Clinical effects and prognostic factors of transjugular intrahepatic portosystemic shunt in the treatment of refractory ascites

Abstract:

Objective：To investigate clinical efficacy and prognostic factors of transjugular intrahepatic portosystemic shunt（TIPS） in the treatment of patients with refractory ascites. Methods：Totally 23 patients with consecutive postoperative refractory ascites were followed up for an average of 9.7 months（range from 1-26 month），and the remission of ascites，serum parameters（platelet，albumin，total bilirubin，creatinine，prothrombin time，etal），survival rate were observed. Paired t test and nonparametric test were used to ana－lyze the changes in clinical serological indexes before and after TIPS. The survival rate was calculated by Kaplan-Merier method. The preoperative risk factors were used to predict the therapy effect of ascites in three months by logistic regression analysis. Multiple factors COX regression was used to analyze the influence of preoperative risk factors on postoperative survival. ROC and AUC determined the best prediction value. Results：The ascites of patients during the first year after operation improved than those of pre-operation. The ascites of 19 patient（82.6%） were effectively controlled one month after operation. Thirteen patients（52.4%） and 23 patients（100%） had a small amount of ascites after 3 month and 6 month respectively. The hepatic functions were damaged in a short time about one week after TIPS，but gradually recoverd within the next month（prothrombin time prolonged，Z=-2.419，P=0.016，median（minimum，maximum）=19.6（14.0，28.7）；Child-Pugh scores increased，t=-2.714，P=0.013，x±s=9.87±1.71；total bilirubin rised，Z=-3.711，P=0.000，median（minimun，maximun）=37.0（13.2，204.3））. The 3 months，6 months and 1 year cumulative survival rate were 95.5%，85.9% and 78.1% respectively. COX regression analysis showed that serum bilirubin（P=0.007，HR=1.049，95%CI=1.012-1.086） and sodium levels（P=0.027，HR=0.677，95%CI=0.479-0.956） were independent risk factors associated with survival rate by using multi－variate analysis. According to ROC and AUC analysis，we selected the cut-off values of 37 μmol/L for serum bilirubin level（AUC=0.676，sensitivity=66.7%，specificity=94.1%，95%CI=0.335-1.000）. In addition，Kaplan-Meier survival analysis demonstrated that the one year cumulative survival in patients with serum bilirubin level <37 μmol/L was 92.3% as compared to 25% in patients with serum bilirubin level ≥37 μmol/L. Conclusion：TIPS is an effective programme of treatment for refractory ascites. The hepatic functions will be damaged in a short term after TIPS. The serum bilirubin level above 37 μmol/L is a prognostic factor of one year cumulative sur－vival in patients with cirrhosis and refractory ascites treated with TIPS，and which should be clinical basis for a judgment of prognosis.