Muscle fat content correlates with postoperative survival of viral-related cirrhosis patients after the TIPS: a retrospective study

PURPOSE

Early prediction of the prognosis of viral-related cirrhosis patients after transjugular intrahepatic portosystemic shunt (TIPS) is beneficial for clinical decision-making. The aim of this study is to explore a comprehensive prognostic assessment model for evaluating the survival outcomes of patients post-TIPS.

MATERIALS AND METHODS

A total of 155 patients treated with TIPS were included in the study. The data were collected from electronic records. The nutritional status of the patient is evaluated using imaging examinations measuring by the axial CT images from the L3 vertebral level. The primary endpoint was set as death within 1 year after TIPS. Multivariate Cox regression was performed to determine the factors associated with mortality.

RESULTS

The Cox regression analysis revealed that the lower PMFI was associated with a lower risk of all-cause mortality after TIPS (hazard ratio [HR] 1.159, 95% confidence interval [CI] 1.063-1.263, p = 0.001). Furthermore, subgroup analyses according to gender revealed the PMFI was associated with postoperative death both in male (HR 2.125, 95% CI, 1.147-3.936, p = 0.017) and female patients (HR 1.070, 95% CI, 1.001-1.144, p = 0.047). The area under the curve (AUC) for predicting death within 1 year was 0.807. The clinical impact curve analysis showed that PMFI had higher levels of risk threshold probability and a smaller gap between actual and predicted curves.

CONCLUSIONS

In viral-related cirrhosis patients with portal hypertension, increased muscle fat content might be a potential prognostic marker and associated with postoperative death after TIPS.

Distinct clusters of bacterial and fungal microbiota in end-stage liver cirrhosis correlate with antibiotic treatment, intestinal barrier impairment, and systemic inflammation

Decompensated liver cirrhosis (dLC) is associated with intestinal dysbiosis, however, underlying reasons and clinical consequences remain largely unexplored. We investigated bacterial and fungal microbiota, their relation with gut barrier integrity, inflammation, and cirrhosis-specific complications in dLC-patients. Competing-risk analyses were performed to investigate clinical outcomes within 90 days. Samples were prospectively collected from 95 dLC-patients between 2017 and 2022. Quantitative metagenomic analyses clustered patients into three groups (G1-G3) showing distinct microbial patterns. G1 (n = 39) displayed lowest diversity and highest Enterococcus abundance, G2 (n = 24) was dominated by Bifidobacteria, G3 (n = 29) was most diverse and clustered most closely with healthy controls (HC). Of note, bacterial concentrations were significantly lower in cirrhosis compared with HC, especially for G1 that also showed the lowest capacity to produce short chain fatty acids and secondary bile acids. Consequently, fungal overgrowth, dominated by Candida spp. (51.63%), was observed in G1. Moreover, G1-patients most frequently received antibiotics (n = 33; 86.8%), had highest plasma-levels of Zonulin (p = 0.044) and a proinflammatory cytokine profile along with numerically higher incidences of subsequent infections (p = 0.09). In conclusion, distinct bacterial clusters were observed at qualitative and quantitative levels and correlated with fungal abundances. Antibiotic treatment significantly contributed to dysbiosis, which translated into intestinal barrier impairment and systemic inflammation.

Interface design features of clinical decision support systems for real-time detection of deterioration: A scoping review

BACKGROUND

Clinical decision support systems (CDSS) can support clinicians with the timely detection of patients' clinical deterioration, however, less than half of clinical decision support (CDS) systems implemented for clinical deterioration are used by clinicians. Poor design of CDS systems has emerged as a contributing factor.

OBJECTIVE

The aim of this study was to 1) identify interface design features that have been used in CDS systems for real-time detection of clinical deterioration; (2) determine which interface design features are preferred by clinicians; and (3) examine other design features (external to the interface) which influence CDS acceptance.

METHODS

Three databases (Medline, Scopus and CINAHL) were searched to identify relevant studies. All studies that met the eligibility criteria were included. A qualitative narrative synthesis was undertaken.

RESULTS

Of 24 eligible articles, 17 described CDS systems in the form of a dashboard and 7 described alerts. Of the 17 dashboards, graphs and tables were the most used interface design features to display vital signs. Colour was the most frequently used interface design feature to signal the presence of deterioration with half of colour-coded dashboards using a traffic light schema to classify patient risk level. Clinicians preferred dashboards that included both graphs and tables. Clinicians have expressed that they were disinclined to use CDS systems with manual recording of vital signs and high alert frequency.

CONCLUSIONS

This scoping review uncovered wide variability in design features across CDS systems for real-time detection of deterioration. Our research calls for better adherence to reporting checklists when reporting on interface designs, and the development of design guidelines to guide interface designs of CDS systems for detecting deterioration in real-time. Our scoping review may serve as a preliminary guide for the design of future CDS systems for detecting deterioration.

Budd-Chiari syndrome in a 33-year-old woman with hypercoagulable state: A case report

Budd-Chiari syndrome (BCS) is a rare disorder caused by hepatic venous outflow obstruction, often linked to underlying prothrombotic conditions. This case describes a 33-year-old woman who presented with abdominal pain and ascites and was diagnosed with BCS secondary to deficiencies in protein C, protein S, and antithrombin III. She also had a history of epilepsy, bipolar disorder, and poor medication adherence. Imaging studies, including Doppler ultrasound and contrast-enhanced CT, played a crucial role in confirming the diagnosis. Despite treatment with anticoagulation and diuretics, recurrent ascites and behavioral issues complicated management, leading to a poor prognosis. This case highlights the importance of early recognition, imaging in diagnosis, and evaluation of prothrombotic disorders in patients with BCS to improve outcomes.

Predicting Hepatic Decompensation in Patients With Metabolic Dysfunction Associated Steatotic Liver Disease-Related Cirrhosis: The ABID-LSM Model

BACKGROUND & AIMS

Predicting the risk of hepatic decompensation guides prognostication and therapy; however, it is challenging in patients with cirrhosis due to metabolic dysfunction-associated steatotic liver disease (MASLD). We aimed to improve a previously developed predictive tool of hepatic decompensation in MASLD cirrhosis (ABIDE) by incorporating liver stiffness measurement (LSM).

METHODS

A multi-centre retrospective cohort of patients with compensated cirrhosis due to MASLD was identified, with decompensation incidence assessed using competing risk regression. The prognostic accuracy of a modified ABIDE model incorporating LSM (ABID-LSM) was assessed using time-dependent AUC (tAUC) and compared with other predictive models.

RESULTS

Out of 388 patients, 273 (70.4%) had available LSM. Hepatic decompensation occurred in 54 (20%) patients during follow-up (median 31 months, range: 20-60). The predictive accuracy at 5 years of ABID-LSM (tAUC 0.80) was better than ABIDE (tAUC 0.75, p = 0.03) and LSM (tAUC 0.63, p < 0.001). The ABID-LSM model calibrated well (slope 0.99) with excellent overall performance (Integrated Brier Score 0.15). A cut-off of 8.1 separated those at high and low risk of hepatic decompensation at 5 years (24% vs. 5%, respectively, sHR = 4.8, p < 0.001). The ABID-LSM model had better predictive ability at 5 years than ALBI, FIB-4, NAFLD Decompensation Risk Score and ANTICIPATE models (all p < 0.001) as well as hepatic vein pressure gradient measurement (tAUC 0.78 vs. 0.71, p < 0.001, n = 60).

CONCLUSIONS

The ABID-LSM model has greater accuracy in predicting hepatic decompensation in patients with cirrhosis due to MASLD than existing predictive models. If externally validated, ABID-LSM may identify those who benefit from pharmacotherapy and close monitoring.

Predictive value of liver enzymes in long-term prognosis of hepatic Wilson disease: results from the Wilson AEEH registry

BACKGROUND AND AIMS

Monitoring Wilson disease (WD) is challenging due to its variable presentation and the absence of reliable biomarkers. This study aims to assess the predictive value of liver enzymes, particularly transaminases, on long-term outcomes in patients with hepatic WD using data from the Spanish Wilson Registry.

PATIENTS AND METHODS

We analysed data from 162 WD patients with hepatic involvement and over one year of follow-up. Patients were classified as mild (no cirrhosis) or severe (with cirrhosis) at diagnosis. An "unstable pattern of transaminases" was defined as recurrent AST or ALT elevations. Unfavourable outcomes included new cirrhosis, elastography progression > 2 Kpa, liver transplant, or liver-related deaths. Logistic regression models were used to evaluate the impact of various factors on disease outcome.

RESULTS

Of 162 patients, 81.5% had mild disease at diagnosis. Most received chelators as first-line therapy, achieving an 81.4% one-year biochemical response. After a median follow-up of 17 years, 59% exhibited an unstable transaminase pattern, and 29% had an unfavourable outcome. Key factors associated with poor outcome included older age at diagnosis (OR = 1.03), lack of early biochemical response (OR = 0.19), advanced disease markers (platelet count, albumin), and an unstable transaminase pattern (OR = 2.92). Transaminase levels did not predict outcomes based on initial disease severity. Even patients with mild disease at diagnosis and persistently normal transaminases could experience progression over time, underscoring the need for more thorough follow-up evaluations.

CONCLUSION

While transaminases are valuable for monitoring WD, they should be used alongside other biomarkers to better predict disease progression.

