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DOI: 10.1055/a-0572-7172
Predictive value of liver and spleen stiffness in advanced alcoholic cirrhosis with refractory ascites
Leber- und Milzsteifigkeit bei therapierefraktärem AszitesPublication History
08 September 2017
29 January 2018
Publication Date:
11 June 2018 (online)
![](https://www.thieme-connect.de/media/zfg/201806/lookinside/thumbnails/zfg-0090_10-1055-a-0572-7172-1.jpg)
Abstract
Background Recurrent ascitic decompensation is a frequent complication of advanced alcoholic liver disease. Ascites can be controlled by transjugular intrahepatic portosystemic shunt (TIPS) implantation, but specific pre-procedural outcome predictors are not well established. Liver and spleen stiffness measurement (LSM, SSM) correlate with outcome of compensated liver disease, but data for decompensated cirrhosis disease are scarce. Therefore, the predictive value of LSM and SSM was evaluated in patients with refractory ascites treated with TIPS insertion or receiving conservative therapy.
Material and Methods Patients with alcoholic liver cirrhosis and recurrent or refractory ascites were stratified according to TIPS eligibility. LSM was prospectively assessed by transient elastography (TE, XL probe) and point shear wave elastography (pSWE). pSWE was also used for SSM. The primary study endpoint was transplant-free survival after 12 months. In addition, correlation of LSM and SSM with TIPS complications was analyzed.
Results 43 patients (16 % female, age 55.5 [28.6 – 79.6] years) were recruited, n = 20 underwent TIPS and n = 23 were treated with repeated paracenteses only. 15 patients died and five underwent liver transplantation during follow-up. LSM and SSM at baseline did not predict the patients’ outcome in the TIPS cohort and in patients with conservative therapy. SSM was increased in two cases with spontaneous TIPS occlusion and declined after revision.
Conclusion LSM and SSM cannot be recommended for risk stratification in cirrhotic patients with refractory ascites. SSM may be useful in monitoring TIPS function during follow-up.
Zusammenfassung
Hintergrund Die aszitische Dekompensation bei fortgeschrittener alkoholinduzierter Leberzirrhose kann durch Implantation eines transjugulären intrahepatischen portosystemischen Shunts (TIPS) kontrolliert werden. Spezifische Marker zur Prognosebeurteilung vor TIPS-Implantation sind jedoch unzureichend evaluiert. In dieser Studie wurde daher der prädiktive Wert der Messung von Leber- und Milzsteifigkeit (LSM, SSM) bei Patienten mit therapierefraktärem Aszites untersucht.
Material und Methoden Patienten mit alkoholinduzierter Leberzirrhose und aszitischer Dekompensation wurden prospektiv rekrutiert und nach der Eignung für eine TIPS-Anlage stratifiziert. LSM wurde mit transienter Elastografie und point shear wave elastography (pSWE) bestimmt, pSWE wurde zudem für SSM verwendet. Primärer Endpunkt war das Überleben ohne Lebertransplantation nach 12 Monaten.
Ergebnisse 43 Patienten (16 % weiblich, medianes Alter 55,5 Jahre) wurden eingeschlossen (n = 20 TIPS, n = 23 konservative Therapie). 20 Patienten verstarben oder erhielten eine Lebertransplantation im Beobachtungszeitraum. LSM und SSM korrelierten weder in der Gesamtkohorte noch in der TIPS-Kohorte mit dem Patientenoutcome. Bei zwei Fällen eines spontanen TIPS-Verschlusses korrelierte SSM mit der Stentfunktion.
Schlussfolgerung LSM und SSM sind für die Risiko-Stratifizierung von Patienten mit Leberzirrhose und therapierefraktärem Aszites nicht geeignet. SSM kann jedoch für das Monitoring der TIPS-Funktion genutzt werden.
Key words
transient elastography (TE) - point shear wave elastography (pSWE) - refractory ascites - transjugular intrahepatic portosystemic shunt (TIPS) - decompensated cirrhosis - spleen stiffnessSchlüsselwörter
Transiente Elastographie (TE) - point shear wave elastography (pSWE) - therapierefraktärer Aszites - Transjugulärer intrahepatischer portosystemischer Shunt (TIPS) - dekompensierte Leberzirrhose - Milzsteifigkeit* FL and RM contributed equally to this work.
