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中华介入放射学电子杂志

中华介入放射学电子杂志 ›› 2022, Vol. 10 ›› Issue (01) : 50 -55. doi: 10.3877/cma.j.issn.2095-5782.2022.01.009

血管介入

经颈静脉肝内门腔分流术后肝功能随访及危险因素分析
谭卿1, 王江云1, 彭崎峰1, 刘芳1, 高一平1, 苏时钦1, 郭备1, 赵剑波1,†()   
  1. 1. 510515　广州，南方医科大学南方医院　普外科血管与介入专科
  • 收稿日期:2021-07-13 出版日期:2022-02-25
  • 通信作者: 赵剑波

Follow-up and risk factors analysis of liver function after transjugular intrahepatic portosystemic shunt

Qing Tan1, Jiangyun Wang1, Qifeng Peng1, Fang Liu1, Yiping Gao1, Shiqin Su1, Bei Guo1, Jianbo Zhao1,†()   

  1. 1. Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangdong Guangzhou 510515, China
  • Received:2021-07-13 Published:2022-02-25
  • Corresponding author: Jianbo Zhao
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谭卿, 王江云, 彭崎峰, 刘芳, 高一平, 苏时钦, 郭备, 赵剑波. 经颈静脉肝内门腔分流术后肝功能随访及危险因素分析[J/OL]. 中华介入放射学电子杂志, 2022, 10(01): 50-55.

Qing Tan, Jiangyun Wang, Qifeng Peng, Fang Liu, Yiping Gao, Shiqin Su, Bei Guo, Jianbo Zhao. Follow-up and risk factors analysis of liver function after transjugular intrahepatic portosystemic shunt[J/OL]. Chinese Journal of Interventional Radiology(Electronic Edition), 2022, 10(01): 50-55.

目的

观察经颈静脉肝内门腔分流术（TIPS）后患者肝功能的变化情况，以及TIPS术后肝损伤的危险因素分析。

方法

收集2017年4月至2019年8月南方医科大学南方医院收治的肝硬化合并门静脉高压患者198例，均成功实施TIPS，随访术后1、3、6、12、18和24个月的终末期肝病模型（MELD）评分以及Child-Pugh评分。采用非条件Logistic回归模型筛选出术后重度肝损伤的独立危险因素，绘制ROC曲线图形，计算AUC以判断各危险因素的预测效能。

结果

MELD评分从术后1个月开始显著升高（13.8 ± 3.9 vs 11.0 ± 3.4；P < 0.001），之后逐渐降低至术后1年又缓慢回升，但始终明显高于术前基线水平。Child-Pugh评分从术后6个月开始逐渐降低，在术后1年降至最低值（6.6 ± 1.3 vs 6.9 ± 1.4；P = 0.027），之后逐渐回升至术前基线水平。原发性肝癌、术前MELD评分以及术前Child-Pugh评分是TIPS术后1年重度肝损伤的独立危险因素（OR = 4.452，P = 0.012；OR = 1.320，P = 0.001；OR = 1.509，P = 0.033），术前MELD评分和Child-Pugh评分的cut-off值分别为13.5、7.5。

结论

TIPS因机械性损伤和肝内门腔分流，导致术后肝功能不同程度受损。原发性肝癌、术前MELD评分以及术前Child-Pugh评分是TIPS术后1年重度肝损伤的独立危险因素。

关键词: 经颈静脉肝内门腔分流术, 肝功能, 重度肝损伤, 危险因素
Objective

To investigate the changes of liver function after transjugular intrahepatic portosystemic shunt (TIPS), and to analyze the risk factors of liver injury after TIPS.

Methods

A total of198 patients with portal hypertension due to cirrhosis admitted to Nanfang Hospital of Southern Medical University from Apr. 2017 to Aug. 2019 were enrolled in this study, and received TIPS successfully. Model for end-stage liver disease (MELD) score and Child-Pugh score were followed up at 1, 3, 6, 12, 18 and 24 months after TIPS. Unconditional Logistic regression model was used to screen out the independent risk factors of postoperative severe liver injury. Receiver operating characteristic curve was plotted and the area under it was calculated to evaluate the diagnose performance.

Results

MELD score increased significantly from 1month after TIPS (13.8 ± 3.9 vs 11.0 ± 3.4; P < 0.001), then gradually decreased until 1 year after TIPS and slowly increased again, but it was always significantly higher than preoperative baseline level. Child-Pugh score gradually decreased from 6 months after TIPS, and reached the lowest value at 1 year after TIPS (6.6 ±1.3 vs 6.9 ± 1.4; P = 0.027), then slowly returned to preoperative baseline level. Liver cancer, preoperative MELD score and Child-Pugh score were independent risk factors for severe liver injury at 1 year after TIPS (OR = 4.452, P = 0.012; OR = 1.320, P = 0.001; OR = 1.509, P = 0.033), the cut-off values of preoperative MELD score and Child-Pugh score were 13.5 and 7.5, respectively.

