The combination of Child-Pugh score and quantitative CT-based spleen volume could predict the risk of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation

Machine learning prediction of hepatic encephalopathy for long-term survival after transjugular intrahepatic portosystemic shunt in acute variceal bleeding

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for managing complications of portal hypertension, particularly acute variceal bleeding (AVB). While effective in reducing portal pressure and preventing rebleeding, TIPS is associated with a considerable risk of overt hepatic encephalopathy (OHE), a complication that significantly elevates mortality rates.

AIM

To develop a machine learning (ML) model to predict OHE occurrence post-TIPS in patients with AVB using a 5-year dataset.

METHODS

This retrospective single-center study included 218 patients with AVB who underwent TIPS. The dataset was divided into training (70%) and testing (30%) sets. Critical features were identified using embedded methods and recursive feature elimination. Three ML algorithms-random forest, extreme gradient boosting, and logistic regression-were validated via 10-fold cross-validation. SHapley Additive exPlanations analysis was employed to interpret the model's predictions. Survival analysis was conducted using Kaplan-Meier curves and stepwise Cox regression analysis to compare overall survival (OS) between patients with and without OHE.

RESULTS

The median OS of the study cohort was 47.83 ± 22.95 months. Among the models evaluated, logistic regression demonstrated the highest performance with an area under the curve (AUC) of 0.825. Key predictors identified were Child-Pugh score, age, and portal vein thrombosis. Kaplan-Meier analysis revealed that patients without OHE had a significantly longer OS (P = 0.005). The 5-year survival rate was 78.4%, with an OHE incidence of 15.1%. Both actual OHE status and predicted OHE value were significant predictors in each Cox model, with model-predicted OHE achieving an AUC of 88.1 in survival prediction.

CONCLUSION

The ML model accurately predicts post-TIPS OHE and outperforms traditional models, supporting its use in improving outcomes in patients with AVB.

Hepatic encephalopathy post-TIPS: Current status and prospects in predictive assessment

Transjugular intrahepatic portosystemic shunt (TIPS) is an essential procedure for the treatment of portal hypertension but can result in hepatic encephalopathy (HE), a serious complication that worsens patient outcomes. Investigating predictors of HE after TIPS is essential to improve prognosis. This review analyzes risk factors and compares predictive models, weighing traditional scores such as Child-Pugh, Model for End-Stage Liver Disease (MELD), and albumin-bilirubin (ALBI) against emerging artificial intelligence (AI) techniques. While traditional scores provide initial insights into HE risk, they have limitations in dealing with clinical complexity. Advances in machine learning (ML), particularly when integrated with imaging and clinical data, offer refined assessments. These innovations suggest the potential for AI to significantly improve the prediction of post-TIPS HE. The study provides clinicians with a comprehensive overview of current prediction methods, while advocating for the integration of AI to increase the accuracy of post-TIPS HE assessments. By harnessing the power of AI, clinicians can better manage the risks associated with TIPS and tailor interventions to individual patient needs. Future research should therefore prioritize the development of advanced AI frameworks that can assimilate diverse data streams to support clinical decision-making. The goal is not only to more accurately predict HE, but also to improve overall patient care and quality of life.

Optic nerve sheath diameters predict mortality and severity in hepatic encephalopathy

OBJECTIVE

The aim of this study was to compare the predictive power of optic nerve sheath diameter (ONSD) measured by brain computed tomography (CT) in patients diagnosed with hepatic encephalopathy (HE) in the emergency department, with other factors for mortality and disease severity.

MATERIALS AND METHODS

A total of 217 patients aged 18 years and older with acute decompensation of cirrhosis diagnosed with HE in the emergency department were included in the study. To compare with patients diagnosed with HE, a total of 217 individuals were included in the study as the healthy control group. ONSD measurements were performed on both the HE patients and the healthy control group in the brain CT.