Non-cirrhotic portal hypertension in pregnancy due to schistosomiasis: A case series

The presence of non-cirrhotic portal hypertension in pregnancy poses a challenging clinical scenario as it predisposes women to several life-threatening complications such as variceal haemorrhage, splenic artery aneurysm, pulmonary hypertension and bacterial peritonitis. The haemodynamic changes in pregnancy along with the demands of a growing fetus may worsen the severity of pre-existing non-cirrhotic portal hypertension. In this case series, we discuss four cases of non-cirrhotic portal hypertension in pregnancy in a low to middle income setting and review the literature related to this condition.

NSBBs, EBL or Combined Therapy for High-Risk Varices: Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Non-selective beta blocker (NSBB) is the preferred treatment option for primary prophylaxis of high-risk oesophageal varices, and endoscopic band ligation (EBL) is reserved for those intolerant to NSBB. In this meta-analysis, we aim to compare the outcomes of NSBB, EBL and combined therapy for primary prophylaxis of high-risk oesophageal varices.

METHODS

Major databases, such as MedLine, Embase and Cochrane Library were searched in October 2024 to identify studies comparing clinical outcomes between combined approaches versus NSBB versus EBL only. Only randomised trials were included. Meta-analysis was performed using the random-effects model, and heterogeneity was assessed by I2% statistics.

RESULTS

Six randomised trials were included, which consisted of 1011 participants (NSBB 302, EBL 300 and 409 combined) (75.27% males), with an average age of 51.06 years. The NSBBs used were propranolol, nadolol and carvedilol, with an average follow-up of 17.54 months. The combined approach significantly reduced the first episode of variceal bleeding compared to NSBB alone (pooled RR 0.39 [95% CI 0.19-0.76], p = 0.009) and EBL alone (RR 0.46, 0.29-0.74; p = 0.002). The pooled rate of bleeding with the combined approach was 9.4% [95% CI 6%-14.3%], with NSBB being 28.2% [95% CI 12.9%-51%] and with EBL being 13.9% [6%-17%]. Pooled ratios for bleeding-related mortality were significantly better with the combined approach when compared to NSBB alone.

CONCLUSION

Primary prophylaxis of high-grade varices by combined therapy demonstrated a significantly lower risk of variceal bleeding than NSBB or EBL alone. We recommend these findings be incorporated into forthcoming guidelines.

Impaired whole blood thrombin generation is associated with procedure-related bleeding in acutely decompensated cirrhosis

BACKGROUND & AIMS

The clinical utility of thrombomodulin-modified thrombin generation (TM-TG) in cirrhosis is uncertain. We conducted a prospective study to evaluate the prognostic value of TM-TG in cirrhosis.

METHODS

Patients were recruited during outpatient clinics (compensated and stable decompensated cirrhosis) or if admitted to our inpatient service (acutely decompensated cirrhosis). We performed whole blood (WB) and platelet-poor plasma (PPP) TM-TG at recruitment. All patients were prospectively followed-up for bleeding/thrombosis, hepatic decompensation, and liver-related death.

RESULTS

We included 231 patients: 80 with compensated, 70 with stable decompensated, and 81 with acutely decompensated cirrhosis. Median follow-up was 414 days (range: 77-668). Eleven patients, all with acutely decompensated cirrhosis, experienced procedure-related bleeding. Both WB-TG and PPP-TG were more altered in bleeding vs. non-bleeding individuals (lower endogenous thrombin potential [ETP] and peak-height). However, only WB-TG could identify - at the individual patient level - those experiencing major bleeding (all having pre-procedural ETP <350 nmol/L∗min). In acutely decompensated cirrhosis, the AUC of WB-TG ETP for bleeding was 0.854 (95% CI 0.732-0.976), which was higher than that of PPP-TG ETP (0.676; 95% CI 0.524-0.809). Neither WB-TG nor PPP-TG could predict development of thrombosis, mostly portal vein thrombosis (n = 15). In compensated cirrhosis, WB-TG and PPP-TG were comparable between patients who experienced decompensation and those who did not. In decompensated cirrhosis, WB-TG and PPP-TG were more significantly altered in patients experiencing further decompensation/ACLF/liver-related death. A higher WB-TG ETP was linked to a lower risk of progression independently of MELD, Child-Pugh, and C-reactive protein (hazard ratio 0.4, 95% CI 0.21-0.79, p <0.01).

CONCLUSIONS

In compensated cirrhosis, WB-TG and PPP-TG do not improve risk stratification. In decompensated cirrhosis, WB-TG may be a promising tool for estimating procedure-related bleeding risk.

IMPACT AND IMPLICATIONS

Thrombomodulin-modified thrombin generation (TM-TG) in cirrhosis is a well-established research tool to assess the complex coagulopathy of cirrhosis; however, its clinical utility is uncertain. In acutely decompensated cirrhosis, a TM-modified whole blood (WB)-TG ETP <350 nmol/L∗min predicted major bleeding after invasive procedures, whereas platelet-poor plasma TG indicated a hypo-coagulable state in bleeding patients but could not identify those at risk. Neither WB-TG nor platelet-poor plasma-TG could predict development of portal vein thrombosis, which was predicted by cirrhosis and portal hypertension severity. In decompensated cirrhosis, a better WB-TG capacity was associated with a lower risk of further decompensation, acute-on-chronic liver failure, and liver-related death independently of MELD score/Child-Pugh stage and C-reactive protein.

Percutaneous recanalization of non-cirrhotic extrahepatic portal vein obstruction in children: technical considerations in a preliminary cohort

OBJECTIVES

Portal hypertension resulting from non-cirrhotic extrahepatic portal vein obstruction (EHPVO) in children has been primarily managed with the Meso-Rex bypass, but only a few patients have a viable Rex recessus, required by surgery. This study reports a preliminary series of patients who underwent interventional radiology attempts at portal vein recanalization (PVR), with a focus on technical aspects and safety.

METHODS

A retrospective review of consecutive patients with severe portal hypertension due to non-cirrhotic EHPVO at a single institution from 2022, who underwent percutaneous attempts at PVR, was performed. Technical and clinical data including fluoroscopy time, radiation exposure, technical and clinical success, complications and follow-up were recorded.

RESULTS

Eleven patients (6 males and 5 females; median age 7 years, range 1-14) underwent 15 percutaneous transhepatic (n = 1), transplenic (n = 11), or simultaneous transhepatic/transplenic (n = 3) procedures. Rex recessus was patent in 4/11 (36%). Fluoroscopy resulted in a high median total dose area product (DAP) of 123 Gycm2 (range 17-788 Gycm2) per procedure. PVR was achieved in 5/11 patients (45%), 3/5 with obliterated Rex recessus. Two adverse events of grade 2 and grade 3 occurred without sequelae. After angioplasty, 4/5 patients required stenting to obtain sustained patency, as demonstrated by colour-Doppler ultrasound in all PVR after a median follow-up of 6 months (range 6-14).

CONCLUSION

Our preliminary experience suggests that 45% of children with non-cirrhotic EHPVO can restore portal flow even with obliterated Rex recessus. In non-cirrhotic EHPVO, PVR may be an option, if a Meso-Rex bypass is not feasible, although the radiation exposure deserves attention.

CLINICAL RELEVANCE STATEMENT

Innovative percutaneous procedures may have the potential to be an alternative option to the traditional surgical approach in the management of non-cirrhotic EHPVO and its complications in children not eligible for Meso-Rex bypass surgery.

KEY POINTS

Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation. Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded. Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.

Clinical Trial: A Multicentre Randomised Controlled Trial of Carvedilol Versus Variceal Band Ligation in Primary Prevention of Variceal Bleeding in Liver Cirrhosis (CALIBRE Trial)

BACKGROUND

The superior efficacy of non-selective beta-blockers (NSBB) compared with variceal band ligation (VBL) in the primary prevention of variceal bleeding is uncertain.

AIM

To compare carvedilol versus VBL for primary prevention of variceal bleeding.

METHODS

CALIBRE was an investigator-initiated, multicentre, randomised, controlled, open-label trial. Participants were randomly assigned to 12.5 mg carvedilol once daily or VBL. Inclusion criteria were cirrhosis and medium to large oesophageal varices that had not bled. The primary outcome is any variceal bleeding within 1 year of randomisation. Secondary outcomes include survival, other complications of cirrhosis, quality of life, cost-effectiveness and adverse events. Recruitment closed early, mainly due to the impact of the pandemic.

RESULTS

265 participants (10% of the intended sample size) from 52 sites were randomised to carvedilol (n = 133) or VBL (n = 132) between 22 January 2019 and 31 August 2022. 5/133 participants (3.8%) in the carvedilol arm vs. 10/132 participants (7.6%) in the VBL arm experienced variceal bleeding (risk ratio 0.50 (95% confidence interval [CI]; 0.17-1.41); risk difference - 0.038 (95% CI; -0.094-0.017)). Serious adverse events occurred in one participant in each treatment arm, with no treatment-related deaths. Of the secondary outcomes, there were no statistically significant differences. Carvedilol was cheaper and resulted in slightly more quality-adjusted life years than VBL.

CONCLUSIONS

The early terminated and, thus, underpowered CALIBRE trial showed no difference between carvedilol and VBL in the primary prevention of variceal bleeding in patients with cirrhosis and medium-to large-sized oesophageal varices. No untoward safety concerns were noted.

TRIAL REGISTRATION

ISRCTN73887615.

