Published online Nov 14, 2023. doi: 10.3748/wjg.v29.i42.5768
Peer-review started: August 18, 2023
First decision: September 18, 2023
Revised: September 30, 2023
Accepted: October 29, 2023
Article in press: October 29, 2023
Published online: November 14, 2023
Processing time: 87 Days and 5 Hours
Transjugular intrahepatic portosystemic shunt (TIPS) has been extensively applied for the treatment of portal hypertension-related complications. However, there is still a subset of patients with a poor prognosis because such patients typically develop advanced cirrhosis with more than one complication when TIPS implantation is needed. Hence, it is warranted to screen patients with a potentially poor prognosis after TIPS for closer follow-up, as they may require more aggressive liver transplantation.
Currently, the post-TIPS survival of patients is commonly predicted by models including Child-Turcotte-Pugh and Model for End-Stage Liver Disease. Nevertheless, the use of these models is limited by two factors. First, these models are constructed based on studies of Western patients who have different pathogeneses from Eastern patients. Second, these models focus on the short-term prognosis of patients after surgery and cannot assess the long-term survival of patients. Thus, a new alternative model is needed to accurately predict the long-term outcome of Asian patients with ascites- or variceal bleeding-induced end-stage liver disease who receive TIPS implantation.
This study aimed to construct a nutrition-based model that could predict the disease progression of cirrhotic patients after TIPS implantation in a sex-dependent manner.
According to the inclusion and exclusion criteria, 186 patients were eventually enrolled in this retrospective study. Skeletal muscle index (SMI) at the third lumbar spine was evaluated according to abdominal computed tomography scans within one month before TIPS implantation. A difference significantly differed at P < 0.05. Continuous variables were compared by the Student's t test or the Mann-Whitney U test. Categorical data are presented as numbers (percentages) and were compared by the chi-square test. Spearman’s correlation coefficients (rs) were used for correlation analyses. Independent predictors of disease progression were evaluated with univariate and multivariate Cox proportional hazard models, followed by the assessment of model calibration by analyzing the C-index. The area under the receiver operating characteristic curve was compared by the DeLong test. Cumulative transplant-free survival rates were plotted as Kaplan-Meier curves and compared by the log-rank test.
Our data demonstrated that among 186 cirrhotic patients receiving TIPS implantation, approximately 20% experienced liver transplantation or death within 30 mo after implantation. Interestingly, our results also exhibited a significant association between SMI and long-term poor prognoses only in male patients with cirrhosis. Subsequent multivariate regression analyses elucidated that a low level of SMI in males was an independent risk factor for long-term adverse outcomes in cirrhotic patients receiving TIPS. Under the low level of SMI, the 30-mo postoperative adverse outcome rate was 42.0% in male patients and 22.6% in female patients. These findings essentially reveal the differential impacts of SMI on the long-term prognosis of patients undergoing TIPS implantation in the context of sex differences. Further multicenter studies are warranted to validate our findings.
Our study highlights the strong correlation between SMI and long-term adverse outcomes in male patients with cirrhosis after TIPS implantation, favoring adequate sex-stratified analyses.
Models constructed based on nutritional indicators hold promise for the effective prediction of prognosis in cirrhotic patients receiving TIPS implantation, assisting clinicians in closely monitoring the dynamics of high-risk populations. Therefore, it is necessary to raise awareness of sex-specific therapeutic interventions in clinical practice.