Predictors of early mortality post transjugular intrahepatic portosystemic shunts and the role of hepatic venous pressure gradient

BackgroundThis study was conducted to identify factors associated with early mortality (30-day, 60-day) among patients with cirrhosis and portal hypertension who undergo transjugular intrahepatic portosystemic shunts (TIPS).MethodsConsecutive patients who underwent TIPS between January 1993 and December 2008 were included in the study. Clinical, laboratory, and procedural data were collected for all patients by retrospective chart review. Qualitative variables were compared by chi square test and quantitative variables by Student's t-test. Multinomial logistic regression was used for multivariate analysis.ResultsA total of 643 patients had complete data and were included in the study. The incidence of 30-day mortality in the study group was 17.4% (112/643), and the incidence of 60-day mortality was 22.6% (145/643). Univariate analysis was carried out comparing these risk factors in patients stratified by 30-day and 60-day mortality. On univariate analysis, pre-TIPS bilirubin >2.0 mg, pre-TIPS albumin <2.5 gm/dL, pre-TIPS international normalized ratio >2, pre-TIPS creatinine >2.0, pre-TIPS MELD (Model for End-stage Liver Disease) score >20, pre-TIPS hepatic venous pressure gradient (HVPG) >20 mmHg, higher pre-TIPS alanine transaminase, and higher pre-TIPS aspartate transaminase were found to be predictors of both 30- and 60-day mortality. Multivariate analysis showed pre-TIPS creatinine >2 mg/dL, pre-TIPS MELD levels >20 and HVPG (hepatic venous portal gradient) >20 mmHg to be independent and significant predictors of both 30- and 60-day mortality. For every 1 mg/dL rise of creatinine exceeding 2 mg/dL, the odds of 30-day mortality increased by 80% [odds ratio = 1.8 (1.3–2.4)]. A pre-TIPS HVPG of more than 20 mmHg was found to be correlated with worsened 30-day and 60-day mortality in patients with variceal bleed but not in patients with ascites or hydrothorax.ConclusionStepwise model selection determined that serum creatinine >2.0 mg/dL, MELD >20, and pre-TIPS HVPG >20 mmHg were independent predictors of early mortality. A pre-TIPS HVPG of more than 20 mmHg was found to be correlated with worsened 30-day and 60-day mortality in patients with variceal bleed but not in patients with ascites or hydrothorax.