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A combination of liver stiffness and international normalized ratio is an ideal prognostic predictor of portosystemic shunt occlusion in patients with portal hypertension

  • Original Article―liver, Pancreas, and Biliary Tract
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Abstract

Background

We previously reported liver stiffness (LS) as a prognostic predictor of portosystemic shunt (PSS) occlusion. This study aims to reinvestigate the predictive factors of the model for end-stage liver disease-sodium (MELD-Na) score amelioration following balloon-occluded retrograde transvenous obliteration (BRTO) and to evaluate the postoperative prognoses of patients with portal hypertension by using newly identified factors.

Methods

Seventy-five patients who underwent BRTO between 2008 and 2021 were retrospectively enrolled. The MELD-Na scores were calculated preoperatively and one month postoperatively. We monitored long-term outcomes and analyzed postoperative survival.

Results

At one month postoperatively, the MELD-Na score decreased in 46 (61.3%) patients. Univariate analyses revealed a significant association of the score amelioration with nine factors, including lower LS levels and a higher international normalized ratio (INR). A multivariate logistic regression analysis with receiver operating characteristic curve analyses identified preoperative LS levels and INR as significant independent predictors of the postoperative MELD-Na score amelioration, with optimal cutoffs of 28.1 kPa and 1.06, respectively. The combination of LS < 28.1 kPa and INR ≥ 1.06 showed a sensitivity and specificity of 84.8% and 75.9% for the prediction of the score amelioration, respectively. For the propensity score model, we matched 24 patients with similar age, sex, MELD-Na score, and concomitant hepatocellular carcinoma. Kaplan–Meier analysis determined significantly higher cumulative survival rates in patients with LS < 28.1 kPa and INR ≥ 1.06 than in other populations.

Conclusions

A combination of LS and INR can predict the MELD-Na score amelioration and prognosis improvement following PSS occlusion.

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Abbreviations

BRTO:

Balloon-occluded retrograde transvenous obliteration

INR:

International normalized ratio

LS:

Liver stiffness

MELD-Na:

Model for end-stage liver disease-sodium

PSS:

Portosystemic shunt

References

  1. Kanagawa H, Mima S, Kouyama H, et al. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 1996;11:51–8.

    Article  CAS  PubMed  Google Scholar 

  2. Hirota S, Matsumoto S, Tomita M, et al. Retrograde transvenous obliteration of gastric varices. Radiology. 1999;211:349–56.

    Article  CAS  PubMed  Google Scholar 

  3. Fukuda T, Hirota S, Sugimura K. Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. J Vasc Interv Radiol. 2001;12:327–36.

    Article  CAS  PubMed  Google Scholar 

  4. Akahane T, Iwasaki T, Kobayashi N, et al. Changes in liver function parameters after occlusion of gastrorenal shunts with balloon-occluded retrograde transvenous obliteration. Am J Gastroenterol. 1997;92:1026–30.

    CAS  PubMed  Google Scholar 

  5. Hirota S, Kobayashi K, Maeda H, et al. Balloon-occluded retrograde transvenous obliteration for portal hypertension. Radiat Med. 2006;24:315–20.

    Article  PubMed  Google Scholar 

  6. Kumamoto M, Toyonaga A, Inoue H, et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric fundal varices: hepatic deterioration links to portosystemic shunt syndrome. J Gastroenterol Hepatol. 2010;25:1129–35.

    Article  PubMed  Google Scholar 

  7. Naeshiro N, Aikata H, Kakizawa H, et al. Long-term outcome of patients with gastric varices treated by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 2014;29:1035–42.

    Article  PubMed  Google Scholar 

  8. Imai Y, Nakazawa M, Ando S, et al. Long-term outcome of 154 patients receiving balloon-occluded retrograde transvenous obliteration for gastric fundal varices. J Gastroenterol Hepatol. 2016;31:1844–50.

    Article  PubMed  Google Scholar 

  9. Yamamoto A, Nishida N, Morikawa H, et al. Prediction for improvement of liver function after balloon-occluded retrograde transvenous obliteration for gastric varices to manage portosystemic shunt syndrome. J Vasc Interv Radiol. 2016;27:1160–7.

    Article  PubMed  Google Scholar 

  10. Ishikawa T, Sasaki R, Nishimura T, et al. Liver stiffness measured by transient elastography as predictor of prognoses following portosystemic shunt occlusion. J Gastroenterol Hepatol. 2019;34:215–23.

    Article  PubMed  Google Scholar 

  11. de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII—renewing consensus in portal hypertension. J Hepatol. 2022;76:959–74.

    Article  PubMed  Google Scholar 

  12. Ishikawa T, Shiratsuki S, Matsuda T, et al. Occlusion of portosystemic shunts improves hyperinsulinemia due to insulin resistance in cirrhotic patients with portal hypertension. J Gastroenterol. 2014;49:1333–41.

    Article  CAS  PubMed  Google Scholar 

  13. Ishikawa T, Aibe Y, Matsuda T, et al. Plasma glucose level is predictive of serum ammonia level after retrograde occlusion of portosystemic shunts. AJR Am J Roentgenol. 2017;209:W169–76.

    Article  PubMed  Google Scholar 

  14. Ishikawa T, Sasaki R, Nishimura T, et al. Comparison of patients with hepatic encephalopathy and those with gastric varices before and after balloon-occluded retrograde transvenous obliteration. Hepatol Res. 2018;48:1020–30.

