Proton Pump Inhibitor Use Is Associated with an Increased Frequency of New or Worsening Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation

Clinical question
Does proton pump inhibitor (PPI) use increase the rate of new or worsening hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) creation?

Take-away point
PPI usage is associated with new or worsening HE after TIPS.

Reference
Lewis, Douglas S., et al. Proton Pump Inhibitor Use is Associated with an Increased Frequency of New or Worsening Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation. Journal of Vascular and Interventional Radiology. February, 2019. Volume 30, Issue 2, 163-169.

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Study design: Retrospective

Funding source: Self-funded or unfunded

Setting: Single institution

Summary

HE after TIPS remains a common and challenging problem and can result in significant quality of life issues for patients’ refractory to medical therapy.

This retrospective review identified 284 patients who had undergone TIPS over a 1 year period, with a median follow-up time of 479 days. PPI types and dosage, in addition to dates of use were noted through review of the electronic medical record. Dates of new or worsening HE after TIPS were also identified. Mixed-effects negative binomial regression was used to test for an association between PPI usage and HE. The authors reported that, among the 284 patients analyzed in this study, there were 375 episodes of new or worsening HE, for an average of 1.32 episodes per person. Among 168 patients on PPIs chronically, there were 235 episodes of new or worsening HE in 106,101 person-days (0.81 episodes per person-year), 55 patients who were never on PPIs had 37 episodes (0.43/person-year), 61 patients intermittently on PPIs had 78 episodes (0.75/person-year), and 16 patients who never took PPIs had 25 episodes (0.26/person-year). Uni- and multivariate regression were performed. PPI usage was associated with a 3.34-fold increase in the rate of new or worsening HE and increasing age, higher MELD score, and history of HE or HE-preventative medication therapy before TIPS were also associated with increased HE after TIPS.

Commentary

This study showed that PPI usage was associated with a statistically significant increase in the rate of new or worsening HE after TIPS. This is an extremely important finding given how common HE is after TIPS and how debilitating HE can be for patients and their families. Of note, the rate of TIPS coarctation or embolization was not significantly different between those patients who were on PPIs and those who were not. However, we know HE significantly affects quality of life and can be difficult to manage medically. The authors cited a number of reasons the patients they studied were prescribed PPIs, including varices, GE reflux, ulcer disease, etc. Surprisingly, almost 40% of patients had no documented indication for PPI use. Recognizing that PPIs can increase the risk of new or worsening HE in post-TIPS patients should prompt us to carefully consider what medications our patients are taking and to discontinue nonessential PPI therapy.

Post Author:
Zagum Bhatti, MD
Assistant Professor
Department of Radiology, Interventional Radiology Division
University of Texas Health Science Center at Houston, Houston, TX
@ZagumBhatti

Use of Drug-Coated Balloons in Dysfunctional Arteriovenous Dialysis Access Treatment: The Effect of Consecutive Treatments on Lesion Patency

Clinical question
What is the outcome in arteriovenous (AV) access circuits that undergo repeat drug-coated balloon (DCB) angioplasty?

Take-away point
In this retrospective study of AV circuits undergoing consecutive DCB, there was no significant difference in the postintervention primary patency (PIPP).

Reference
Park, Joong-Won, et al. Sorafenib with or without concurrent transarterial chemoembolization in patients with advanced hepatocellular carcinoma: The phase III STAH trial. Journal of Hepatology. December, 2018. In Press.

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Study design: Retrospective Longitudinal Analysis

Funding source: None identified.

Setting: University hospital setting - Greece.

Summary 

This is a retrospective longitudinal study evaluating the recurrent use of DCB in dysfunctional AV circuits. The authors evaluated 165 patients undergoing 257 procedures. From this cohort, the authors then selected the 38 patients who had a single lesion treated at minimum 2 times with a DCB. They then evaluated from this study population the postintervention primary patency (PIPP), with the goal to evaluate noninferiority of the second (repeat) intervention. 22/38 patients underwent two treatments with DCB, the remaining ranging from 3-6 treatments. The most common treatment site was cephalic vein. The authors concluded the use of repetitive DCB was safe from an AV access circuit standpoint and that recurrent use was noninferior to the first use with regard to PIPP. The authors did note that there was a significant increase in PIPP in patients undergoing a total of two interventions, favoring the second intervention (N= 22 for this population).

Commentary

This is a retrospective study with a relatively small number of patients that evaluates the use of repeat DCB in dysfunctional AV circuits. The authors noted that repeat use of DCB on the same lesion did not result in inferior primary patency rates. They did note a significant trend towards increased postintervention primary patency in patients who required a total of two interventions over the study period. This study suggests that consecutive DCB is safe with regard to the patency of the access circuit. However, given the recent literature surrounding overall risk regarding the use of DCB, it is unclear to me the impact on clinical practice change this article will have.

Post Author:
Daniel P. Sheeran, MD
Assistant Professor
Department of Radiology and Medical Imaging
Division of Vascular and Interventional Radiology
University of Virginia