Risk factors for hepatic encephalopathy in patients following transjugular intrahepatic portosystemic shunt: a...

Hepatic encephalopathy (HE) remains a major complication following transjugular intrahepatic portosystemic shunt (TIPS) placement. The objective of this study was to systematically evaluate and quantify risk factors for HE after TIPS through a meta-analysis.

A comprehensive search of multiple databases was conducted from inception until December 16, 2025 to identify observational studies (cohort or case-control designs) investigating risk factors for HE in adult patients after TIPS. Literature screening, data extraction, and quality assessment using the Newcastle-Ottawa Scale (NOS) were performed independently by two reviewers. Meta-analyses were conducted using Stata software. Odds ratios (ORs) or mean differences (MD) with 95% confidence intervals (CIs) were pooled for 26 potential risk factors.

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Twenty-seven studies (total 3,934 patients, 862 HE cases) were included. The overall methodological quality was moderate to high. Significant predictors of post-TIPS HE included advanced age (MD = 4.12 years, 95% CI: 2.68 to 5.56), Child-Pugh class C (OR = 2.87, 95% CI: 1.89 to 4.36), prior history of HE (OR = 3.28, 95% CI: 1.92 to 5.61), preoperative hyperammonemia (MD = 8.02 µmol/L, 95% CI: 4.15 to 11.89), hyponatremia (MD = -3.85 mmol/L, 95% CI: -4.72 to -2.98), significant pleural effusion (OR = 2.45, 95% CI: 1.28 to 4.68), and insufficient portal pressure gradient (PPG) reduction (MD = 2.31 mmHg, 95% CI: 1.15 to 3.47). Child-Pugh class A (OR = 0.45, 95% CI: 0.32 to 0.63) and the use of stents with a diameter ≥ 8 mm (OR = 0.58, 95% CI: 0.39 to 0.86) were protective factors.

This meta-analysis identifies post-TIPS hepatic encephalopathy as a multifactorial condition determined by the interplay of hepatic functional reserve (Child-Pugh score, ammonia), patient characteristics (age, prior HE), electrolyte balance (sodium), hemodynamic response (PPG reduction), and procedural factors (stent diameter). The quantification of 26 distinct factors underscores the necessity of a comprehensive, multidimensional risk assessment that integrates metabolic, neurological, and hemodynamic profiles.