Impact and prediction model construction of spontaneous portosystemic shunts on the prognosis of patients with hepatitis B virus-related decompensated cirrhosis

doi:10.11958/20253576

Abstract

Abstract:

Objective To analyze the impact of spontaneous portosystemic shunts (SPSS) on the prognosis of patients with hepatitis B virus-related decompensated cirrhosis (HBV-DC), and to develop and validate a prognostic nomogram model based on the total cross-sectional SPSS area (TSA). Methods A total of 641 patients with HBV-DC were divided into three groups according to TSA measured by abdominal computed tomography: the non-SPSS group (n=169), the small-SPSS group (TSA<83 mm², n=343) and the large-SPSS group (TSA≥83 mm², n=129). General data, cirrhosis-related complications and prognosis were compared between the three groups. The Cox proportional hazards model was applied to identify independent risk factors for death in patients with HBV-DC, and a prognostic nomogram model was constructed and validated. The predictive performance of this model was compared with that of traditional prognostic models by calculating the area under the receiver operating characteristic curve (AUC). Results Compared with the non-SPSS group, there were lower levels of hemoglobin (Hb) and platelet counts (PLT), higher levels of international normalized ratio (INR), serum creatinine, higher incidence of portal vein thrombosis and esophagogastric variceal bleeding (EGVB) in the small-SPSS group and the large-SPSS group (P<0.05). Compared with the small-SPSS group, there were lower levels of PLT and incidence of moderate-to-massive ascites, and higher levels of INR and model for end-stage liver disease (MELD) score, higher incidence of portal vein thrombosis and hepatic encephalopathy in the large-SPSS group (P<0.05). The cumulative overall survival rates decreased gradually in the non-SPSS group, the small-SPSS group and the large-SPSS groups (P<0.05). Multivariate Cox regression analysis showed that advanced age, decreased hemoglobin, increased total bilirubin (TBil), INR and TSA, presence of massive ascites and hepatic encephalopathy were independent risk factors for death in patients (P<0.05). The nomogram model constructed based on aforementioned factors had a C-index of 0.711 (95%CI：0.639-0.783). The calibration curve showed that the model had a relatively high degree of calibration, and decision curve analysis indicated that the model had a clear positive net benefit. ROC curve analysis at 6, 12 and 24 months showed that the predictive value of the nomogram model was significantly superior to the Child-Turcotte-Pugh (CTP) score, MELD score and albumin-bilirubin (ALBI) score (P<0.05). Conclusion Increased TSA is an independent risk factor for death in patients with HBV-DC, and the established predictive model has a high value in evaluating the prognosis of patients.

Key words: hepatitis B, liver cirrhosis, prognosis, nomograms, spontaneous portosystemic shunts

CLC Number:

