Prediction of Mortality and Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Placement: Baseline and Longitudinal Body Composition Measurement
Clinical question
Are baseline and longitudinal body composition measurements predictive of mortality and hepatic encephalopathy outcomes following transjugular intrahepatic portosystemic shunt placement?Take away point
Body composition measurements can be used for risk stratification in patients undergoing TIPS procedures; with improved prediction of mortality over MELD-Na and post-TIPS RA pressures alone.Reference
Tisileli S. Tuifua, Baljendra Kapoor, Sasan Partovi, Shetal N. Shah, Jennifer A. Bullen, Jacob Enders, Sobia Laique, Abraham Levitin, Sameer Gadani, Prediction of Mortality and Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Placement: Baseline and Longitudinal Body Composition Measurement, Journal of Vascular and Interventional Radiology, Volume 35, Issue 5, 2024, Pages 648-657.e1, ISSN 1051-0443, https://doi.org/10.1016/j.jvir.2024.01.012. (https://www.sciencedirect.com/science/article/pii/S1051044324000253)Click here for abstract.
Study design
Retrospective case control study with Cox proportional hazard model analysis of 280 cirrhotic patients with CT scans performed 1 month prior to and 3 months status post TIPS (n = 34) from 1995-2020.Funding Source
Not explicitly mentioned.Setting
Academic setting, Cleveland Clinic Foundation.Figure
Representative segmental examples of body composition measurements obtained at the level of L3 in a 66-year-old cirrhotic male. Subcutaneous adipose tissue (mSAT) in blue (a), macroscopic visceral adipose tissue (mVAT) in green (b), and core muscle area (CMA) in orange (c)
The quantity and quality of muscle and adipose tissues are known to be associated with mortality and hepatic encephalopathy after transjugular intrahepatic portosystemic shunt placement (TIPS). However, the timing of body composition measurements remains undetermined, and the additive utility of these measures compared to the Model for End-stage Liver Disease (MELD) score alone remains unknown.
To better delineate the temporal relationship and investigate the association between body composition measurements and outcomes following transjugular intrahepatic portosystemic shunt placement, researchers performed Cox proportional hazard model analysis of TIPS registry data obtained from cirrhotic patients who had CT scans performed 2-6 weeks prior to and within 8-12 weeks status post TIPS. Multiple body composition measurements, including core muscle area and macroscopic subcutaneous adipose tissue were assessed against mortality and hepatic encephalopathy after TIPS.
Results demonstrated that higher baseline core muscle area, interval increases in core muscle area, and interval decreases in muscle adiposity index were associated with decreased mortality. Increases in macroscopic subcutaneous adipose tissue area following TIPS were associated with improved survival and yet increased risks of hepatic encephalopathy. In plain language, for every 10 cm2 decrease in core muscle area at base line, risk of death or hepatic encelphalopathy any time after TIPS placement was 18% higher for either outcome. A 10 cm2 increase in core muscle area 3-months after TIPS placement, was associated with 40% decreased risk of death any time after TIPS placement.
These findings underscore the potential utility of body composition measures in risk stratification and intervention planning for patients undergoing TIPS procedures.
This retrospective case control study with Cox proportional hazard model analysis of 280 cirrhotic patients including 34 patients with available post-TIPS imaging preliminarily addresses a clinically relevant question about the timing and multidisciplinary utility of body composition measurements after TIPS placement. Specifically, baseline core muscle area 2-6 weeks prior to TIPS and interval changes in core muscle area 8-12 weeks after TIPS may serve as predictor or risk stratifier of mortality after TIPS placement, independent of Model for End-stage Liver Disease – Sodium modification score and post-TIPS right atrial pressure. These results encourage clinicians to have increased awareness of post-procedural complications of TIPS and preemptively initiate or modify medical management, especially in patients with sarcopenia. The current research augments prior information and the statistical methods are appropriate for analyzing the collected data. However, the small sample size in addition to the possibility of introducing selection bias due to the retrospective nature of the study may limit result strength. Future studies with larger sample sizes, prospective designs which account for confounders such as comorbid conditions and nutritional status, as well as the inclusion of other markers of liver disease severity may build upon this research. Lastly, there remains a need for basic science research to elucidate underlying the pathophysiological mechanisms. The journey is arduous, but with each study examining the causal relationship among body composition, nutritional status, and overall survival after TIPS placement, we are one step closer to individualized care in this ever-growing population of patients with liver disease.
Diagnostic Radiology Resident, PGY3/R2
Hartford Hospital
@RyanBabayevMD
Summary
The quantity and quality of muscle and adipose tissues are known to be associated with mortality and hepatic encephalopathy after transjugular intrahepatic portosystemic shunt placement (TIPS). However, the timing of body composition measurements remains undetermined, and the additive utility of these measures compared to the Model for End-stage Liver Disease (MELD) score alone remains unknown.
To better delineate the temporal relationship and investigate the association between body composition measurements and outcomes following transjugular intrahepatic portosystemic shunt placement, researchers performed Cox proportional hazard model analysis of TIPS registry data obtained from cirrhotic patients who had CT scans performed 2-6 weeks prior to and within 8-12 weeks status post TIPS. Multiple body composition measurements, including core muscle area and macroscopic subcutaneous adipose tissue were assessed against mortality and hepatic encephalopathy after TIPS.
Results demonstrated that higher baseline core muscle area, interval increases in core muscle area, and interval decreases in muscle adiposity index were associated with decreased mortality. Increases in macroscopic subcutaneous adipose tissue area following TIPS were associated with improved survival and yet increased risks of hepatic encephalopathy. In plain language, for every 10 cm2 decrease in core muscle area at base line, risk of death or hepatic encelphalopathy any time after TIPS placement was 18% higher for either outcome. A 10 cm2 increase in core muscle area 3-months after TIPS placement, was associated with 40% decreased risk of death any time after TIPS placement.
These findings underscore the potential utility of body composition measures in risk stratification and intervention planning for patients undergoing TIPS procedures.
Commentary
This retrospective case control study with Cox proportional hazard model analysis of 280 cirrhotic patients including 34 patients with available post-TIPS imaging preliminarily addresses a clinically relevant question about the timing and multidisciplinary utility of body composition measurements after TIPS placement. Specifically, baseline core muscle area 2-6 weeks prior to TIPS and interval changes in core muscle area 8-12 weeks after TIPS may serve as predictor or risk stratifier of mortality after TIPS placement, independent of Model for End-stage Liver Disease – Sodium modification score and post-TIPS right atrial pressure. These results encourage clinicians to have increased awareness of post-procedural complications of TIPS and preemptively initiate or modify medical management, especially in patients with sarcopenia. The current research augments prior information and the statistical methods are appropriate for analyzing the collected data. However, the small sample size in addition to the possibility of introducing selection bias due to the retrospective nature of the study may limit result strength. Future studies with larger sample sizes, prospective designs which account for confounders such as comorbid conditions and nutritional status, as well as the inclusion of other markers of liver disease severity may build upon this research. Lastly, there remains a need for basic science research to elucidate underlying the pathophysiological mechanisms. The journey is arduous, but with each study examining the causal relationship among body composition, nutritional status, and overall survival after TIPS placement, we are one step closer to individualized care in this ever-growing population of patients with liver disease.
Post Author
Ryan R. Babayev, MD, MScDiagnostic Radiology Resident, PGY3/R2
Hartford Hospital
@RyanBabayevMD
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