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Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy


Full title

Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis



Michael Praktiknjo, Macarena Simón-Talero, Julia Römer, Davide Roccarina, Javier Martínez, Katharina Lampichler, Anna Baiges, Gavin Low, Elba Llop, Martin H. Maurer, Alexander Zipprich, Michela Triolo, Geert Maleux, Annette Dam Fialla, Claus Dam, Judit Vidal-González, Avik Majumdar, Carmen Picón, Daniel Toth, Anna Darnell, Juan G. Abraldes, Marta López, Christian Jansen, Johannes Chang, Robert Schierwagen, Frank Uschner, Guido Kukuk, Carsten Meyer, Daniel Thomas, Karsten Wolter, Christian P. Strassburg, Wim Laleman, Vincenzo La Mura, Cristina Ripoll, Annalisa Berzigotti, José Luis Calleja, Puneeta Tandon, Virginia Hernandez-Gea, Thomas Reiberger, Agustín Albillos, Emmanuel A. Tsochatzis, Aleksander Krag, Joan Genescà, Jonel Trebicka, Sergi Quiroga, Dominic Yu, Luis Téllez, Mattias Mandorfer, Juan Carlos Garcia-Pagan, Claudia Berbel, José Ferrusquia, Michel Ble, Mari Angeles Garcia-Criado, Ernest Belmonte, Michael Ney, Cristina Margini, Stefania Casu, Giuseppe Murgia, Christiane Ludwig, Franz Stangl



Background & Aims
Spontaneous portosystemic shunts (SPSS) frequently develop in liver cirrhosis. Recent data suggested that the presence of a single large SPSS is associated with complications, especially overt hepatic encephalopathy (oHE). However, the presence of >1 SPSS is common. This study evaluates the impact of total cross-sectional SPSS area (TSA) on outcomes in patients with liver cirrhosis.
In this retrospective international multicentric study, CT scans of 908 cirrhotic patients with SPSS were evaluated for TSA. Clinical and laboratory data were recorded. Each detected SPSS radius was measured and TSA calculated. One-year survival was the primary endpoint and acute decompensation (oHE, variceal bleeding, ascites) was the secondary endpoint.
A total of 301 patients (169 male) were included in the training cohort. Thirty percent of all patients presented with >1 SPSS. A TSA cut-off of 83 mm 2 was used to classify patients with small or large TSA (S-/L-TSA). Patients with L-TSA presented with higher model for end-stage liver disease score (11 vs. 14) and more commonly had a history of oHE (12% vs. 21%, p < 0.05). During follow-up, patients with L-TSA experienced more oHE episodes (33% vs. 47%, p < 0.05) and had lower 1-year survival than those with S-TSA (84% vs. 69%, p < 0.001). Multivariate analysis identified L-TSA (hazard ratio 1.66; 95% CI 1.02–2.70, p < 0.05) as an independent predictor of mortality. An independent multicentric validation cohort of 607 patients confirmed that patients with L-TSA had lower 1-year survival (77% vs. 64%, p < 0.001) and more oHE development (35% vs. 49%, p < 0.001) than those with S-TSA.
This study suggests that TSA >83 mm 2 increases the risk for oHE and mortality in patients with cirrhosis. Our results support the clinical use of TSA/SPSS for risk stratification and decision-making in the management of patients with cirrhosis.
Lay summary

The prevalence of spontaneous portosystemic shunts (SPSS) is higher in patients with more advanced chronic liver disease. The presence of more than 1 SPSS is common in advanced chronic liver disease and is associated with the development of hepatic encephalopathy. This study shows that total cross-sectional SPSS area (rather than diameter of the single largest SPSS) predicts survival in patients with advanced chronic liver disease. Our results support the clinical use of total cross-sectional SPSS area for risk stratification and decision-making in the management of SPSS.


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