R575.21

Figures/Tables 10

References 19

[1]	ZAMANI M, ALIZADEH-TABARI S, AJMERA V, et al. Global prevalence of advanced liver fibrosis and cirrhosis in the general population: a systematic review and meta-analysis[J]. Clin Gastroenterol Hepatol, 2025, 23(7):1123-1134. doi:10.1016/j.cgh.2024.08.020.
[2]	YI F, GUO X, WANG L, et al. Impact of spontaneous splenorenal shunt on liver volume and long-term survival of liver cirrhosis[J]. J Gastroenterol Hepatol, 2021, 36(6):1694-1702. doi:10.1111/jgh.15386.
[3]	SIMÓN-TALERO M, ROCCARINA D, MARTÍNEZ J, et al. Association between portosystemic shunts and increased complications and mortality in patients with cirrhosis[J]. Gastroenterology, 2018, 154(6):1694-1705.e4. doi:10.1053/j.gastro.2018.01.028.
[4]	PRAKTIKNJO M, SIMÓN-TALERO M, RÖMER J, et al. Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis[J]. J Hepatol, 2020, 72(6):1140-1150. doi:10.1016/j.jhep.2019.12.021.
[5]	TURCO L, GARCIA-TSAO G, MAGNANI I, et al. Cardiopulmonary hemodynamics and C-reactive protein as prognostic indicators in compensated and decompensated cirrhosis[J]. J Hepatol, 2018, 68(5):949-958. doi:10.1016/j.jhep.2017.12.027.
[6]	ABRALDES J G, TREBICKA J, CHALASANI N, et al. Prioritization of therapeutic targets and trial design in cirrhotic portal hypertension[J]. Hepatology, 2019, 69(3):1287-1299. doi:10.1002/hep.30314.
[7]	HEO S, LEE S S, CHOI S H, et al. CT rule-in and rule-out criteria for clinically significant portal hypertension in chronic liver disease[J]. Radiology, 2023, 309(1):e231208. doi:10.1148/radiol.231208.
[8]	NARDELLI S, RIGGIO O, TURCO L, et al. Relevance of spontaneous portosystemic shunts detected with CT in patients with cirrhosis[J]. Radiology, 2021, 299(1):133-140. doi:10.1148/radiol.2021203051.
[9]	GREINERT R, ZIPPRICH A, SIMÓN-TALERO M, et al. Covert hepatic encephalopathy and spontaneous portosystemic shunts increase the risk of developing overt hepatic encephalopathy[J]. Liver Int, 2020, 40(12):3093-3102. doi:10.1111/liv.14660.
[10]	TARANTINO G, CITRO V, CONCA P, et al. What are the implications of the spontaneous spleno-renal shunts in liver cirrhosis?[J]. BMC Gastroenterol, 2009, 9:89. doi:10.1186/1471-230X-9-89.
[11]	LIPINSKI M, SABOROWSKI M, HEIDRICH B, et al. Clinical characteristics of patients with liver cirrhosis and spontaneous portosystemic shunts detected by ultrasound in a tertiary care and transplantation centre[J]. Scand J Gastroenterol, 2018, 53(9):1107-1113. doi:10.1080/00365521.2018.1498913.
[12]	SAKS K, JENSEN K K, MCLOUTH J, et al. Influence of spontaneous splenorenal shunts on clinical outcomes in decompensated cirrhosis and after liver transplantation[J]. Hepatol Commun, 2018, 2(4):437-444. doi:10.1002/hep4.1157.
[13]	VIDAL-GONZÁLEZ J, MARTÍNEZ J, MULAY A, et al. Evolution of spontaneous portosystemic shunts over time and following aetiological intervention in patients with cirrhosis[J]. JHEP Rep, 2023, 6(2):100977. doi:10.1016/j.jhepr.2023.100977.
[14]	DAJTI E, RENZULLI M, COLECCHIA A, et al. Size and location of spontaneous portosystemic shunts predict the risk of decompensation in cirrhotic patients[J]. Dig Liver Dis, 2022, 54(1):103-110. doi:10.1016/j.dld.2020.12.114.
[15]	SAAD W E. Portosystemic shunt syndrome and endovascular management of hepatic encephalopathy[J]. Semin Intervent Radiol, 2014, 31(3):262-265. doi:10.1055/s-0034-1382795.
[16]	GINÈS P, KRAG A, ABRALDES J G, et al. Liver cirrhosis[J]. Lancet, 2021, 398(10308):1359-1376. doi:10.1016/S0140-6736(21)01374-X.
[17]	LLERENA VELASTEGUI J, VERA SANCHEZ M, Villacis Lopez C. Characteristics of spontaneous portosystemic shunts in cirrhotic patients as a predictor of decompensation[J]. Dig Liver Dis, 2022, 54(9):1285-1286. doi:10.1016/j.dld.2022.05.018.
[18]	SONG X, ROMEIRO F G, WANG J, et al. Development and validation of modified Liaoning score for predicting the prognosis of liver cirrhosis:a retrospective,international multicenter,observational study[J]. Expert Rev Gastroenterol Hepatol, 2024, 18(1/2/3):121-128. doi:10.1080/17474124.2024.2320238.
[19]	VIZZUTTI F, CELSA C, CALVARUSO V, et al. Mortality after transjugular intrahepatic portosystemic shunt in older adult patients with cirrhosis:a validated prediction model[J]. Hepatology, 2023, 77(2):476-488. doi:10.1002/hep.32704.

组别			n		性别（男/女）				年龄/岁
无SPSS组			169		128/41				53.80±11.63		4.69（3.44，5.98）
小型SPSS组			343		259/84				55.45±12.52		4.19（3.14，6.05）
大型SPSS组			129		100/29				54.12±12.38		3.93（2.54，5.80）^a
χ²、F或H					0.214				1.227		7.420^＊
组别				Hb/（g/L）				PLT/（×10⁹/L）							ALB/（g/L）
无SPSS组				122（109，137）				101（69，133）					31（26，35）
小型SPSS组				108（90，123）^a				77（57，107）^a					30（26，34）
大型SPSS组				102（86，117）^a				62（38，87）^ab					29（26，33）^a
H				52.854^＊＊				55.309^＊＊					7.174^＊
组别	TBil/（μmol/L）						INR							SCr/（μmol/L）
无SPSS组	37.2（22.2，99.8）						1.25（1.09，1.51）					66（56，76）
小型SPSS组	36.3（20.1，72.3）						1.30（1.17，1.54）^a					69（57，84）^a
大型SPSS组	45.8（27.5，77.0）						1.48（1.26，1.76）^ab					69（59，86）^a
H	5.475						30.022^＊＊					6.612^＊
组别		CTP评分/分				MELD评分/分				ALBI评分/分
无SPSS组		9（7，10）				12（9，17）				-1.51（-1.98，-1.08）
小型SPSS组		9（8，11）				13（10，17）				-1.42（-1.93，-1.05）
大型SPSS组		9（8，11）^a				15（12，18）^ab				-1.37（-1.65，-1.00）
H		6.979^＊				14.594^＊＊				5.979

