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Influence of shunt occlusion on liver volume and functions in hyperammonemic cirrhosis patients having large porto-systemic shunts: a randomized control trial

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A Correction to this article was published on 10 October 2022

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Abstract

Background and aims

Spontaneous-portosystemic-shunts (SPSS) in cirrhosis deprive the liver of nutrient-rich portal blood and contribute to recurrent hepatic encephalopathy (HE). We evaluated the effects of shunt occlusion and redirecting portal blood to liver on its volume and functions.

Methods

Cirrhosis patients presenting with recurrent HE and having SPSS were randomized to receive standard medical treatment (SMT) or shunt occlusion (SO). The later was performed by plug-assisted or balloon-occluded retrograde transvenous obliteration. The primary endpoint was change in liver volume after a minimum follow-up of 3 months. Secondary objectives included clinical course, liver disease severity indices, arterial ammonia levels and bone density.

Results

Of 40 enrolled patients, 4 in SMT and 2 in SO group were lost to follow-up. The SO was complete in 17 and partial in one, achieving non-recurrence of HE in 17 (94.4%). In these patients, the mean liver volume increased (baseline 1040 ± 335 ml to 1132 ± 322 ml, 8.8% increase, p < 0.001) and was observed in 16/18 (88.89%) patients. In the SMT group, the liver volume decreased (baseline 988 ± 270 ml to 904 ± 226 ml, 8.6% reduction, p = 0.009) during the same period. Serum albumin increased in SO group (2.92 ± 0.40 g/dl to 3.30 ± 0.49 g/dl, p = 0.006) but reduced in SMT group (2.89 ± 0.43 g/dl to 2.59 ± 0.65 g/dl, p = 0.047). After SO, the patients showed a reduction in serum-ammonia levels (181.06 ± 86.21 to 107.28 ± 44.53 μ/dl, p = 0.001) and an improvement in MELD-Na and bone density compared to SMT group. There were no major adverse events following shunt occlusion.

Conclusion

Occlusion of large SPSS results in improving the volume and synthetic functions of the liver by restoring hepato-petal portal flow besides reducing serum-ammonia level and recurrence of HE.

ClinicalTrials.gov number, NCT03293459.

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Funding

The work was not funded/received any financial support.

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Authors and Affiliations

  1. Department of Intervention Radiology, ILBS, New Delhi, India

    Amar Mukund, Tara Prasad Tripathy & Venkatesh Hosur Ananthashayana

  2. Department of Hepatology, Institute of Liver and Biliary Sciences, ILBS, New Delhi, 110070, India

    Shakti Prasad Choudhury, Rakesh Kumar Jagdish, Vinod Arora, Satender Pal Singh, Ajay Kumar Mishra & Shiv Kumar Sarin

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  1. Amar Mukund
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  2. Shakti Prasad Choudhury
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Contributions

AM, SPC and SKS contributed to hypothesis, experimental design, intellectual support, supervised the study and manuscript writing. SPC, TPT, VHA performed the experiments and data collection. RKJ, SPS, AKM did the patient selection and patient management and patient follow-up. SPC and TPT contributed for statistical and data analysis. All the authors have approved this manuscript.

Corresponding author

Correspondence to Shiv Kumar Sarin.

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Conflict of interest

Amar Mukund, Shakti Prasad Choudhury, Tara Prasad Tripathy, Venkatesh H. A, Rakesh Kumar Jagdish, Vinod Arora, Satender Pal Singh, Ajay Kumar Mishra and Shiv Kumar Sarin declare no conflict of interest.

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This study was approved by the institute’s ethics committee (IEC/2017/51/MA09).

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12072_2022_10418_MOESM1_ESM.docx

Supplementary file1 (DOCX 15 KB) Interclass correlation between two radiologists was found to be 97.2% (95% CI. 95.5–98.3. p < 0.001). The bland Altman graph shows that observations (2.94%) were not in agreement.

Supplementary file2 (TIFF 98 KB)

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Mukund, A., Choudhury, S.P., Tripathy, T.P. et al. Influence of shunt occlusion on liver volume and functions in hyperammonemic cirrhosis patients having large porto-systemic shunts: a randomized control trial. Hepatol Int 17, 150–158 (2023). https://doi.org/10.1007/s12072-022-10418-4

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