Non-Invasive Stratification of Portal Hypertension in Patients With BCR::ABL1-Negative Myeloproliferative Neoplasms

BACKGROUND & AIMS

The course of BCR::ABL1-negative myeloproliferative neoplasms (MPN) is frequently complicated by thromboembolic events in the splanchnic venous system, resulting in portal hypertension (PH). Therefore, the introduction of spleen stiffness measurement (SSM) might improve the diagnosis of PH. The aim of this study was to evaluate the clinical utility of SSM (performed by using the 100 Hz probe) in non-invasive stratification of PH in these patients.

METHODS

We performed a retrospective, monocentric, cross-sectional analysis including consecutive patients with BCR::ABL1-negative MPN attending the haematological outpatient clinic at the Medical University of Vienna with available liver stiffness (LSM)/SSM from 10/2023 to 09/2024. LSM/SSM were linked to signs and events of PH.

RESULTS

Fifty-five patients were included (mean age 57.9 ± 14.2 years, 69% females, polycythaemia vera as main entity). One fourth of patients had splanchnic vein thrombi. Nineteen patients (34.5%) had specific and 29 patients (52.7%) had unspecific signs of PH. Twelve patients (21.8%) experienced PH events prior to study inclusion. SSM correlated with disease severity (i.e., JAK2 V617F allele frequency). LSM/SSM adequately stratified patients with vs. without PH. While SSM was strongly linked with splenomegaly, it yielded independent information regarding PH on top of splenomegaly. The implementation of sequential LSM (< 5 & ≥ 15 kPa) and SSM (< 21 & ≥ 50 kPa) for ruling in and out PH reduced the grey zone (24%) with adequate sensitivity/specificity.

CONCLUSIONS

While SSM is strongly correlated with splenomegaly and disease severity, it is independently associated with PH in patients with BCR::ABL1-negative MPN. Implementation of LSM/SSM might improve patient management.

Safety of Anticoagulant Treatment in Patients With Splanchnic Vein Thrombosis and History of Portal Hypertension-Related Bleeding

Splanchnic vein thrombosis (SVT) can be associated with liver cirrhosis or prothrombotic conditions, including myeloproliferative disorders, intra-abdominal inflammation, solid cancers or surgery. While anticoagulation therapy improves outcomes in noncirrhotic patients and reduces all-cause mortality in cirrhotic populations, its safety in patients with a history of portal hypertension (PH)-related bleeding is less clear. This systematic review examines the impact of anticoagulant therapy on rebleeding risk in SVT patients with a history of PH-related bleeding. A systematic review and meta-analysis were conducted according to PRISMA guidelines. A comprehensive search of PubMed, Web of Science and Scopus was performed for studies published up to September 2024. Studies were included if they compared SVT patients with a history of PH-related bleeding receiving anticoagulant therapy versus those not receiving anticoagulants. The primary outcome was the cumulative incidence of PH-related rebleedings. Of 2853 identified studies, five (186 participants) met the inclusion criteria: two randomised controlled trials (RCTs) and three observational studies. The cumulative incidence of PH-related rebleeding was significantly lower in the anticoagulant group at 17.10% [95% CI 17.02, 17.19] compared to the control group at 40.00% [95% CI 39.90, 40.09]. The overall odds ratio (OR) from observational studies was 0.15 [95% CI 0.04, 0.52], indicating a reduced bleeding risk, while the OR from RCTs was 0.84 [95% CI 0.31, 2.32], showing a nonsignificant trend. Anticoagulant therapy may reduce rebleeding risk in SVT patients with a history of PH-related bleeding, but further high-quality studies are needed.

TIPS versus endoscopic cyanoacrylate injection for the treatment of gastric fundal variceal rebleeding: a propensity score-matched retrospective cohort study

BACKGROUND

The optimal strategy for preventing rebleeding with gastroesophageal varices type 2 (GOV2) and isolated gastric varices type 1 (IGV1) is unclear. In this retrospective study, we aimed to compare the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic cyanoacrylate injection (ECI) on GOV2 and IGV1 varices.

METHODS

In this retrospective cohort study, we collected data from patients with cirrhosis with GOV2 and IGV1 varices who received TIPS or ECI treatment between June 2018 and June 2023. The primary endpoint was rebleeding, and the secondary endpoints were death and overt hepatic encephalopathy (OHE). Propensity score matching (PSM) and adjusted survival curves were used to assess the robustness of the results.

RESULTS

A total of 111 eligible patients were included, of whom, 35 patients received TIPS and 76 patients received ECI. The median follow-up time for the TIPS and ECI groups were 746 and 683 days, respectively. TIPS reduced the all-cause rebleeding rate (14.3% versus 33.8%, p = 0.033; after PSM, 16.7% versus 40.0%, p = 0.045) compared with ECI, with lower risk of ectopic embolism (all were in the ECI group). The Incidence of OHE in the TIPS group was higher than that in the ECI group (28.6% versus 1.4%, p < 0.001; after PSM, 33.3% versus 3.3%, p < 0.001). However, no significant difference was found in mortality (17.1% versus 12.2%, p = 0.684; after PSM, 16.7% versus 16.7%, p = 1.000). The results were not affected by the adjusted survival curve.

CONCLUSION

TIPS was more effective than ECI in preventing rebleeding in patients with GOV2 and IGV1 varices with similar survival rates and lower risk of ectopic embolism, although TIPS was associated with a higher incidence of OHE.

Real-world effectiveness and safety of bulevirtide monotherapy for up to 96 weeks in patients with HDV-related cirrhosis

BACKGROUND & AIMS

Bulevirtide (BLV) 2 mg/day is EMA approved for the treatment of compensated chronic HDV infection; however, real-world data in large cohorts of patients with cirrhosis are lacking.

METHODS

Consecutive HDV-infected patients with cirrhosis starting BLV 2 mg/day from September 2019 were included in a European retrospective multicenter real-world study (SAVE-D). Patient characteristics before and during BLV treatment were collected. Virological, biochemical, combined responses, adverse events and liver-related events (hepatocellular carcinoma [HCC], decompensation, liver transplant) were assessed.

RESULTS

A total of 244 patients with HDV-related cirrhosis receiving BLV monotherapy for a median of 92 (IQR 71-96) weeks were included: at BLV start, median (IQR) age was 49 (40-58) years and 61% were men; median ALT, LSM and platelet count were 80 (55-130) U/L, 18.3 (13.0-26.3) kPa, and 94 (67-145) x103/mm3, respectively; 54% had esophageal varices, 95% Child-Pugh A cirrhosis, and 10% HIV coinfection; 92% were on nucleos(t)ide analogues; median HDV RNA and HBsAg were 5.4 (4.1-6.5) log10 IU/ml and 3.8 (3.4-4.1) log10 IU/ml, respectively. At weeks 48 and 96, virological, biochemical and combined responses were observed in 65% and 79%, 61% and 64%, 44% and 54% of patients, respectively. AST, GGT, albumin, IgG and LSM values significantly improved throughout treatment. Serum bile acid levels increased in most patients, but only 10% reported mild and transient pruritus, which was independent of bile acid levels. The week 96 cumulative risks of de novo HCC and decompensation were 3.0% (95% CI 2-6%) and 2.8% (95% CI 1-5%), respectively. Thirteen (5%) patients underwent liver transplantation (n = 11 for HCC, n = 2 for decompensation).

CONCLUSION

BLV 2 mg/day monotherapy for up to 96 weeks was safe and effective in patients with HDV-related cirrhosis. Virological and clinical responses increased over time, while the incidence of liver-related complications was low.

IMPACT AND IMPLICATIONS

Bulevirtide 2 mg/day is EMA approved for the treatment of compensated chronic hepatitis delta; however, real-world data in large cohorts of patients with cirrhosis are lacking. Bulevirtide 2 mg/day monotherapy for up to 96 weeks was safe and effective (week 96: 79% virological, 64% biochemical and 54% combined response) in a large real-world cohort of patients with HDV-related cirrhosis, including patients with clinically significant portal hypertension. Liver function tests and liver stiffness improved, suggesting a potential clinical benefit in patients with advanced liver disease, while the incidence of de novo liver-related events (hepatocellular carcinoma and decompensation) was low during the 96-week study period.

Patients with cirrhosis have a disbalance between coagulation and fibrinolysis resulting in a prothrombotic phenotype

BACKGROUND

Patients with cirrhosis develop multiple hemostatic alterations. Although fibrinolysis is also affected by liver disease, studies have produced conflicting results, highlighting the need for a reliable fibrinolysis assay. Assessing the kinetics of plasmin generation (PG) is a new method to study the fibrinolytic state of cirrhosis patients.

OBJECTIVES

This study aimed to compare fibrinolysis between patients with cirrhosis and healthy subjects.

METHODS

This single-center cohort study included cirrhosis patients from the Padova University Hospital. Fibrinolysis and hemostasis were assessed with PG, thrombin generation (TG), and clot lysis time. To quantify malalignment between TG and PG, ratios were calculated.

RESULTS

In total, 101 patients with cirrhosis (Child-Pugh A/B/C: 36/24/41) and 20 healthy subjects were included. Compared with healthy subjects, patients showed a significantly lower endogenous plasmin potential and plasmin peak. The PG capacity decreased with liver disease severity. The lag time to PG was prolonged in patients. No differences in endogenous thrombin potential and lag time were found when comparing TG profiles. Patients had a shorter clot lysis time. Increased TG/PG ratios for the endogenous plasmin potential and plasmin peak were found in patients compared with that in controls. TG/PG ratios increased with liver disease severity.