RESULTS

The mortality rate of HE patients was 32.7%. Regarding the severity of the disease, 53% of the patients had late-stage HE. The presence of acute-on-chronic liver failure was detected in 51.4% of patients. The mortality rate among acute-on-chronic liver failure patients was 56.6%. According to the study data, ONSD, creatinine, lactate, and procalcitonin were independent predictors of mortality. Meanwhile, Child-Pugh score, direct bilirubin, ONSD, ammonia, and total bilirubin were independent predictors of disease severity. In the receiver operating characteristic curve analysis, the ONSD had the highest predictive power for mortality and disease severity among the determined predictive values.

CONCLUSION

The data from the study suggests that assessing the ONSD through brain CT scans in individuals diagnosed with HE in the emergency department may provide valuable insights for clinicians, aiding in the prediction of both mortality rates and the severity of the disease.

The impact of hepatic and splenic volumetric assessment in imaging for chronic liver disease: a narrative review

Chronic liver disease is responsible for significant morbidity and mortality worldwide. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) can fully visualise the liver and adjacent structures in the upper abdomen providing a reproducible assessment of the liver and biliary system and can detect features of portal hypertension. Subjective interpretation of CT and MRI in the assessment of liver parenchyma for early and advanced stages of fibrosis (pre-cirrhosis), as well as severity of portal hypertension, is limited. Quantitative and reproducible measurements of hepatic and splenic volumes have been shown to correlate with fibrosis staging, clinical outcomes, and mortality. In this review, we will explore the role of volumetric measurements in relation to diagnosis, assessment of severity and prediction of outcomes in chronic liver disease patients. We conclude that volumetric analysis of the liver and spleen can provide important information in such patients, has the potential to stratify patients' stage of hepatic fibrosis and disease severity, and can provide critical prognostic information. CRITICAL RELEVANCE STATEMENT: This review highlights the role of volumetric measurements of the liver and spleen using CT and MRI in relation to diagnosis, assessment of severity, and prediction of outcomes in chronic liver disease patients. KEY POINTS: Volumetry of the liver and spleen using CT and MRI correlates with hepatic fibrosis stages and cirrhosis. Volumetric measurements correlate with chronic liver disease outcomes. Fully automated methods for volumetry are required for implementation into routine clinical practice.

Prediction of mortality and overt hepatic encephalopathy undergoing transjugular intrahepatic portosystemic shunt: a retrospective cohort study

PURPOSE

Data on medium- and long-term efficacy and safety of Transjugular intrahepatic portosystemic shunt (TIPS) using Viatorr stents in Chinese patients are limited. This study aimed to evaluate the 5-year mortality and the incidence of overt hepatic encephalopathy (OHE) after Viatorr stent insertion, and construct a model to predict post-TIPS OHE preoperatively.

METHODS

One hundred thirty-two patients undergoing Viatorr stent insertion in our institution between August 2016 and December 2019 were included, and randomly divided into training and validation cohort at a 70/30 ratio. Patients were followed up until death or the end date of follow-up (December 31st, 2021). The primary end point was all-cause mortality, and the secondary end points were OHE, variceal rebleeding, recurrent ascites and shunt dysfunction.

RESULTS

The 1-, 2-, 3-, 4- and 5-year cumulative survival rates were 92.4%, 87.9%, 85.3%, 80.2% and 80.2%, respectively. Post-TIPS OHE and Child-Pugh grade were independent prognostic factors. The rates of variceal rebleeding, recurrent ascites, shunt dysfunction and post-TIPS OHE were 9.1%, 14.3%, 5.3% and 28.0%, respectively. The variables of nomogram predicting post-TIPS OHE included age, diabetes and ascites grade. The area under time-dependent receiver operation characteristic (ROC) curve (AUC) in training and validation cohort were 0.806 and 0.751, respectively. The decision curve analysis (DCA) showed good net benefit both in training and validation cohort.

CONCLUSION

Post-TIPS OHE and Child-Pugh grade are independent prognostic factors for early mortality in cirrhosis patients, thus we construct a simple and convenient prediction model for post-TIPS OHE to identify high-risk patients preoperatively.

A nomogram for predicting prognosis in patients with transjugular intrahepatic portosystemic shunt creation based on deep learning-derived spleen volume-to-platelet ratio

OBJECTIVES

The objective of our study was to develop a nomogram to predict post-transjugular intrahepatic portosystemic shunt (TIPS) survival in patients with cirrhosis based on CT images.