Conclusions

Liver function after TIPS was impaired to varying degrees due to mechanical injury and intrahepatic portosystemic shunt. Liver cancer, preoperative MELD score and Child-Pugh score were independent risk factors for severe liver injury at 1 year after TIPS.

Key words: Transjugular intrahepatic portosystemic shunt, Liver function, Severe liver injury, Risk factors
表1 198例患者术前基线资料
指标 数值
年龄 51.6 ± 11.0
  ≤50岁 101（51.0%）
  > 50岁 097（49.0%）
性别  
  男性 148（74.7%）
  女性 050（25.3%）
病因  
  病毒性 140（70.7%）
  酒精性 016（8.1%）
  其他 042（21.2%）
术前症状  
  消化道出血 164（82.8%）
  顽固性腹水 034（17.2%）
原发性肝癌 021（10.6%）
术前PPG 23.3 ± 5.3
术后PPG 10.3 ± 3.6
PPG差值 13.0 ± 4.8
自发性分流 027（13.6%）
门静脉血栓 044（22.2%）
门静脉穿刺部位  
  左支 083（41.9%）
  右支 115（58.1%）
曲张静脉栓塞 158（79.8%）
血小板 89.4 ± 70.6
MELD评分 11.0 ± 3.4
Child-Pugh评分 7.1 ± 1.5
  A级 074（37.4%）
  B级 113（57.1%）
  C级 011（5.5%）
图1 TIPS术后随访MELD评分和Child-Pugh评分
表2 TIPS术后随访MELD评分和Child-Pugh评分
  MELD评分 Child-Pugh评分
均值±标准差 P值 均值±标准差 P值
术前 11.0 ± 3.4 < 0.001a 7.1 ± 1.5 0.717
术后1个月 13.8 ± 3.9 （n = 198） 7.1 ± 1.4 （n = 198）
术前 10.9 ± 3.3 < 0.001a 7.1 ± 1.5 1.000
术后3个月 13.5 ± 3.8 （n = 180） 7.1 ± 1.5 （n = 180）
术前 10.9 ± 3.2 < 0.001a 7.0 ± 1.5 0.211
术后6个月 13.1 ± 3.5 （n = 159） 6.9 ± 1.4 （n = 159）
术前 10.9 ± 3.1 < 0.001a 6.9 ± 1.4 0.027a
术后12个月 12.6 ± 3.5 （n = 135） 6.6 ± 1.3 （n = 135）
术前 10.7 ± 2.9 < 0.001a 6.9 ± 1.4 0.818
术后18个月 12.7 ± 3.1 （n = 74） 6.8 ± 1.4 （n = 74）
术前 10.8 ± 3.1 < 0.001a 6.7 ± 1.4 1.000
术后24个月 12.9 ± 4.0 （n = 50） 6.7 ± 1.5 （n = 50）
表3 TIPS术后1年重度肝损伤的危险因素分析
  单因素分析 多因素分析
P值 OR（95%CI） P值 OR（95%CI）
年龄        
  ≤50岁 NA      
  > 50岁 0.476 1.270（0.657~2.454）    
性别        
  男性 NA      
  女性 0.372 1.420（0.658~3.063）    
病因        
  病毒性 NA      
  酒精性 0.512 0.634（0.163~2.471）    
  其他 0.569 0.778（0.328~1.844）    
术前症状        
  消化道出血 NA NA    
  顽固性腹水 0.001a 4.157（1.819~9.499） 0.547 1.365（0.497~3.748）
原发性肝癌        
  否 NA NA    
  是 0.020a 3.389（1.210~9.487） 0.012a 4.452（1.382~14.340）
术前PPG 0.596 1.017（0.956~1.081）    
术后PPG 0.181 1.061（0.973~1.158）    
PPG差值 0.645 0.984（0.921~1.052）    
自发性分流        
  否 NA      
  是 0.127 0.413（0.132~1.287）    
门静脉血栓        
  否 NA      
  是 0.301 1.504（0.694~3.263）    
门静脉穿刺部位        
  左支 NA      
  右支 0.480 0.786（0.404~1.533）    
曲张静脉栓塞        
  否 NA      
  是 0.929 0.965（0.439~2.119）    
血小板 0.268 0.997（0.992~1.002）    
MELD评分 < 0.001a 1.482（1.282~1.714） 0.001a 1.320（1.116~1.561）
Child-Pugh评分 < 0.001a 2.186（1.626~2.940） 0.033a 1.509（1.035~2.200）
图2 TIPS术后1年重度肝损伤与术前MELD评分、术前Child-Pugh评分的ROC曲线
[1]
Boyer TD, Haskal ZJ. American Association for the Study of Liver Diseases practice guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension[J]. Journal of Vascular and Interventional Radiology, 2005, 16(5): 615-629.
[2]
Saugel B, Phillip V, Gaa J, et al. Advanced hemodynamic monitoring before and after transjugular intrahepatic portosystemic shunt: implications for selection of patients—a prospective study[J]. Radiology, 2012, 262(1): 343-352.
[3]
Rouillard , Smita S. Severe hyperbilirubinemia after creation of transjugular intrahepatic portosystemic shunts: natural history and predictors of outcome[J]. Annals of Internal Medicine, 1998, 128(5): 374-377.