CONCLUSION

Patients with cirrhosis have a complex fibrinolytic profile, with a delayed and decreased capacity to generate plasmin and a more rapid clot lysis. A disbalance was found between coagulation and fibrinolysis, with a normal-to-increased TG capacity and a decreased PG capacity. These results support the theory that cirrhosis patients are in a prothrombotic state.

Current Situation and Prospects of Digital Therapeutics in the Field of Liver Diseases in China

Digital therapeutics have developed rapidly in recent years, providing a new method for disease management. The burden of liver diseases in China is heavy, and there are obvious problems in disease management. This paper expounds on the definition and classification of digital therapeutics, introduces their application in liver disease treatment and management in detail, and analyzes their development prospects in the field of liver diseases and future challenges.Graphical abstract available for this article.

Inferior vena cava-splenic vein shunt for the treatment of complete portal trunk occlusion and portal cavernoma in liver cirrhosis

OBJECTIVES

The transjugular intrahepatic portosystemic shunt procedure remains technically challenging in cases involving occlusion of the portal trunk. This study aimed to evaluate the feasibility, efficacy, and safety of utilizing the inferior vena cava-splenic vein shunt (IVCSS) as a new treatment option in cirrhotic patients with complete portal trunk occlusion and portal cavernoma.

METHODS

The IVCSS procedure was performed on twelve patients, involving the creation of a shunt using a covered stent between the inferior vena cava and the proximal end of the splenic vein to reduce distal portal pressure.

RESULTS

Technical success was achieved in all patients, with a mean procedure duration of 71.7 ± 44.2 min. The portosystemic gradient was reduced by a mean of 11.0 ± 5.6 mmHg after the procedure. After a median follow-up of 6.7 [2.8-11.4] months, clinical symptoms improved in all patients. Stent dysfunction occurred in 1 patient, the recurrence rates for variceal bleeding and ascites were 8.3% and 16.7%, respectively. One patient (8.3%) experienced a procedure-related complication of retroperitoneal hemorrhage. Three patients (25%) had an episode of hepatic encephalopathy, which improved after conservative treatment.

CONCLUSION

IVCSS effectively reduced distal portal pressure, which contributed to an improvement of the patients' clinical symptoms with an acceptable procedure-related complication rate. IVCSS may serve as an alternative strategy to manage symptomatic portal hypertension for patients with complete portal trunk occlusion and portal cavernoma.

KEY POINTS

Question What is an alternative treatment for cirrhotic patients with symptomatic portal hypertension caused by chronic portal vein occlusion other than TIPS? Findings Inferior vena cava-splenic vein shunt (IVCSS) is feasible for reducing distal portal pressure and effectively improving clinical symptoms. Clinical relevance For cirrhotic patients with complete portal trunk occlusion and portal cavernoma, the IVCSS approach seemed to be a promising alternative treatment for symptomatic portal hypertension.

Carvedilol and traditional nonselective beta blockers for the secondary prophylaxis of variceal hemorrhage and portal hypertension related complications among patients with decompensated cirrhosis: a systematic review and network meta-analysis

BACKGROUND

Carvedilol has limited research on decompensated cirrhosis. This study compared the effects of carvedilol, traditional nonselective beta blockers (NSBBs), including propranolol and nadolol, and other interventions in patients using carvedilol or traditional NSBBs for secondary prophylaxis of variceal hemorrhage (VH) and portal hypertension (PH)-related complications.

METHODS

A systematic search of databases, including PubMed, Embase, Cochrane Library, and Scopus, was conducted through October 2023. Randomized controlled trials (RCTs) evaluating carvedilol or traditional NSBBs for secondary prophylaxis of VH were included. The outcomes were the occurrence of VH and portal PH-related complications, including new or worsening ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome. A network meta-analysis was performed using a random-effects model.

RESULTS

A total of 60 RCTs involving 5,600 patients with a median Child Pugh score of 8.0 (range 6.8-10) were included. The risk of carvedilol plus variceal band ligation (VBL) on VH was lower than placebo (relative risk (RR) 0.24; 95% confidence interval (CI): 0.10-0.57), and the risk of carvedilol on new or worsening ascites was lower than placebo (RR = 0.10, 95%CI; 0.01-0.93). Traditional NSBBs plus VBL also had preventive effects on VH compared to placebo (RR = 0.31, 95%CI; 0.18-0.54). However, there were no differences between carvedilol and traditional NSBBs in other outcomes.

CONCLUSION

Carvedilol can prevent PH-related complications, including VH and new or worsening ascites, in cirrhosis patients with a history of VH. No significant differences were observed between the effects of carvedilol and traditional NSBBs, both combined with VBL.

Longitudinal Relationship Between Elevated Liver Biochemical Tests and Negative Clinical Outcomes in Primary Biliary Cholangitis: A Population-Based Study

BACKGROUND

Elevated liver biochemistries are associated with increased risk of negative outcomes in patients with primary biliary cholangitis (PBC).

AIMS

To evaluate whether longitudinal monitoring of liver biochemistries and fibrosis scores provides additional prognostic value and to assess the relationship between the degree of elevation of multiple biomarkers within different alkaline phosphatase (ALP) strata.

METHODS

Adults with PBC were identified from Komodo's Healthcare Map. A Cox proportional hazards model examined time to first occurrence of hospitalisation due to hepatic decompensation, liver transplantation, or death as a function of the proportion of time during follow-up that liver biochemistries and fibrosis scores exceeded thresholds. Within ALP strata (ALP ≤ upper limit of normal [ULN]; ALP>ULN to ≤ 1.67 × ULN; ALP > 1.67 × ULN), separate multivariate Cox hazard models assessed the association between time-varying covariates and the composite endpoint.

RESULTS

Overall, 3974 patients were included; 88.2% were female, with a mean age of 59.4 years. The median follow-up was 2.5 years. Increasing magnitude and duration beyond established thresholds of ALP, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TB), AST/platelet ratio index (APRI) and fibrosis-4 (FIB-4) were associated with increased risk of negative outcomes. Elevated ALT, AST, TB, APRI and FIB-4 were associated with increased risk of negative outcomes across all ALP strata.

CONCLUSIONS

Prolonged elevation of multiple hepatic biomarkers and fibrosis scores is associated with a greater risk of negative clinical outcomes, underscoring the importance of ongoing monitoring beyond the guideline-recommended initial treatment response to guide timely treatment decisions and improve PBC management.

Visual prediction models for predicting rebleeding events after the first esophageal variceal ligation

BACKGROUND

Sequential endoscopic variceal ligation (EVL) is a standard therapy for esophageal variceal bleeding, yet poor compliance often compromises its efficacy. This study aimed to identify high-risk factors for rebleeding after initial EVL and establish a visual predictive model to improve patient follow-up and education.

METHODS

In this retrospective study, we enrolled patients who underwent first-time EVL for esophageal variceal bleeding at Xiangya Hospital, Central South University, between January 2017 and January 2023. Patients were allocated to training and validation cohorts. Clinical data were systematically collected, and rebleeding incidence rates within 6 weeks and 6 months post-EVL were analyzed. Logistic regression was used to explore high-risk factors influencing postoperative rebleeding and to establish visual models, evaluated with a validation set.

RESULTS

The study involved 629 patients in the training set and 312 in the validation set. Rebleeding occurred in 34.8% (219/629) and 80.1% (504/629) of patients within 6 weeks and 6 months after initial EVL, respectively. Esophageal variceal severity and platelet count emerged as shared independent risk factors for both 6-week and 6-month rebleeding. The nomogram models demonstrated robust predictive accuracy in the validation cohort, with areas under the curve (AUC) of 0.942 (95% CI 0.901-0.983) for 6-week rebleeding risk and 0.852 (95% CI 0.759-0.945) for 6-month rebleeding risk.

CONCLUSION

This study proposes a visual prediction model designed to assess the risk of rebleeding following initial EVL in patients with esophageal variceal hemorrhage to optimize clinical decision-making and improve patient management strategies.

Transjugular mesenteric-caval shunt for portal vein cavernous transformation with recurrent variceal bleeding: preliminary results

OBJECTIVES

This study aimed to evaluate the feasibility, safety, and efficacy of the transjugular mesenteric-caval shunt (TMCS) as a treatment for the cavernous transformation of the portal vein (CTPV) and recurrent variceal bleeding.

METHODS

This retrospective case series was conducted with approval from the institutional review board. It involved seven patients diagnosed with CTPV and recurrent variceal bleeding who underwent the TMCS procedure. We analyzed the rate of procedural complications, incidents of rebleeding, stent stenosis, hepatic encephalopathy, and overall survival to assess treatment outcomes.

RESULTS

The TMCS was successfully performed in all seven patients without any life-threatening complications. Postoperatively, one patient developed a lung infection and pleural effusion, which resolved with appropriate treatment. Additionally, two patients experienced an increase in total bilirubin levels, but there was no further deterioration in liver function. The median portal pressure gradient significantly decreased from a preoperative value of 27 mmHg (range 20-36 mmHg) to a postoperative value of 6 mmHg (range 4-11 mmHg). A notable improvement was observed in one cirrhotic patient, with liver function progressing from Child-Pugh class B (score 9) to class A (score 6). Over a median follow-up period of 14 months (range 7-18 months), none of the patients encountered rebleeding, stent stenosis, hepatic encephalopathy, or mortality.

CONCLUSION

The TMCS appears to be a viable and effective alternative for managing CTPV with recurrent variceal bleeding. Its long-term outcome requires further evaluation.