    Article  PubMed  Google Scholar 

  15. Ishikawa T, Sasaki R, Nishimura T, et al. Splenic non-infarction volume determines a clinically significant hepatic venous pressure gradient response to partial splenic embolization in patients with cirrhosis and hypersplenism. J Gastroenterol. 2021;56:382–94.

    Article  PubMed  Google Scholar 

  16. Yeh WC, Li PC, Jeng YM, et al. Elastic modulus measurements of human liver and correlation with pathology. Ultrasound Med Biol. 2002;28:467–74.

    Article  PubMed  Google Scholar 

  17. The Liver Cancer Study Group of Japan. The general rules for the clinical and pathological study of primary liver cancer. 6th ed. Tokyo: Kanehara; 2015.

    Google Scholar 

  18. Kudo M, Kitano M, Sakurai T, et al. General rules for the clinical and pathological study of primary liver cancer, nationwide follow-up survey and clinical practice guidelines: the outstanding achievements of the liver cancer study group of Japan. Dig Dis. 2015;33:765–70.

    Article  PubMed  Google Scholar 

  19. Garcia-Tsao G, Groszmann RJ, Fisher RL, et al. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology. 1985;5:419–24.

    Article  CAS  PubMed  Google Scholar 

  20. Ripoll C, Groszmann R, Garcia-Tsao G, et al. Portal hypertension collaborative group. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology. 2007;133:481–8.

    Article  CAS  PubMed  Google Scholar 

  21. Ripoll C, Groszmann RJ, Garcia-Tsao G, et al. Hepatic venous pressure gradient predicts development of hepatocellular carcinoma independently of severity of cirrhosis. J Hepatol. 2009;50:923–8.

    Article  PubMed  PubMed Central  Google Scholar 

  22. de Franchis R. Expanding consensus in portal hypertension: report of the Baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63:743–52.

    Article  PubMed  Google Scholar 

  23. Bosch J, Abraldes JG, Berzigotti A, et al. The clinical use of HVPG measurements in chronic liver disease. Nat Rev Gastroenterol Hepatol. 2009;6:573–82.

    Article  CAS  PubMed  Google Scholar 

  24. Vizzutti F, Arena U, Romanelli RG, et al. Liver stiffness measurement predicts severe portal hypertension in patients with HCV-related cirrhosis. Hepatology. 2007;45:1290–7.

    Article  PubMed  Google Scholar 

  25. Saad WE. Portosystemic shunt syndrome and endovascular management of hepatic encephalopathy. Semin Intervent Radiol. 2014;31:262–5.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Ishikawa T, Sasaki R, Nishimura T, et al. Improved hepatic reserve and fibrosis in a case of “portal-systemic liver failure” by portosystemic shunt occlusion. Am J Case Rep. 2020;21: e921236.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Wood AJ, Villeneuve JP, Branch RA, et al. Intact hepatocyte theory of impaired drug metabolism in experimental cirrhosis in the rat. Gastroenterology. 1979;76:1358–62.

    Article  CAS  PubMed  Google Scholar 

  28. Kawasaki S, Imamura H, Bandai Y, et al. Direct evidence for the intact hepatocyte theory in patients with liver cirrhosis. Gastroenterology. 1992;102:1351–5.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We would like to thank Editage (www.editage.jp) for the English language editing.

Funding

Our work was partially supported by Gilead Sciences, Inc. and a Grant-in-Aid for Research on Hepatitis from the Ministry of Health Labor and Welfare of Japan and the Japan Agency for Medical Research and Development (JP22fk0210113).

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Authors and Affiliations

  1. Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, 7558505, Japan

    Tsuyoshi Ishikawa, Maho Egusa, Tsuyoshi Fujioka, Natsuko Nishiyama, Daiki Kawamoto, Ryo Sasaki, Tatsuro Nishimura, Norikazu Tanabe, Takashi Oono, Issei Saeki & Taro Takami

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  1. Tsuyoshi Ishikawa
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  2. Maho Egusa
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  3. Tsuyoshi Fujioka
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  4. Natsuko Nishiyama
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  11. Taro Takami
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Contributions

Conceptualization: TI. Methodology: TI. Data collection: TI, ME, TF, NN, DK, RS, TN, NT, TO, IS. Formal analysis and investigation: TI. Writing-original draft preparation: TI. Writing-review and editing: RS, TN, TT. Supervision: TT.

Corresponding author

Correspondence to Tsuyoshi Ishikawa.

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The authors declare that they have no conflicts of interest concerning this article.

Ethical approval

The research performed was in accordance with the Declaration of Helsinki and was approved by our hospital’s institutional review board (2022–092).

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Supplementary Information

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535_2022_1947_MOESM1_ESM.tif

Supplementary file1 Supplemental Fig. E1. Correlation between preoperative LS levels and INR among the 75 enrolled patients. There is a significant positive correlation between preoperative LS levels and INR (r = 0.2757, P = 0.0166). In total, 46 (61.3%) patients fulfilled the criteria with both LS < 28.1 kPa and INR ≥ 1.06 (black enclosure). r means correlation coefficient. LS, liver stiffness; INR, international normalized ratio. (TIF 77 KB)

Supplementary file2 (DOCX 17 KB)

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Ishikawa, T., Egusa, M., Fujioka, T. et al. A combination of liver stiffness and international normalized ratio is an ideal prognostic predictor of portosystemic shunt occlusion in patients with portal hypertension. J Gastroenterol 58, 246–256 (2023). https://doi.org/10.1007/s00535-022-01947-8

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  • DOI: https://doi.org/10.1007/s00535-022-01947-8

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