[4]
Chalasani N, Clark WS, Martin LG, et al. Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting[J]. Gastroenterology, 2000, 118(1): 138-144.
[5]
Casadaban LC, Parvinian A, Couture PM, et al. Characterization of liver function parameter alterations after transjugular intrahepatic portosystemic shunt creation and association with early mortality[J]. AJR Am J Roentgenol, 2014, 203(6): 1363-1370.
[6]
Casadaban LC, Parvinian A, Minocha J, et al. Clearing the confusion over hepatic encephalopathy after TIPS creation: incidence, prognostic factors, and clinical outcomes[J]. Digestive Diseases&Sciences, 2015, 60(4): 1059-1066.
[7]
Gaba RC, Couture PM, Bui JT, et al. Prognostic capability of different liver disease scoring systems for prediction of early mortality after transjugular intrahepatic portosystemic shunt creation[J]. Journal of Vascular & Interventional Radiology, 2013, 24(3): 411-420.e4.
[8]
Routhu M, Safka V, Routhu SK, et al. Observational cohort study of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS)[J]. Annals of Hepatology, 2017, 16(1): 140-148.
[9]
Ferral H, Gamboa P, Postoak DW, et al. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score[J]. Radiology, 2004, 231(1): 231.
[10]
Lodato F, Berzigotti A, Lisotti A, et al. Transjugular intrahepatic portosystemic shunt placement for refractory ascites: a single-centre experience[J]. Scandinavian Journal of Gastroenterology, 2012, 47(12): 1494-1500.
[11]
Zipprich A. Hemodynamics in the isolated cirrhotic liver[J]. Journal of Clinical Gastroenterology, 2007, 41: 254-258.
[12]
Gaba RC, Lakhoo J. What constitutes liver failure after transjugular intrahepatic portosystemic shunt creation? A proposed definition and grading system[J]. Ann Hepatol, 2016, 15(2): 230-235.
[13]
童玉云, 王家平, 朱清亮, 等. 肝硬化门脉高压患者经颈静脉肝内门腔分流术后肝功能随访及疗效评估[J]. 介入放射学杂志, 2013(7): 540-544.
[14]
Radeleff B, Sommer CM, Heye T, et al. Acute increase in hepatic arterial flow during TIPS identified by intravascular flow measurements[J]. Cardiovasc Intervent Radiol, 2009, 32(1): 32-37.
[15]
杨拴元, 周密旺. TACE联合TIPS治疗肝癌并发门静脉高压的疗效及对肝功能的影响[J]. 检验医学与临床, 2020(15): 2182-2185.
[16]
Luca A, Miraglia R, Maruzzelli L, et al. Early liver failure after transjugular intrahepatic portosystemic shunt in patients with cirrhosis with model for end-stage liver disease score of 12 or less: incidence, outcome, and prognostic factors[J]. Radiology, 2016, 280(2): 622-629.
[17]
Reichert MC, Schulz A, Massmann A, et al. Predictive power of liver maximum function capacity test in transjugular intrahepatic portosystemic shunt patients: a pilot study[J]. Digestive Diseases, 2019, 38(3): 1-8.
[18]
Liu J, Ma J, Zhou C, et al. Potential benefits of underdilation of 8-mm covered stent in transjugular intrahepatic portosystemic shunt creation[J]. Clinical and Translational Gastroenterology, 2021, 12(6): e00376.
[19]
Praktiknjo M, Abu-Omar J, Chang J, et al. Controlled underdilation using novel VIATORR controlled expansion stents improves survival after transjugular intrahepatic portosystemic shunt implantation[J]. JHEP Reports, 2021, 3(3): 100264.
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