CLINICAL RELEVANCE STATEMENT

TMCS provides a promising treatment for patients with life-threatening CTPV complications when occluded portal vein cannot be recanalized and portal vein recanalization TIPS is not an option.

KEY POINTS

Performing TIPS in patients with portal vein cavernoma is complex due to the requirement for recanalization of the occluded portal vein. Creating a mesenteric-caval shunt through a transjugular approach is a feasible technique. Establishing a TMCS provides a means to manage life-threatening complications arising from portal vein cavernoma.

Noninvasive Evaluation of Prolonged-Release Pirfenidone in Compensated Liver Cirrhosis. ODISEA Study, a Randomised Trial

BACKGROUND

Advanced liver fibrosis (ALF) predicts an adverse prognosis in chronic liver disease. In addition to etiological treatment, a new approach to stop or reverse residual fibrosis is desirable.

OBJECTIVE

To assess the efficacy and safety of prolonged-release pirfenidone (PR-PFD) versus placebo in compensated cirrhosis.

METHODS

180 patients with ALF (F4) were randomly assigned to: placebo, 1200 mg/d, and 1800 mg/d PR-PFD, plus standardised care, for 24mo. Frequency of lab tests: (3mo), liver stiffness measurement (LSM), FibroTest, ultrasound (US) (6mo), and endoscopy (annually).

RESULTS

Fibrosis evolution estimated from LSM was significantly lower only in the 1200 compared to placebo and 1800 groups (24.2 ± 2.4 vs. 15.4 ± 2.4; 27.6 ± 2.4 vs. 24.6 ± 2.4; 24.4 ± 2.3 vs. 23.3 ± 2.3 kPa, respectively, p < 0.001), in intergroup analysis, meeting the primary endpoint. Fibrotest was significantly lower only in the 1200 mg/d group, compared to baseline values (0.86 ± 0.02 vs. 0.83 ± 0.02 units, p < 0.001). Liver function test (LFT's) also improved as well as Model for End-Stage Liver Disease (MELD) score and quality of life (QoL). Decompensations occurred in 19 patients: 12 ascites (more frequent in placebo, p = 0.003), 5 variceal bleeding, 4 encephalopathies, 4 hepatocarcinomas. Adverse events were mainly mild gastrointestinal (n = 35, 48 and 46, p = 0.010) and cutaneous (n = 12, 15, and 22, p = 0.0001) in placebo, 1200 and 1800 mg/day, respectively.

CONCLUSION

PR-PFD at a dose of 1200 mg significantly decreased non-invasive liver fibrosis markers at 24 months and induced improvement in LFT's, MELD, and QoL in compensated cirrhosis, without safety concerns.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01046474.

Development and validation of a machine learning model based on multiple kernel for predicting the recurrence risk of Budd-Chiari syndrome

Background

Budd-Chiari syndrome (BCS) is a rare global condition with high recurrence rates. Existing prognostic scoring models demonstrate limited predictive efficacy for BCS recurrence. This study aims to develop a novel machine learning model based on multiple kernel learning to improve the prediction of 3-year recurrence in BCS patients.

Methods

Data were collected from BCS patients admitted to the Affiliated Hospital of Xuzhou Medical University between January 2015 and July 2022. The dataset was divided into training, validation, and test sets in a 6:2:2 ratio. Models were constructed by evaluating all combinations of four kernel functions in the training set. Hyperparameters for each model were optimized using the particle swarm optimization (PSO) algorithm on the validation set. The test set was used to compare kernel function combinations, with the area under the curve (AUC), sensitivity, specificity, and accuracy as evaluation metrics. The optimal model, identified through the best-performing kernel combination, was further compared with three classical machine learning models.

Result

A kernel combination integrating all four basic kernels achieved the highest average AUC (0.831), specificity (0.772), and accuracy (0.780), along with marginally lower but more stable sensitivity (0.795) compared to other combinations. When benchmarked against classical machine learning models, our proposed MKSVRB (Multi-Kernel Support Vector Machine Model for Three-Year Recurrence Prediction of Budd-Chiari Syndrome) demonstrated superior performance. Additionally, it outperformed prior studies addressing similar objectives.

Conclusion

This study identifies risk factors influencing BCS recurrence and validates the MKSVRB model as a significant advancement over existing prediction methods. The model exhibits strong potential for early detection, risk stratification, and recurrence prevention in BCS patients.

Understanding acute kidney injury in cirrhosis: Current perspective

Acute kidney injury (AKI) is present in 30%-40% of hospitalized patients with cirrhosis. Its incidence is higher in patients with severe alcoholic hepatitis, spontaneous bacterial peritonitis, and acute-on-chronic-liver failure (ACLF). Kidney injury is an important landmark event in the natural history of cirrhosis as it is associated with higher mortality. Overwhelming systemic vasodilation, cardiac dysfunction, hypoperfusion, endotoxemia, and direct nephrotoxicity predispose patients with cirrhosis to kidney injury. Infection is present in 25% of patients with decompensated cirrhosis and 35%-40% of patients with ACLF. Advanced cirrhosis with portal hypertension leads to a sluggish portal flow, leading to increased gut congestion, altered gut permeability and bacterial translocations. They drive infection and endotoxemia in such patients. Pathogen-associated molecular patterns activate inflammatory cascades, which leads to further deterioration in hemodynamics and reduced glomerular filtration rate. Infections and pro-inflammatory cytokines like interleukin 6 (IL-6), IL-1, and tumor necrosis factor alpha may directly cause kidney parenchymal injury. The combined effect of dysfunctional albumin and systemic and splanchnic vasodilatation leads to low effective blood volume, activating the renin-angiotensin-aldosterone system. This causes renal vasoconstriction, water retention, and ascites, which progresses to hepatorenal physiology and AKI development. Vasoconstriction and volume expansion effectively improve arterial blood volume and systemic hemodynamics, thereby improving renal blood flow. It is of paramount importance to predict, detect, and treat AKI in its early state, as progressive renal dysfunction is invariably associated with higher mortality in patients with decompensated cirrhosis and ACLF. This comprehensive review will focus on the recent evolving concepts of the pathophysiology, diagnosis, and management of AKI in patients with cirrhosis.

The Value of Remote Vital Signs Monitoring in Detecting Clinical Deterioration in Patients in Hospital at Home Programs or Postacute Medical Patients in the Community: Systematic Review

BACKGROUND

Vital signs monitoring (VSM) is used in clinical acuity scoring systems (APACHE [Acute Physiology and Chronic Health Evaluation], NEWS2 [National Early Warning Score 2], and SOFA [Sequential Organ Failure Assessment]) to predict patient outcomes for early intervention. Current technological advances enable convenient remote VSM. While the role of VSM for ill, hospital ward-treated patients is clear, its role in the community for acutely ill patients in the hospital at home (HAH) or postacute setting (patients who have just been discharged from an acute hospital stay and at increased risk of deterioration) is less well defined.

OBJECTIVE

We assessed the efficacy of remote VSM for patients in the HAH or postacute setting.

METHODS

This systematic review adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. We searched studies in PubMed (MEDLINE), Embase, and Scopus. Studies focused on the postacute phase were included, as only 2 case series addressed the HAH setting. Risk of bias (ROB) was evaluated using the Cochrane Risk of Bias Tool for randomized controlled trials (RCTs), the Newcastle-Ottawa scale for observational studies, and the case methods outlined by Murad et al for case reports. The GRADE (Grading Recommendations Assessment, Development, and Evaluation) framework was used to assess the certainty of evidence. Outcomes of interest included hospital readmissions, mortality, patient satisfaction, and compliance. Risk ratios (RR) were used to measure effect sizes for readmission and mortality, with patient satisfaction and compliance reported descriptively.

RESULTS

The search yielded 5851 records, with 28 studies meeting eligibility criteria (8 RCTs, 7 cohort studies, and 13 case series). Two focused on HAH, while 26 studies addressed the postacute phase. Nineteen studies looked at heart failure, 3 studied respiratory conditions, and 6 studies studied other conditions. Meta-analysis was conducted with 6 studies looking at hospital readmission within 60 days and 4 studies at mortality within 30 days. Readmissions did not significantly decrease (RR 0.81, 95% CI 0.61-1.09; P=.16). Significant heterogeneity was observed for readmissions (I2=58%). Conversely, mortality reduced significantly (RR 0.65, 95% CI 0.42-0.99; P=.04). There was no significant heterogeneity in mortality (I2=0%). There was high heterogeneity in the study populations, interventions, and outcomes measured. Many studies were of poor quality, with 50% (4/8) of RCTs exhibiting a high ROB. The certainty of evidence for both readmission and mortality was very low.

CONCLUSIONS

Published data on the effects of remote VSM in acutely ill patients at home remains scarce. Future studies evaluating all common vital signs (heart rate, blood pressure, oxygen saturation, and temperature) with consistent monitoring frequencies and clear intervention protocols to better understand how to integrate remote VSM into HAH programs are needed.

TRIAL REGISTRATION

PROSPERO CRD42023388827; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023388827.

Neutrophil–lymphocyte ratio is associated with worse outcomes in patients with cirrhosis: insights from the PRO-LIVER Registry

Background

Liver cirrhosis (LC) is a leading global cause of morbidity and mortality, with inflammation playing a key role in disease progression and clinical complications of LC. The Neutrophil/Lymphocyte Ratio (NLR), a readily available marker of systemic inflammation, has been linked to short-term adverse outcomes in LC, but data on long-term follow-up are limited. This study aimed to investigate the relationship between NLR and long-term all-cause mortality in an unselected cohort of LC patients.

