1. Outcomes for patients undergoing TIPS insertion at KUMC since 01-JAN-2010
Samantha King, Jill Jones MD, Russ Waitman PhD
PRVM 868 Biomedical Informatics Driven Clinical Research
Final Presentation
Thursday, December 1st, 2016

2. What is TIPS? Transjugular intrahepatic portosystemic shunt
Used in patients with severe portal hypertension (usually from advanced liver disease)
Indications: refractory ascites or bleeding esophageal varices
Creates an artificial shunt from the portal vein to the hepatic vein, allowing blood to bypass the fibrotic liver. This relieves pressure downstream.

3. Research Interest
Masters thesis project: ultrasound elastography measurement of splenic stiffness before and after TIPS insertion
Hypothesis: there will be a significant decrease in splenic stiffness after TIPS
Long-term goal: validate splenic elastography as an accurate tool to monitor shunt function in TIPS patients
In doing background research for this project,
I found a wide array of dysfunction rates in literature
I found data on in-hospital mortality, but could not find data on overall mortality
I could not find much data on TIPS in transplant patients

4. Background
Benito et al. in 2004: “The reported cumulative rate of dysfunction ranges between…” (pooled data from several studies)
Benito A, Bilbao J, Hernández T, Martinez-Cuesta A, Larrache J, González I, Vivas I. Doppler ultrasound for TIPS: does it work? Abdom Imaging Jan-Feb;29(1): PubMed PMID:
TIME FRAME
DYSFUNCTION RATE
In the first six months
17-73%
In the first year
23-87%
In the first two years
80-83%

5. Study Design: Heron query
Cohort: all patients undergoing TIPS insertion since 01-JAN-2010
“Shopping cart” of data including
CPT codes (TIPS insertion, TIPS revision, transplant)
Diagnosis codes
Vital status/death date
Resulting query: 322 patients

6. Aims
Aim #1: Characterize the population of patients undergoing TIPS insertion at KU.
Aim #2: Quantify prognosis for TIPS patients in terms of:
Need for TIPS revision
Undergoing liver transplantation
Mortality
Aim #3: Determine how the prognosis differs based on etiology of liver disease

7. Aim #1
Characterize the population of patients undergoing TIPS insertion at KU.

8. Aim #1: Characterize the population: sex
FEMALE
MALE

9. Aim #1: Characterize the population: race
WHITE

10. Aim #1: Characterize the population: age

11. Aim #1: Characterize the population: vital status
LIVING

12. Aim #2 Quantify prognosis for TIPS patients in terms of:
Need for TIPS revision
Undergoing liver transplantation
Mortality

13. Aim #2: Quantify prognosis
Time zero = initial TIPS insertion
6 MONTHS
1 YEAR
2 YEARS
REVISION?
TRANSPLANT?
DEATH?
REVISION?
TRANSPLANT?
DEATH?
REVISION?
TRANSPLANT?
DEATH?

14. Aim #2: Quantify prognosis
Initial cohort: 322 patients
Endpoints:
TIPS revision
Liver Transplant
Death
Exclusions:
11 patients with “Deceased (death date unknown)” were excluded.
13 patients with negative value for “Time to transplant” or “Time to revision” were excluded.
Excluded: 11 patients “Deceased (death date unknown)”
Excluded: 2 patients time_to_revision < 0
Excluded: 11 patients time_to_transplant < 0
Final analysis cohort: 298 patients

15. Aim #2: Quantify prognosis: Revisions
How many patients needed at least one revision? 90/298 = 30%
What is the average number of revisions per patient? 0.45

16. Aim #2: Quantify prognosis: Revisions
Among those who did undergo shunt revision, what was the average time from insertion to 1st revision? days / = 0.77 years
Time zero = initial TIPS insertion
Average time to first revision
6 MONTHS
1 YEAR
2 YEARS

17. Aim #2: Quantify prognosis: Transplant
47 (16%) patients had a transplant at some point after TIPS insertion
Among those who did undergo transplant, what was the average time from TIPS to transplant? days / = years
Time zero = initial TIPS insertion
Average time to transplant
6 MONTHS
1 YEAR
2 YEARS

18. Aim #2: Quantify prognosis: Mortality
82 (27.5%) patients died
Among those who died, what was the average time from TIPS insertion to death? days / = years
Time zero = initial TIPS insertion
Average time to death
6 MONTHS
1 YEAR
2 YEARS

19. Dysfunction Benito et al
Aim #2: Quantify prognosis: summary
Revision?
Transplant?
Died?
Dysfunction Benito et al
By 6 months
17% (51)
7% (21)
15% (46)
17-73%
By 1 year
22% (66)
10% (30)
21% (62)
23-87%
By 2 years
27% (79)
14% (42)
24% (72)
80-83%

20. Aim #3
Determine how the prognosis differs based on etiology of liver disease.

21. Aim #3: Prognosis by etiology
Most common causes of cirrhosis in the US:
Hepatitis C virus infection
Alcoholic liver disease
Nonalcoholic fatty liver disease
Diagnoses I pulled from Heron (ICD9 and ICD10 codes):
NASH/NAFLD
Alcoholic cirrhosis
Hepatitis B
Hepatitis C
Autoimmune Hepatitis
Primary Biliary Cirrhosis
Primary Sclerosing Cholangitis

22. Aim #3: Prognosis by etiology
Time zero = initial TIPS insertion
30 DAY WINDOW
I pulled diagnosis codes from HERON because I am interested in stratifying prognosis post-TIPS based on underlying etiology of liver disease. Because my goal was to establish the cause of liver disease, I put a temporal qualifier around each diagnosis. I considered the patient as having that diagnosis as the cause if their liver disease if it was present before TIPS insertion, or within 30 days after.
DIAGNOSIS = “ETIOLOGY”

23. Aim #3: Prognosis by etiology
How many patients have each of the listed diagnoses? (see right)
These do not add up to 322. I was expecting these diagnoses to give me a pretty clear indication of the etiology of each patient’s cirrhosis, but it turns out that quite a few patients don’t have any of the listed diagnoses, and quite a few have more than one.

24. Aim #3: Prognosis by etiology
So how many patients have none of the listed diagnoses? How many have one? More than one?
Num_dx is the number of distinct diagnoses that each patient has

25. Aim #3: Prognosis by etiology
Solution for now: analyze alcoholic liver disease vs. “other”
“Alcohol” = any patient with a diagnosis of alcoholic cirrhosis (could be their sole dx, or they could have others in addition) →151 patients
“Other” = any patient who does not have a diagnosis of alcoholic cirrhosis (could have no listed dx, could have multiple others besides alcohol) →147 patients

26. Aim #3: Prognosis by etiology: Revisions

27. Aim #3: Prognosis by etiology: Transplant

28. Aim #3: Prognosis by etiology: Mortality

29. Future of this project
Refine how we set “etiology” of liver disease. Should I have included additional etiologies? Maybe I could stratify by num_dx?
How I will use this data
“Preliminary studies” in the grant I am working on
Thesis defense
Student research forum?
“Background” section of the manuscript for my masters project?