METHODS

This retrospective cohort study included patients who had received TIPS operation at the Wenzhou Medical University First Affiliated Hospital between November 2013 and April 2017. To predict prognosis, a nomogram and Web-based probability were developed to assess the overall survival (OS) rates at 1, 3, and 5 years based on multivariate analyses. With deep learning algorithm, the automated measurement of liver and spleen volumes can be realized. We assessed the predictive accuracy and discriminative ability of the nomogram using the concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

RESULTS

Age, total bilirubin, and spleen volume-to-platelet ratio (SVPR) were identified as the independent risk factors for OS. The nomogram was constructed based on the above risk factors. The C-index (0.80, 0.74, 0.70), ROC curve (area under curve: 0.828, 0.761, 0.729), calibration curve, and DCA showed that nomogram good at predictive value, stability, and clinical benefit in the prediction of 1-, 3-, 5-year OS in patients with TIPS creation.

CONCLUSIONS

We constructed a nomogram for predicting prognosis in patients with TIPS creation based on risk factors. The nomogram can help clinicians in identifying patients with poor prognosis, eventually facilitating earlier treatment and selecting suitable patients before TIPS.

ADVANCES IN KNOWLEDGE

This study developed the first nomogram based on SVPR to predict the prognosis of patients treated with TIPS. The nomogram could help clinician in non-invasive decision-making.

Pre-existing Hepatic Encephalopathy: Really a Contraindication to Elective TIPS?

PURPOSE

To evaluate the impact of pre-transjugular intrahepatic portosystemic shunt (TIPS) hepatic encephalopathy (HE) on developing post-TIPS HE.

MATERIALS AND METHODS

In this retrospective, single center observational study, all patients who underwent successful TIPS placement between January 2005 and May 2020 with data pertaining to HE in their chart were included. Patient demographics and procedural details were recorded. Clinical outcomes post-TIPS, were collected and compared across patients with and without pre-TIPS HE.

RESULTS

Of 326 included patients, 159 (159/326, 48.8%) had a history of pre-TIPS HE. In total those without a history of HE were more likely to develop HE during follow up (136 (136/167, 81.4%) vs 107 (107/159, 67.3%), p = 0.001). When evaluating for predictors of developing HE within 3 months of TIPS placement, no significant variables were found on logistic regression, including prior history of HE (HR 1.16 (95% CI 0.73-1.84), p = 0.529). Univariate and multivariate regression analysis, however, showed that a history of HE was predictive of developing HE at any point in the follow-up period (p = 0.002 and p = 0.008, respectively). However, on Kaplan-Meier analysis no significant difference in the development of HE (p = 0.574) or hospital admission for HE (p = 0.554) post-TIPS was seen between patients with and without pre-TIPS HE. Additionally, there was no difference in 3-month survival (p = 0.412) or overall survival post-TIPS survival (p = 0.798).

CONCLUSION

Pre-TIPS HE did not predict the development of HE within 3 months of TIPS. Outcomes such as hospital admission and survivability were not different between patients with and without prior HE.

Transjugular intrahepatic portosystemic shunt in patients with autoimmune hepatitis-induced cirrhosis and variceal bleeding

BACKGROUND AND AIM

An increasing number of patients with autoimmune hepatitis (AIH)-induced cirrhosis and variceal bleeding are currently referred for transjugular intrahepatic portosystemic shunt (TIPS). The aim of this study was to evaluate the safety and efficacy of TIPS in such patients, and to compare these results with data from patients with hepatitis B virus (HBV)-induced cirrhosis.

MATERIALS AND METHODS

This retrospective study consisted of 211 patients between August 2016 and May 2021, and patients were allocated to AIH (n = 35) and HBV (n = 176) groups according to the etiology of the cirrhosis. The primary endpoint was mortality after TIPS use; the secondary endpoints were recurrent bleeding, overt hepatic encephalopathy (OHE), shunt dysfunction, and dynamic changes in liver function over time.

