决定长期生存。这些组别的患者应被视为高危患者，并尽早进行原位肝移植评估。初始门静脉压力梯度>18 mmHg的患者的分流功能需要密切监测。肝性脑病患者应采用较小的分流，并采取预防措施以防止肝性脑病恶化。