Methods

Data were gathered from the Italian multicenter observational study “PRO-LIVER”. Patients with available data to calculate NLR at baseline were included. Baseline clinical determinants of NLR and the association of NRL with all-cause mortality at 2-year follow-up were evaluated.

Results

From the overall cohort (n = 753), 506 patients with LC (31% female, mean age 64.8 ± 11.9 years) were included in the analysis. Median value of NLR was 2.42 (Interquartile Range [IQR]: 1.61–3.52). At baseline, patients with NLR ≥ 2.42 were more likely to have Child–Pugh B or C, hepatocellular carcinoma (HCC), or portal vein thrombosis (PVT). After a median follow-up of 21 months, 129 patients died: 44 (17%) with NLR < 2.42 and 85 (34%) with NLR ≥ 2.42 (p < 0.001). At multiple-adjusted Cox regression analysis, NLR ≥ 2.42 was independently associated with all-cause mortality (HR: 1.65; 95% CI: 1.12–2.44; p = 0.012), along with age, Child–Pugh C class, HCC and PVT.

Conclusions

NLR is associated with long-term all-cause mortality in LC. NLR may serve as a potentially easily available tool to aid risk refinement in LC.

Trial registration number

ClinicalTrials.gov Identifier: NCT01470547.

Cyanoacrylate injection assisted by endosonographic mini-probe in the management of gastric varices: a single-center, retrospective cohort study

BACKGROUND

Gastric varices (GV) pose the potential risk of massive bleeding. Endoscopic ultrasound (EUS) guided real-time delivery of adhesives and devices has emerged as a promising therapeutic modality for GV but was limited in its generalizability due to the unavailability and lack of expertise of linear echoendoscopy. Therefore, we utilized the more readily available EUS mini-probe (EMP) in assisting cyanoacrylate (CYA) injection in the management of GV.

METHODS

This is a retrospective cohort study from a single tertiary medical center. One hundred and thirty-three eligible patients were divided into three groups based on the treatment modalities including EMP-guided CYA injection via a dual-channel gastroscope (EMP-D group), EMP-guided injection via a single-channel gastroscope (EMP-S group) and direct endoscopic injection (DEI group). The clinical characteristics, procedural parameters, outcomes, adverse events and follow-up data were analyzed.

RESULTS

An overall statistical significance was achieved in the number of puncture site (p < 0.001), the number of instant blood return upon puncture (p = 0.001), cyanoacrylate dose (p = 0.004), late rebleeding rate (p = 0.018), post-injection ulcer (p = 0.005), and non-rebleeding interval (p = 0.026) among the three groups. Patients in EMP-D group exhibited a lower rate of post-injection ulcer than those in DEI group (p = 0.009). Procedural time of EMP-D was shorter than that of EMP-S (p < 0.001). Less amount of cyanoacrylate was needed per reinjection session in EMP-D than in DEI (p = 0.002).

CONCLUSIONS

EMP-guided cyanoacrylate injection exhibited superior effectiveness and safety to DEI, while use of the dual-channel gastroscope further enhanced the precision and efficiency.

Comparison of Carvedilol to Propranolol in Reduction of Hepatic Venous Pressure Gradient in Liver Cirrhosis: A Meta-Analysis

BACKGROUND

Nonselective beta-blockers, such as propranolol and carvedilol, are used to prevent first decompensation in patients with clinically significant portal hypertension.

METHODS

We performed a systematic literature search of English language articles from inception in PubMed, Medline, and Cochrane databases to compare the effect of carvedilol and propranolol on systemic and splanchnic hemodynamics. Mean differences were pooled using a random-effect model, and a p-value of < 0.05 was considered statistically significant.

RESULTS

Seven RCTs with a total of 351 patients were involved in the final analysis. Reduction in hepatic venous pressure gradient was significantly greater in the carvedilol group (MD = -0.76, 95% CI = -1.45 to -0.08; p = 0.03). Decrease in systemic vascular resistance and mean arterial pressure was significantly greater in the carvedilol group ([MD = -190.55, 95% CI = -307.5 to -73.58; p = 0.001] and [MD = -3.65, 95% CI = -5.94 to -1.36; p = 0.002], respectively). Decrease in cardiac output was greater in the propranolol group (MD = 0.92, 95% CI = 0.45-1.38; p = 0.004). Decrease in hepatic blood flow and right atrial pressure appeared to be greater in the propranolol group; however, this did not reach statistical significance ([MD = 0.13, 95% CI = -0.06 to 0.32; p = 0.17] and [MD = 0.28, 95% CI = -0.27 to 0.83; p = 0.32], respectively). Decrease in mean pulmonary arterial pressure appeared to be greater in the carvedilol group; however, this was not statistically significant (MD = -0.75, 95% CI = -1.60 to 0.10; p = 0.08). There was no difference in incidence of rebleeding, shortness of breath, hepatic encephalopathy, and hypotension between the two groups.

CONCLUSION

Carvedilol demonstrated a significantly greater reduction in HVPG, SVR, and MAP compared to propranolol, with no significant difference in adverse effects.

The burden of ascites in cirrhosis

OBJECTIVES

Liver cirrhosis is a leading cause of morbidity and mortality worldwide, with complications such as ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS) significantly worsening prognosis. This paper aims to review the pathophysiology, diagnostic approaches, and management strategies for ascites and the complication of it, emphasizing the role of portal hypertension.

METHODS

We conducted a comprehensive review of the literature on liver cirrhosis, portal hypertension, ascites formation, and related complications. Existing evidence was evaluated and ranked using the GRADE system: A (high) to D (verly low). Recommendation strength was graded 1 (strong) or 2 (weak).

RESULTS

Portal hypertension is the key factor in ascites development. Non-invasive tools such as liver stiffness measurement (LSM) have proven to be effective in identifying patients at risk for clinically significant portal hypertension (CSPH), thus guiding treatment decisions. Carvedilol, recommended over propranolol, offers superior efficacy in reducing portal pressure. Diuretics, in combination with a moderate sodium-restricted diet, are the first-line treatment for ascites. However, refractory ascites requires advanced interventions. Spontaneous bacterial peritonitis (SBP) remains a major complication in patients with ascites, while hepatorenal syndrome - acute kidney injury (HRS-AKI) demands early recognition and timely vasoconstrictor therapy.

CONCLUSIONS

Liver cirrhosis and the complication of it significantly impact patient quality of life and survival. Portal hypertension is a critical driver of ascites and other complications, making early identification through non-invasive diagnostic methods essential for appropriate management. Medical treatments, including non-selective beta-blockers (NSBBs), diuretics, and advanced procedures, offer substantial benefits in controlling ascites and preventing further decompensation.

Efficacy and safety of rifaximin in preventing hepatic encephalopathy: A systematic review and meta-analysis

Rifaximin (RFX) is recommended for the treatment of hepatic encephalopathy (HE). However, evidence on whether RFX application could yield additional benefits for preventing HE in patients with cirrhosis is limited. In this study, we aimed to assess the safety and efficacy of RFX in preventing HE. We conducted a systematic search of randomized controlled trials to evaluate the use of RFX by analyzing HE incidence, hospitalization, all-cause mortality, and adverse events. Compared with the control group, RFX had a beneficial effect on the primary prevention of HE (RR = 0.58, 95% CI: 0.50-0.68), with noncomparable effects to NADs (including lactulose and lactitol, RR = 0.65, 95% CI: 0.38-1.11), but more effective than placebo (RR = 0.57, 95% CI: 0.47-0.69). After more than 1 month of RFX treatment, the risk of HE decreased significantly (RR = 0.55, 95% CI: 0.47-0.65). In secondary prevention of HE, RFX decreased the recurrence risk (RR = 0.49, 95% CI: 0.40-0.61). RFX helped to reduce the incidence of HE after transjugular intrahepatic portosystemic stent shunt (TIPSS) (RR = 0.70, 95% CI: 0.51-0.96). In terms of adverse effects, RFX was associated with a lower risk of diarrhea than NADs (RR = 0.04, 95% CI: 0.00-0.25). So, RFX therapy is effective and well-tolerated in preventing HE, and can be used as the first choice in the prophylaxis of HE after TIPSS.

How I manage major hemorrhage

ABSTRACT

Acute hemorrhage can be a life-threatening emergency that is complex in its management and affects many patient populations. The past 15 years has seen the introduction of comprehensive massive hemorrhage protocols, wider use of viscoelastic testing, new coagulation factor products, and the publication of robust randomized controlled trials in diverse bleeding patient populations. Although gaps continue to exist in the evidence base for several aspects of patient care, there is now sufficient evidence to allow for an individualized hemostatic response based on the type of bleeding and specific hemostatic defects. We present 3 clinical cases that highlight some of the challenges in acute hemorrhage management, focusing on the importance of interprofessional communication, rapid provision of hemostatic resuscitation, repeated measures of coagulation, immediate administration of tranexamic acid, and prioritization of surgical or radiologic control of hemorrhage. This article provides a framework for the clear and collaborative conversation between the bedside clinical team and the consulting hematologist to achieve prompt and targeted hemostatic resuscitation. In addition to providing consultations on the hemostatic management of individual patients, the hematology service must be involved in setting hospital policies for the prevention and management of patients with major hemorrhage.