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References
- 1 European Association for the Study of Liver. EASL clinical practical guidelines: management of alcoholic liver disease. J Hepatol 2012; 57: 399-420
- 2 Salerno F, Guevara M, Bernardi M. et al. Refractory ascites: pathogenesis, definition and therapy of a severe complication in patients with cirrhosis. Liver Int 2010; 30: 937-947
- 3 European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010; 53: 397-417
- 4 Bureau C, Thabut D, Oberti F. et al. Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites. Gastroenterology 2017; 152: 157-163
- 5 Rössle M. TIPS: 25 years later. J Hepatol 2013; 59: 1081-1093
- 6 Suhocki PV, Lungren MP, Kapoor B. et al. Transjugular intrahepatic portosystemic shunt complications: prevention and management. Semin Intervent Radiol 2015; 32: 123-132
- 7 Pereira K, Carrion AF, Martin P. et al. Current diagnosis and management of post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy. Liver Int 2015; 35: 2487-2494
- 8 Lerrigo R, Beste LA, Leipertz SL. et al. Characteristics and outcomes of transjugular intrahepatic portosystemic shunt recipients in the VA Healthcare System. Eur J Gastroenterol Hepatol 2016; 28: 667-675
- 9 Parvinian A, Bui JT, Knuttinen MG. et al. Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites. Diagn Interv Radiol 2014; 20: 58-64
- 10 Dietrich CF, Bamber J, Berzigotti A. et al. EFSUMB guidelines and recommendations on the clinical use of liver ultrasound elastography, update 2017 (long version). Ultraschall Med 2017; 38: 377-394
- 11 European Association for Study of Liver. EASL-ALEH Clinical Practice Guidelines: non-invasive tests for evaluation of liver disease severity and prognosis. J Hepatol 2015; 63: 237-264
- 12 Berzigotti A. Non-invasive evaluation of portal hypertension using ultrasound elastography. J Hepatol 2017; 67: 399-411
- 13 Kohlhaas A, Durango E, Millonig G. et al. Transient elastography with the XL probe rapidly identifies patients with nonhepatic ascites. Hepat Med 2012; 4: 11-18
- 14 Bota S, Sporea I, Sirli R. et al. Value of acoustic radiation force impulse elastography for the assessment of ascites syndrome. World J Radiol 2011; 3: 205-209
- 15 Attia D, Schoenemeier B, Rodt T. et al. Evaluation of liver and spleen stiffness with acoustic radiation force impulse quantification elastography for diagnosing clinically significant portal hypertension. Ultraschall Med 2015; 36: 603-610
- 16 Colecchia A, Montrone L, Scaioli E. et al. Measurement of spleen stiffness to evaluate portal hypertension and the presence of esophageal varices in patients with HCV-related cirrhosis. Gastroenterology 2012; 143: 646-654
- 17 Takuma Y, Morimoto Y, Takabatake H. et al. Measurement of spleen stiffness with acoustic radiation force impulse imaging predicts mortality and hepatic decompensation in patients with liver cirrhosis. Clin Gastroenterol Hepatol 2017; 15: 1782-1790
- 18 Takuma Y, Nouso K, Morimoto Y. et al. Portal hypertension in patients with liver cirrhosis: diagnostic accuracy of spleen stiffness. Radiology 2016; 279: 609-619
- 19 Han H, Yang J, Zhuge YZ. et al. Point shear wave elastography to evaluate and monitor changing portal venous pressure in patients with decompensated cirrhosis. Ultrasound Med Biol 2017; 43: 1134-1140
- 20 Gao J, Ran HT, Ye XP. et al. The stiffness of the liver and spleen on ARFI Imaging pre and post TIPS placement: a preliminary observation. Clin Imaging 2012; 36: 135-141
- 21 Gao J, Zheng X, Zheng YY. et al. Shear wave elastography of the spleen for monitoring transjugular intrahepatic portosystemic shunt function: a pilot study. J Ultrasound Med 2016; 35: 951-958
- 22 De Santis A, Nardelli S, Bassanelli C. et al. The modification of splenic stiffness on acoustic radiation force impulse parallels the variation of portal pressure induced by transjugular intrahepatic portosystemic shunt. J Gastroenterol Hepatol 2017; Jul 28 DOI: 10.1111/jgh.13907. [Epub ahead of print].
