Simón-Talero M, et al. - The prevalence and characteristics of spontaneous portosystemic shunts (SPSS) were investigated in patients with cirrhosis. Researchers also determined their outcomes. Almost 2000 patients were retrospectively analyzed, 60% of these had SPSS. Prevalence increased with deterioration of liver function. The risk for hepatic encephalopathy (HE) and chronic course increased in association with SPSS. SPSS increased the risk for complications and death among patients with preserved liver function.

Methods

• A retrospective study of 1,729 patients with cirrhosis who underwent abdominal computed tomography or magnetic resonance imaging analysis from 2010 through 2015 at 14 centers in Canada and Europe.
• Data on demographic features, etiology of liver disease, comorbidities, complications, treatments, laboratory and clinical parameters, Model for End-Stage Liver Disease (MELD) score, and endoscopy findings was collected.
• A radiologist (or a hepatologist trained by a radiologist) reviewed abdominal images and searched for the presence of SPSS, defined as spontaneous communications between the portal venous system or splanchnic veins and the systemic venous system, excluding gastroesophageal varices.
• Researchers assigned the patients to groups with large SPSS (L-SPSS, ≥8 mm), small SPSS (S-SPSS, <8 mm), or without SPSS (W-SPSS).
• The incidence of complications of cirrhosis and mortality according to the presence of SPSS was assessed as the main outcome.
• The prevalence of SPSS in patients with cirrhosis and their radiologic features was measured secondarily.

Results

• Researchers identified L-SPSS in 488 (28%) patients, S-SPSS in 548 (32%) patients, and no shunt (W-SPSS) in 693 (40%) patients.
• L-SPSS most commonly observed was splenorenal (46% of L-SPSS).
• With liver dysfunction, increase in the presence and size of SPSS was noted: among patients with MELD scores of 6–9, 14% had L-SPSS and 28% had S-SPSS; among patients with MELD scores of 10–13, 30% had L-SPSS and 34% had S-SPSS; among patients with MELD scores of 14 or higher, 40% had L-SPSS and 32% had S-SPSS (P < .001 for multiple comparison among MELD groups).
• They noted HE in 48% of patients with L-SPSS, 34% of patients with S-SPSS, and 20% of patients W-SPSS (P < .001 for multiple comparison among SPSS groups).
• In 52% of patients with L-SPSS, 44% of patients with S-SPSS, and 37% of patients W-SPSS, recurrent or persistent HE was reported (P=.007 for multiple comparison among SPSS groups).
• A larger number of portal hypertension-related complications (bleeding or ascites) were noted among patients with SPSS compared to those W-SPSS.
• Patients with SPSS vs without showed lower quality of life and transplantation-free survival.
• In multivariate analysis, they identified SPSS to be an independent factor associated with death or liver transplantation (hazard ratio, 1.26; 95% confidence interval, 1.06–1.49) (P=.008).
• SPSS were associated with HE irrespective of liver function when patients were stratified by MELD score: among patients with MELD scores of 6–9, HE was reported in 23% with L-SPSS, 12% with S-SPSS, and 5% with W-SPSS (P < .001 for multiple comparison among SPSS groups); among those with MELD scores of 10–13, HE was reported in 48% with L-SPSS, 33% with S-SPSS, and 23% with W-SPSS (P < .001 for multiple comparison among SPSS groups); among patients with MELD scores of 14 or more, HE was reported in 59% with L-SPSS, 57% with S-SPSS, and 48% with W-SPSS (P=.043 for multiple comparison among SPSS groups).
• Findings revealed that patients with SPSS and MELD scores of 6–9 were at higher risk for ascites (40.5% vs 23%; P < .001) and bleeding (15% vs 9%; P=.038) compared to patients W-SPSS and had lower odds of transplant-free survival (hazard ratio 1.71; 95% confidence interval, 1.16–2.51) (P=.006).