CT-Derived spleen volume accurately diagnoses severe portal hypertension at HVPG thresholds of 16 mmhg

To investigate the diagnostic utility of a noninvasive method based on spleen volume for the accurate diagnosis of severe portal hypertension (PH). We enrolled 260 patients undergoing hepatic venous pressure gradient (HVPG) assessment and enhanced CT at Tianjin Third Central Hospital (December 2019-July 2023), with clinical data collected. Patients were stratified by HVPG levels: ≥16 mmHg (severe PH group) and < 16 mmHg (non-severe PH group). We included 120 cirrhotic patients who met the inclusion criteria. Splenic volume exhibited a linear correlation with HVPG (r = 0.364, p < 0.001). Univariate and multivariate logistic regression analyses identified spleen volume, age, and serum albumin as independent risk factors for severe PH (p < 0.05). Accordingly, a clinical diagnostic model was developed, named the "S-HVPG" score. The area under the curve (AUC) for the "S-HVPG" score was 0.803, with an optimal threshold of 0.694, achieving sensitivity, specificity, positive predictive value(PPV), and negative predictive value (NPV) of 78.8%, 74.3%, 88.2%, and 59.1%, respectively. The spleen volume-based "S-HVPG" scoring system introduces a novel, straightforward, noninvasive approach for diagnosing severe PH. A cutoff value of 0.694 for the S-HVPG score effectively distinguishes patients with severe PH from those with cirrhosis.

Sodium-glucose cotransporter-2 inhibitor therapy improves renal and hepatic function in patients with cirrhosis secondary to metabolic dysfunction associated steatotic liver disease and type 2 diabetes

Purpose

Metabolic dysfunction-associated steatotic liver disease (MASLD) increases the risk of chronic kidney disease (CKD), compounding morbidity in patients with cirrhosis. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are disease-modifying agents in type 2 diabetes mellitus (T2DM) and CKD, but studies on their use in cirrhosis are limited. We aimed to assess the effect of SGLT2i therapy on renal and hepatic function in patients with Child-Turcotte-Pugh (CTP) B cirrhosis and T2DM.

Methods

We conducted a 48-month longitudinal, retrospective cohort study of 54 patients with CTP B cirrhosis secondary to MASLD and T2DM who were initiated on SGLT2i (n=27) or insulin (n=27). Laboratory data were collected every 3 months. Liver stiffness (LS) was measured every 6 months via transient elastography (TE) and acoustic radiation force impulse with shear wave velocity (ARFI-SWV). The primary outcome was change in glomerular filtration rate (GFR) and chronic kidney disease (CKD) stage. Secondary outcomes included LS changes measured via TE and ARFI. Additional end points included MELD-Na, MELD 3.0, CTP scores, hepatic decompensations, proteinuria, body mass index (BMI), hemoglobin A1c (Hb-A1c), blood glucose (BG).

Results

At baseline, the two groups were comparable in GFR (SGLT2i: 55.6 ± 1.9 vs. insulin: 58.1 ± 2.1 mL/min/1.73 m², p = 0.37), CKD stage, ARFI-SWV (2.9 ± 0.1 vs. 2.8 ± 0.1 m/s, p = 0.26), MELD-Na, and MELD 3.0. The SGLT2i group was older (p < 0.01) and had higher AST (p=0.01), ALT (p<0.01), and CTP scores (p=0.02), but lower LS by TE (p = 0.03). Over 48 months, GFR increased in the SGLT2i group (+13.5 ± 1.3) and declined in the insulin group (-4.2 ± 1.4; p < 0.01). A greater proportion of SGLT2i patients transitioned from CKD stage 3a to 2 (p = 0.04). Liver stiffness by TE decreased in the SGLT2i group (-4.0 ± 1.1 kPa), while it increased in the insulin group (+3.0 ± 2.5 kPa; p < 0.01). ARFI-SWV also declined in the SGLT2i group but increased in the insulin group (2.5 ± 0.1 vs. 3.2 ± 0.1 m/s; p < 0.01). The SGLT2i group also demonstrated significant improvement in MELD-Na, MELD 3.0 and CTP scores, with greater resolution of hepatic decompensations, proteinuria, as well as better BMI and HbA1c outcomes (all p < 0.01).

Conclusions

Patients with CTP B cirrhosis and T2DM receiving SGLT2i therapy experienced a significant improvement in renal, hepatic function, and glycemic control over 48 months compared to patients treated with insulin.

Role of liver transient elastography in detecting cirrhosis with esophageal and gastric varices and evaluating variceal severity

OBJECTIVE

To explore the application and clinical value of liver transient elastography (TE) in diagnosing and assessing the degree of liver cirrhosis combined with esophageal and gastric varices (EGV).

METHODS

We chose 136 patients with cirrhosis and EGV admitted to the Liver Disease Department of our hospital from December 2022 to December 2024. The patients were divided into mild EGV (n = 71), moderate EGV (n = 40), and severe EGV (n = 25) based on the gastroscopic results, and another 50 cases of healthy physical examination at the same period were admitted into the control group. All cases underwent liver TE, biochemical parameters, and immune parameters examination to observe the diagnostic efficacy of liver TE in cirrhosis combined with EGV and the degree of varices.

RESULTS

The differences in TBIL, ALT, AST, PTA, and other biochemical parameters between all of groups were not statistically significant (P > 0.05). The differences were not statistically significant for the four groups of IgM, IgG, and other immune indices (P > 0.05). There was no significant difference in blood flow among these groups (P > 0.05). The interior diameter (ID) of the portal vein, blood flow velocity, and liver stiffness values were significant (P < 0.05). Portal vein ID, blood velocity, and liver stiffness values showed well diagnostic efficacy in cirrhosis with EGV, and liver stiffness values were the best in evaluating cirrhosis with EGV (P < 0.05). Liver stiffness values were more effective in assessing the degree of varices in cirrhosis combined with EGV and the best in diagnosing cirrhosis combined with severe EGV (P < 0.05).

CONCLUSION

The application of liver TE has a high value in diagnosing cirrhosis combined with EGV and their degree of varices, especially in identifying severe curves, which has good clinical value.

Incidence and Clinical Significance of Recompensation After HCV Cure

BACKGROUND AND AIMS

Baveno VII has proposed criteria for cirrhosis recompensation, but their prognostic significance in decompensated patients cured of hepatitis C virus (HCV) deserves further investigation. Thus, we studied the incidence and impact of recompensation after HCV cure as well as its predictors.

METHODS

A total of 2570 patients with advanced chronic liver disease (ACLD) from 10 European centers were retrospectively included, including 2209 and 361 patients with compensated ACLD and decompensated cirrhosis who achieved sustained virologic response to direct-acting antivirals (DAAs). The association between achieving recompensation and clinical outcomes (hepatocellular carcinoma [HCC], portal vein thrombosis [PVT], and [liver-related] death) was investigated.

RESULTS

During a median follow-up of 8.4 years from treatment initiation, 132 patients (36.6%) achieved recompensation. Lower albumin levels and diabetes were negatively associated with achieving recompensation. The incidence rates of liver-related death (4.2 vs 8.8 per 100 patient-years) and PVT (2.7 vs 5.4) were substantially lower after recompensation vs in the nonrecompensated state, while HCC incidence remained high (3.9 vs 5.5). Compared with decompensated cirrhosis, achieving recompensation was independently associated with decreased risks of subsequent liver-related death (adjusted hazard ratio, 0.384; 95% confidence interval, 0.225-0.655) and of PVT (adjusted hazard ratio, 0.421; 95% confidence interval, 0.224-0.759), but both risks remained higher than in compensated ACLD. Importantly, HCC incidence was not reduced as compared with decompensated cirrhosis.

CONCLUSIONS

Recompensation after HCV cure is associated with substantially decreased risks of (liver-related) mortality and PVT, but not of HCC.

Endovascular management of acute superior mesenteric vein thrombosis: a retrospective study on thrombolysis outcomes

BACKGROUND

Acute superior mesenteric vein thrombosis (ASMVT) is a rare but life-threatening condition associated with high morbidity and mortality. While anticoagulation remains the standard treatment, endovascular therapies such as thrombolysis, thrombectomy, and angioplasty are increasingly utilized in selected cases. However, evidence on their outcomes remains limited. This study retrospectively reports the clinical outcomes of ASMVT patients treated with endovascular combination therapies.

METHODS

Between August 2019 and May 2024, 12 patients (males = 9; mean age, 52.33 ± 12.51 years) were diagnosed with ASMVT. The study collected comprehensive data on demographic details, presenting symptoms, etiology, treatment modalities, response to treatment, and follow-up outcomes. Computed Tomography (CT) was available from diagnosis, and an average of 6.3 CT scans with a median follow-up of 3 months (IQR: 2-20 months).

RESULTS

The average time from symptom onset to angiographic treatment initiation was 8.0 ± 4.71 days, preceded by anticoagulation with heparin from the time of diagnosis. Patients were treated with combination therapy involving endovascular thrombolysis, rheolytic thrombectomy, and balloon angioplasty via transjugular (n = 9, 75%) or percutaneous (n = 3, 25%) approaches. Thrombolysis was performed with an average recombinant tissue plasminogen activator (rt-PA) infusion duration of 2.75 ± 1.14 days and a total dose of 61.25 ± 18.48 mg rt-PA. Superior mesenteric vein (SMV) flow was initially restored almost completely in 58.3% and partially in 41.7% of patients. Complications observed were hepatic artery bleeding (n = 2, 16.7%), hepatic arteriovenous fistula (n = 1, 8.3%), hepatic parenchymal bleeding (n = 1, 8.3%), melena (n = 1, 8.3%), and nostril bleeding (n = 1, 8.3%). Two patients experienced worsening symptoms of post-intervention, leading to bowel resection revealing intestinal necrosis. SMV patency was almost complete in 25%, and partially in 25% of patients at follow-up.