- 23 Grattagliano I, Ubaldi E, Bonfrate L. et al. Management of liver cirrhosis between primary care and specialists. World J Gastroenterol 2011; 17: 2273-2282
- 24 Millonig G, Reimann FM, Friedrich S. et al. Extrahepatic cholestasis increases liver stiffness (FibroScan) irrespective of fibrosis. Hepatology 2008; 48: 1718-1723
- 25 Millonig G, Friedrich S, Adolf S. et al. Liver stiffness is directly influenced by central venous pressure. J Hepatol 2010; 52: 206-210
- 26 Boursier J, Zarski JP, de Ledinghen V. et al. Determination of reliability criteria for liver stiffness evaluation by transient elastography. Hepatology 2013; 57: 1182-1191
- 27 Karlas T, Pfrepper C, Wiegand J. et al. Acoustic radiation force impulse imaging (ARFI) for non-invasive detection of liver fibrosis: examination standards and evaluation of interlobe differences in healthy subjects and chronic liver disease. Scand J Gastroenterol 2011; 46: 1458-1467
- 28 Karlas T, Lindner F, Troltzsch M. et al. Assessment of spleen stiffness using acoustic radiation force impulse imaging (ARFI): definition of examination standards and impact of breathing maneuvers. Ultraschall Med 2014; 35: 38-43
- 29 Berzigotti A, Bosch J, Boyer TD. Use of noninvasive markers of portal hypertension and timing of screening endoscopy for gastroesophageal varices in patients with chronic liver disease. Hepatology 2014; 59: 729-731
- 30 Potthoff A, Attia D, Pischke S. et al. Influence of different frequencies and insertion depths on the diagnostic accuracy of liver elastography by acoustic radiation force impulse imaging (ARFI). Eur J Radiol 2013; 82: 1207-1212
- 31 Elkrief L, Rautou PE, Ronot M. et al. Prospective comparison of spleen and liver stiffness by using shear-wave and transient elastography for detection of portal hypertension in cirrhosis. Radiology 2015; 275: 589-598
- 32 Sharma P, Kirnake V, Tyagi P. et al. Spleen stiffness in patients with cirrhosis in predicting esophageal varices. Am J Gastroenterol 2013; 108: 1101-1107
- 33 Piecha F, Paech D, Sollors J. et al. Rapid change of liver stiffness after variceal ligation and TIPS implantation. J Hepatol 2017; 66: 120-121
- 34 Mueller S. Does pressure cause liver cirrhosis?. The sinusoidal pressure hypothesis. World J Gastroenterol 2016; 22: 10482-10501
- 35 Toomey PG, Ross SB, Golkar FC. et al. Outcomes after transjugular intrahepatic portosystemic stent shunt: a “bridge” to nowhere. Am J Surg 2013; 205: 441-446
- 36 Trebicka J. Emergency TIPS in a Child-Pugh B patient: when does the window of opportunity open and close?. J Hepatol 2017; 66: 442-450
- 37 Berres ML, Asmacher S, Lehmann J. et al. CXCL9 is a prognostic marker in patients with liver cirrhosis receiving transjugular intrahepatic portosystemic shunt. J Hepatol 2015; 62: 332-339
- 38 Colecchia A, Marasco G, Festi D. Are noninvasive methods clinically useful in advanced, decompensated liver cirrhosis when “les jeux sont faits”?. Radiology 2016; 278: 304-305
- 39 Heinzow HS, Lenz P, Kohler M. et al. Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis. World J Gastroenterol 2012; 18: 5211-5218
- 40 Ascha M, Hanouneh M, Ascha MS. et al. Transjugular intrahepatic porto-systemic shunt in patients with liver cirrhosis and model for end-stage liver disease ≥15. Dig Dis Sci 2017; 62: 534-542
- 41 Chen H, Bai M, Qi X. et al. Child-Na score: a predictive model for survival in cirrhotic patients with symptomatic portal hypertension treated with TIPS. PLoS One 2013; 8: e79637
- 42 Kim WR, Biggins SW, Kremers WK. et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med 2008; 359: 1018-1026
- 43 Heuman DM, Abou-Assi SG, Habib A. et al. Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death. Hepatology 2004; 40: 802-810
- 44 Parvinian A, Shah KD, Couture PM. et al. Older patient age may predict early mortality after transjugular intrahepatic portosystemic shunt creation in individuals at intermediate risk. J Vasc Interv Radiol 2013; 24: 941-946
- 45 Ran HT, Ye XP, Zheng YY. et al. Spleen stiffness and splenoportal venous flow: assessment before and after transjugular intrahepatic portosystemic shunt placement. J Ultrasound Med 2013; 32: 221-228
- 46 Mueller S, Millonig G, Sarovska L. et al. Increased liver stiffness in alcoholic liver disease: differentiating fibrosis from steatohepatitis. World J Gastroenterol 2010; 16: 966-972
- 47 Mueller S, Englert S, Seitz HK. et al. Inflammation-adapted liver stiffness values for improved fibrosis staging in patients with hepatitis C virus and alcoholic liver disease. Liver Int 2015; 35: 2514-2521
- 48 Hernandez-Gea V, Berzigotti A. Clinical evaluation and prognosis. Dig Dis 2015; 33: 515-523
- 49 Grunwald D, Tapper EB, Jiang ZG. et al. A standardized assessment of functional disability predicts 1-year mortality in patients undergoing transjugular intrahepatic portosystemic shunt for refractory ascites. J Clin Gastroenterol 2016; 50: 75-79