RESULTS

During a median follow-up period of 27 months, 23 (10.9%) patients died, 22 (10.4%) experienced recurrent bleeding, 50 (23.7%) experienced OHE, and 25 (11.8%) developed shunt dysfunction. Compared with the HBV group, the AIH group exhibited a similar mortality risk (adjusted hazard ratio, HR 1.199; 95% confidence interval, CI 0.367-3.917; p = 0.764), OHE (adjusted HR 1.023, 95% CI 0.483-2.167, p = 0.954), and shunt dysfunction (adjusted HR 0.862, 95% CI 0.285-2.610, p = 0.792); but a higher risk of recurrent bleeding (adjusted HR 2.731, 95% CI 1.112-6.708, p = 0.028). The dynamic changes in liver function manifested an initial trend toward deterioration, and then subsequent recovery in both the AIH and HBV groups.

CONCLUSIONS

TIPS is a safe and effective treatment, and should be considered for those patients with AIH-induced cirrhosis and variceal bleeding.

Development and Validation of Prognostic Models to Estimate the Risk of Overt Hepatic Encephalopathy After TIPS Creation: A Multicenter Study

INTRODUCTION

Overt hepatic encephalopathy (HE) is a major complication of transjugular intrahepatic portosystemic shunt (TIPS). This study aimed to develop and validate prognostic models to identify patients at different risks of overt HE within 3 months after TIPS.

METHODS

Two cohorts of patients with cirrhosis undergoing TIPS insertion were retrospectively included. In the derivation cohort of 276 patients, 3 models were established in increasing order of complexity: core model (age + Child-Pugh class), sarcopenia model (core model + sarcopenia), and full model (sarcopenia model + post-TIPS portal pressure gradient). All models were internally validated for discrimination and calibration and externally validated in an independent cohort of 182 patients.

RESULTS

During a 3-month follow-up period, 61 (22.1%) and 33 patients (18.1%) developed overt HE in the derivation and validation cohort, and sarcopenia was associated with increased risk of the outcome. In the derivation cohort, the core model showed a c-statistic of 0.68 (95% confidence interval [CI] 0.61-0.75), and discrimination improved in the sarcopenia model (c-statistic 0.73; 95% CI 0.66-0.80). The full model that extended the core model with inclusion of sarcopenia and post-TIPS portal pressure gradient showed a significant improvement in discriminative ability (0.77; 95% CI 0.71-0.83; P = 0.001). Both sarcopenia and full model yielded comparable performances in the validation cohort.

DISCUSSION

We developed and externally validated 2 prediction models applied before (sarcopenia model) and after TIPS (full model) to estimate the risk of post-TIPS overt HE. These tools could aid to select appropriate candidates for TIPS and guide postoperative management.

Prediction and Risk Factors for Prognosis of Cirrhotic Patients with Hepatic Encephalopathy

BACKGROUND AND AIMS

Hepatic encephalopathy (HE) is characterized by recurrence and poor quality of life. Acute-on-chronic liver failure (ACLF) mainly occurs in patients with chronic liver diseases and often presents with HE. Several predictive models have been proposed to predict the outcomes of these patients. Our study is aimed at identifying associated risk factors and the prognostic accuracies of predictive models in HE patients with or without ACLF.

METHODS

Patients with liver cirrhosis were retrospectively enrolled. Risk factors were evaluated by multivariate regression analyses. The predictive capabilities of models were calculated using the receiver operating characteristic (ROC) curve analyses and compared by the DeLong tests. Outcomes were defined as in-hospital mortality, HE severity, and ACLF occurrence.

RESULTS

In multivariate regression analyses, serum biomarkers neutrophil and total bilirubin (TBIL) were independently correlated with in-hospital death. Alanine aminotransferase (ALT) and blood urea nitrogen (BUN) were independent serum biomarkers associated with HE severity. Hemoglobin, TBIL, BUN, and international normalized ratio (INR) were significant indicators associated with ACLF incidence. For prediction of in-hospital mortality, Child-Pugh was superior to the others in the whole patients, while NLR showed the best capability in the ACLF group.

CONCLUSION

In cirrhotic patients present with HE, BUN is a risk factor associated with HE severity and ACLF incidence. Child-Pugh and NLR scores may be effective prognosticators in patients with HE.