CONCLUSION

Endovascular combination therapy with long-term thrombolysis and thrombectomy in patients with ASMVT demonstrated promising technical outcomes. In view of complications, individual indication for intervention needs to be confirmed in a multidisciplinary team.

Establishment and validation of systemic inflammatory index model and risk assessment of PVT in cirrhosis after splenectomy-a retrospective study

Objective

The study aimed to create and validate a straightforward nomogram to predict portal vein thrombosis (PVT) in cirrhotic patient post-splenectomy, and investigate the predictive potential of systemic inflammation markers. One objective of the study was to develop a predictive model utilizing these markers to detect high-risk individuals early on.

Methods

A retrospective analysis was conducted on 184 cases of patients with cirrhosis who underwent splenectomy at The First Affiliated Hospital of University of South China from January 2015 to September 2023. The cohort was randomly divided into training (n = 130) and validation (n = 54) groups. Univariate and multivariate logistic regression analysis was employed to construct the prediction model. The performance of the nomogram was evaluated based on its ability to discriminate, calibrate, and demonstrate clinical utility.

Results

According to univariate and multivariate logistic regression analysis, we found six prediction indexes of PVT in patients with cirrhosis after splenectomy: postoperative neutrophil-to-lymphocyte ratio (NLR), postoperative derived NLR (dNLR), C-reactive protein to albumin ratio (CAR), portal vein diameter (DPV), platelet change value (PVB), and D-dimer (p-value < 0.05). Our clinical prediction model was created based on the aforementioned risk factors and demonstrated superior predictive power in both the primary cohort (AUC = 0.876) and validation cohort (AUC = 0.817). The calibration curve demonstrated satisfactory agreement between model predictions and actual observations, and the decision curve analysis (DCA) curve indicated high clinical net benefit.

Conclusion

Postoperative NLR, dNLR, CAR, PVB, DPV, and D-dimer were identified as the independent risk factors of PVT in cirrhotic patients post splenectomy. We had successfully established and validated a novel predictive model with good performance, based on systemic inflammatory indices in predicting PVT in cirrhosis after splenectomy.

Prevalence of portal vein thrombosis in pediatric patients with cirrhosis and intrahepatic non-cirrhotic portal hypertension

INTRODUCTION

Portal vein thrombosis (PVT) has been increasingly diagnosed in pediatric patients owing to the widespread use of non-invasive radiological techniques. Although the prevalence of PVT in adults with cirrhosis and intrahepatic non-cirrhotic portal hypertension ranges from 0.6 to 26 % and 13 to 46 %, respectively, no available data exist in the pediatric population. The prevalence of PVT in children with cirrhotic and intrahepatic non-cirrhotic portal hypertension was evaluated in this study.

METHODS

This retrospective study included children with cirrhosis and intrahepatic non-cirrhotic portal hypertension, which consisted of congenital hepatic fibrosis (CHF) and idiopathic noncirrhotic portal hypertension (INCPH). Patients with extrahepatic portal venous obstruction were excluded from the study. The presence of PVT was evaluated using abdominal Doppler ultrasonography and/or CT. Etiological, clinical, and laboratory findings were compared between the groups.

RESULTS

One hundred and forty-two patients with cirrhosis (mean admission age: 64.6 months ± 66.4, mean follow-up duration: 46.8 months ± 45.6) and 41 patients with non-cirrhotic patients (CHF=16, INCPH = 25, mean admission age: 126 months ± 64.2) were enrolled in this study. The prevalence of PVT was not significantly different between cirrhotic (8.5 %) and non-cirrhotic (9.7 %) patients. The incidence of PVT was significantly higher in patients with biliary atresia than in those with other etiologies in the cirrhotic group (p = 0.022). The frequency of PVT was higher in patients who had Child-Pugh score ≥7 in the cirrhotic group, but the difference was not statistically significant (p = 0066). The PVT group required more liver transplantations than the non-PVT group (p = 0.038).

CONCLUSION

The prevalence of PVT was similar in pediatric patients with cirrhosis and intrahepatic non-cirrhotic portal hypertension in our cohort, which is compatible with adult studies. Biliary atresia is found to be an important risk factor for PVT in our pediatric population. It might be associated with rapid progression of the disease, ascending cholangitis, and embryological abnormalities. These patients should be routinely evaluated to identify portal vein complications and early warning signs during follow-up.

Portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) in liver transplant candidates with cirrhosis and complex portal anastomosis

BACKGROUND & AIMS

Portal vein (PV) thrombosis may represent a relative contraindication to liver transplantation (LT). Transjugular intrahepatic portosystemic shunt (TIPS) used in portal hypertension complications, may allow portal vein recanalization (PVR).

METHODS

We reported PVR-TIPS in patients who were candidates for LT for clinical conditions but deemed contraindicated because of PV anatomy. We included consecutive patients undergoing PVR-TIPS at our center from February 2014 to May 2024.

RESULTS

We identified 25 patients (19 males [76 %], mean age 56 years [IQR 51-62]) in which PVR-TIPS was offered because foreseen high complex PV anastomosis. Twelve (48 %) patients showed main PV thrombosis, 8 (32 %) had cavernoma and 5 (20 %) had PV with very small diameter. PVR-TIPS was successfully achieved in all but one patient. All patients were listed after PVR-TIPS, with a listing MELD-Na score higher than pre-PVR-TIPS values (19 [IQR 15-23] vs. 16 [IQR 13-18], p < 0.018). Overall, 3 patients (13 %) were delisted for clinical improvement, 2 (8 %) died on the waiting-list and 16 (66 %) underwent LT. LT was technically feasible in all patients, without immediate major vascular complication.

CONCLUSIONS

PVR-TIPS may be a strategy to enable LT in patients otherwise excluded due to PV anatomy. This needs high technical expertise and often at the expense of a worsening in liver function.

Efruxifermin in Compensated Liver Cirrhosis Caused by MASH

BACKGROUND

In phase 2 trials involving patients with stage 2 or 3 fibrosis caused by metabolic dysfunction-associated steatohepatitis (MASH), efruxifermin, a bivalent fibroblast growth factor 21 (FGF21) analogue, reduced fibrosis and resolved MASH. Data are needed on the efficacy and safety of efruxifermin in patients with compensated cirrhosis (stage 4 fibrosis) caused by MASH.

METHODS

In this phase 2b, randomized, placebo-controlled, double-blind trial, we assigned patients with MASH who had biopsy-confirmed compensated cirrhosis (stage 4 fibrosis) to receive subcutaneous efruxifermin (at a dose of 28 mg or 50 mg once daily) or placebo. The primary outcome was a reduction of at least one stage of fibrosis without worsening of MASH at week 36. Secondary outcomes included the same criterion at week 96.

RESULTS

A total of 181 patients underwent randomization and received at least one dose of efruxifermin or placebo. Of these patients, liver biopsy was performed in 154 patients at 36 weeks and in 134 patients at 96 weeks. At 36 weeks, a reduction in fibrosis without worsening of MASH occurred in 8 of 61 patients (13%) in the placebo group, in 10 of 57 patients (18%) in the 28-mg efruxifermin group (difference from placebo after adjustment for stratification factors, 3 percentage points; 95% confidence interval [CI], -11 to 17; P = 0.62), and in 12 of 63 patients (19%) in the 50-mg efruxifermin group (difference from placebo, 4 percentage points; 95% CI, -10 to 18; P = 0.52). At week 96, a reduction in fibrosis without worsening of MASH occurred in 7 of 61 patients (11%) in the placebo group, in 12 of 57 patients (21%) in the 28-mg efruxifermin group (difference from placebo, 10 percentage points; 95% CI, -4 to 24), and in 18 of 63 patients (29%) in the 50-mg efruxifermin group (difference from placebo, 16 percentage points; 95% CI, 2 to 30). Gastrointestinal adverse events were more common with efruxifermin; most events were mild or moderate.

CONCLUSIONS

In patients with compensated cirrhosis caused by MASH, efruxifermin did not significantly reduce fibrosis at 36 weeks. (Funded by Akero Therapeutics; SYMMETRY ClinicalTrials.gov number, NCT05039450.).

EASL Clinical Practice Guidelines on the management of hepatitis B virus infection

The updated EASL Clinical Practice Guidelines on the management of hepatitis B virus (HBV) infection provide comprehensive, evidence-based recommendations for its management. Spanning ten thematic sections, the guidelines address diagnostics, treatment goals, treatment indications, therapeutic options, hepatocellular carcinoma surveillance, management of special populations, HBV reactivation prophylaxis, post-transplant care, HBV prevention strategies, and finally address open questions and future research directions. Chronic HBV remains a global health challenge, with over 250 million individuals affected and significant mortality due to cirrhosis and hepatocellular carcinoma. These guidelines emphasise the importance of early diagnosis, risk stratification based on viral and host factors, and tailored antiviral therapy. Attention is given to simplified algorithms, vaccination, and screening to support global HBV elimination targets. The guidelines also discuss emerging biomarkers and evolving definitions of functional and partial cure. Developed through literature review, expert consensus, and a Delphi process, the guidelines aim to equip healthcare providers across disciplines with practical tools to optimise HBV care and outcomes worldwide.