Increased radiographic muscle area after transjugular intrahepatic portosystemic shunting in patients with cirrhosis

patient characteristics

In this retrospective study, we included 52 patients (42 men, 10 women) with a mean age of 54.2 years (± 10.3 years) who underwent TIPS for complications of cirrhosis between 2010 and 2021 Operation. In addition, they all underwent TIPS surgery. CT or MR imaging before and after intervention (Table 1).

The majority of patients (69.2%) had alcoholic liver disease (ALD). The second most common cause of cirrhosis is NASH, followed by autoimmune hepatitis. Most patients are classified as Child-Pugh B and have ascites and associated esophageal or gastric varices. The incidence of encephalopathy was lower at 9.6%.

Treatment results of TIPS surgery

The TIPS procedure was performed between April 2010 and April 2021.

TIPS is performed for treatment-refractory ascites in two-thirds of cases. The second most common cause is secondary prevention of variceal bleeding. Overall, the majority of surgeries (n = 49) were elective.

After TIPS implantation, the pressure gradient dropped from 21.9±3.8 to 9.8±3.1mmHg, meeting the recommended target pressure gradient of <12mmHg.^{twenty four}. Nine patients (17.3%) had to undergo revision for further expansion of the stent or stent graft. On follow-up imaging, ascites resolved in 57.7% of cases.

Due to lack of imaging examinations, this retrospective analysis could not include 35 patients who were also treated in our department. Among them, only 4 patients were lost to follow-up one year but at least 6 months after TIPS surgery. Supplementary material Table 1 provides baseline data for these patients.

Increased muscle area and reduced sarcopenia after TIPS

For the majority of patients (74.0%), we analyzed CT images obtained at baseline and at least six months of follow-up and after a median follow-up of 16.5 months. We analyzed MR images from one quarter of the patients (26.0%).

There was a positive correlation between the manually outlined psoas region and the semi-automatic segmentation of the psoas region (r = 0.773, p< 0.001).

Before TIPS, there was no correlation between SMI and PMI (r = 0.26; p= 0.11); however, we found a positive correlation after TIPS (r = 0.564; p< 0.001).

After TIPS, average gain was 9.7 cm² In TMA (p= 0.016) and 4.1 cm² In PMA (p< 0.001) were observed (Table 2 and Figures 1a, b and 2). This results in SMI (0.020) and PMI (p< 0.001).

To classify possible sarcopenia, we applied the previously used SMI cutoff (39.5 cm)²/rice² Female, ≤ 52 cm²/rice² for men)²⁵ and PMI (≤ 6.36 cm²/rice² Male ≤ 3.92 cm²/rice² in women)²⁶. Based on these cutoff values, the majority of patients were classified as sarcopenic at baseline (84.6%, 92.3%). After TIPS surgery, the proportion of patients with sarcopenia dropped to 69.8% (SMI, p= 0.109) and 68.1% (PMI, p= 0.004). In a subgroup analysis of male patients, we found a significant reduction in sarcopenia according to SMI (p= 0.039) and PMI (p= 0.008). Before TIPS surgery, patients not classified as sarcopenic had no significant changes in muscle area/index (e.g., PMA, p= 0.50).

We did not assess body weight and body mass index because most patients had associated ascites and information on body weight after drainage of ascites is often not available.

Based on the follow-up imaging analysis of patients with post-TIPS ascites, we found that the psoas muscle area was significantly reduced (15.5 cm vs. 12.7 cm).², p= 0.037) and lower PMI (5.1 vs. 4.2 cm²/rice², p= 0.045) compared with patients without ascites.

The muscle area of ​​patients with ascites still increased after TIPS (TMA 135.4 vs. 138.7 cm², p= 0.281; PMA 11.9 vs. 13.0 cm², p= 0.184), but these results were not statistically significant.

MELD and FIPS

On average, the MELD score before TIPS was 12.8. There was a slight increase to 13.4 after TIPS (Table 2). Before the TIPS program, the average FIPS was − 0.263. According to FIPS, the overall survival rate after TIPS is estimated to be 95.0% at 1 month, 85.6% at 3 months, and 80.1% at 6 months. Before TIPS, there were 3 high-risk patients based on cutoff ≥0.92, and 9 high-risk patients based on FIPS higher than ≥0.64. In our study cohort, the overall survival rate assessed 6 months after TIPS was 100.0%.

Since MELD and FIPS are based on similar parameters, there is a positive correlation between the two scores (r = 0.513; p< 0.001), MELD in high-risk patients was significantly elevated (p= 0.001).

MELD after TIPS was also negatively correlated with PMA (r = − 0.296, p= 0.039) and PMI after TIPS (r = − 0.536, p< 0.001).

However, we found no correlation between FIPS and muscle area/index, nor found a significant difference between high-risk and average-risk patients with reduced survival after TIPS (Supplementary Material Table S1).

Analyzing the parameters used to calculate MELD and FIPS separately, we found no significant differences between sarcopenic and non-sarcopenic patients. Albumin levels increased slightly but not significantly compared with all patients before and after TIPS (p= 0.091) (Table 2).

Interestingly, we found that serum albumin levels were significantly higher in patients with increased SMI than in patients with no increase after TIPS (36.0 vs. 28.7; p= 0.022).

Analysis from the Origin of Liver Cirrhosis

We analyzed differences in muscle area and index between patient subgroups according to the origin of cirrhosis (Supplementary Material Table S2 and Figure S1). For computational reasons, we divided into four groups: ALD, NASH, autoimmune hepatitis, and other. The “other” group contained different entities, with one patient each: primary sclerosing cholangitis (PSC), primary biliary cholangitis (PBC), Budd-Chiari syndrome, and unknown.

Comparing patients with alcoholic liver disease to all other patients, we found significant differences in PMA (16.5 vs. 9.7; p= 0.006) and PMI (5.3 vs. 3.3; p= 0.016) were not significantly different after TIPS than before the TIPS procedure (Table 3 and Figure 3). Furthermore, patients with alcoholic liver disease had significantly greater changes in PMA than all other patients (5.7 vs. 1.1; p= 0.041).