Early Occurrence of Hepatic Encephalopathy Following Transjugular Intrahepatic Portosystemic Shunt Insertion is Linked to Impaired Survival: A Multicenter Cohort Study

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BACKGROUND & AIMS: Hepatic encephalopathy (HE) is a common complication following transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, the prognostic significance of overt HE post-TIPS remains controversial. METHODS: We screened 2137 patients who underwent TIPS insertion at 8 German tertiary care centers between 2004 and 2021. Patients with pre-emptive TIPS placement, hepatocellular carcinoma, missing data, and non-PTFE covered stents were excluded. Competing risk analysis was performed, considering liver transplantation as a competing event. To correct for immortal time bias, landmark analyses were conducted, with the landmark being set at 30 and 90 days post-TIPS. Outcome data were assessed for up to 30 months post-TIPS insertion. RESULTS: A total of 1356 patients (median Model for End-stage Liver Disease [MELD], 13 [interquartile range (IQR), 10-17]; age, 60 years [IQR, 54-67 years]; 64% male; 12% HE before TIPS), were included. Overall, HE post-TIPS was linked to impaired survival (P < .001; subdistribution hazard ratio [sHR], 1.41; 95% confidence interval [CI],1.15-1.73). However, this was only confirmed if HE occurred within the first 30 days post-TIPS (early HE; P < .001; sHR, 2.02; 95% CI, 1.59-2.57). Additionally, patients with a history of HE (P < .001; sHR, 1.59; 95% CI, 1.21-2.07) and history of HE and early HE post-TIPS (P < .001; sHR, 3.44; 95% CI, 2.34-5.04) showed impaired survival. These findings were confirmed in the landmark and multivariable analyses. CONCLUSIONS: Early HE post-TIPS is associated with significantly reduced survival. Therefore, patients who experience early HE or have a history of HE should be closely monitored by physicians, as they constitute a particularly vulnerable group with impaired survival.