组别			n		性别（男/女）				年龄/岁
无SPSS组			169		128/41				53.80±11.63		4.69（3.44，5.98）
小型SPSS组			343		259/84				55.45±12.52		4.19（3.14，6.05）
大型SPSS组			129		100/29				54.12±12.38		3.93（2.54，5.80）^a
χ²、F或H					0.214				1.227		7.420^＊
组别				Hb/（g/L）				PLT/（×10⁹/L）							ALB/（g/L）
无SPSS组				122（109，137）				101（69，133）					31（26，35）
小型SPSS组				108（90，123）^a				77（57，107）^a					30（26，34）
大型SPSS组				102（86，117）^a				62（38，87）^ab					29（26，33）^a
H				52.854^＊＊				55.309^＊＊					7.174^＊
组别	TBil/（μmol/L）						INR							SCr/（μmol/L）
无SPSS组	37.2（22.2，99.8）						1.25（1.09，1.51）					66（56，76）
小型SPSS组	36.3（20.1，72.3）						1.30（1.17，1.54）^a					69（57，84）^a
大型SPSS组	45.8（27.5，77.0）						1.48（1.26，1.76）^ab					69（59，86）^a
H	5.475						30.022^＊＊					6.612^＊
组别		CTP评分/分				MELD评分/分				ALBI评分/分
无SPSS组		9（7，10）				12（9，17）				-1.51（-1.98，-1.08）
小型SPSS组		9（8，11）				13（10，17）				-1.42（-1.93，-1.05）
大型SPSS组		9（8，11）^a				15（12，18）^ab				-1.37（-1.65，-1.00）
H		6.979^＊				14.594^＊＊				5.979

组别	n	腹水分级（无-少/中/大量）	门静脉血栓	肝性脑病	EGVB
无SPSS组	169	68/76/25	2（1.18）	15（8.88）	7（4.14）
小型SPSS组	343	96/169/78^a	26（7.58）^a	39（11.37）	45（13.12）^a
大型SPSS组	129	52/55/22^b	22（17.05）^ab	32（24.81）^ab	25（19.38）^a
χ²		12.346^＊	25.672^＊＊	18.642^＊＊	16.927^＊＊

组别	n	腹水分级（无-少/中/大量）	门静脉血栓	肝性脑病	EGVB
无SPSS组	169	68/76/25	2（1.18）	15（8.88）	7（4.14）
小型SPSS组	343	96/169/78^a	26（7.58）^a	39（11.37）	45（13.12）^a
大型SPSS组	129	52/55/22^b	22（17.05）^ab	32（24.81）^ab	25（19.38）^a
χ²		12.346^＊	25.672^＊＊	18.642^＊＊	16.927^＊＊

变量	β	SE	Wald χ²	P	HR（95%CI）
性别	-0.246	0.143	-1.718	0.086	0.782（0.590~1.035）
年龄	0.013	0.005	2.421	0.015	1.013（1.002~1.024）
WBC	0.034	0.019	1.847	0.065	1.035（0.998~1.074）
Hb	-0.013	0.002	-5.217	<0.001	0.987（0.982~0.992）
PLT	-0.002	0.001	-1.922	0.055	0.998（0.995~1.000）
ALB	-0.060	0.012	-5.118	<0.001	0.941（0.920~0.963）
TBil	0.002	0.001	3.995	<0.001	1.002（1.001~1.003）
INR	0.649	0.098	6.627	<0.001	1.914（1.579~2.319）
SCr	0.003	0.002	2.121	0.034	1.003（1.001~1.006）
TSA	0.002	0.001	6.676	<0.001	1.003（1.002 ~1.004）
腹水分级			10.524	0.005
中量	0.265	0.152	1.740	0.082	1.303（0.967~1.755）
大量	0.573	0.178	3.216	0.001	1.773（1.251~2.513）
肝性脑病	0.885	0.156	5.661	<0.001	2.424（1.784~3.293）
门静脉血栓	0.158	0.223	0.706	0.480	1.171（0.756~1.814）
EGVB	0.009	0.198	0.047	0.962	1.009（0.685~1.487）