Pharmacologic prevention of variceal bleeding and rebleeding

Update on the Complications and Management of Liver Cirrhosis

Liver cirrhosis represents the advanced pathological stage of chronic liver disease, characterized by the progressive destruction and regeneration of the hepatic parenchyma over years, culminating in fibrosis and disruption of the vascular architecture. As a leading global cause of morbidity and mortality, it continues to affect millions worldwide, imposing a substantial burden on healthcare systems. Alcoholic/nonalcoholic fatty liver disease and chronic viral hepatitis infection, hepatitis C (HCV) in particular, remain leading causes of cirrhosis. Despite significant advances in understanding the pathogenesis of cirrhosis, its management is still complex due to the multifaceted complications, including ascites, hepatic encephalopathy, variceal bleeding, and hepatocellular carcinoma, all of which severely compromise the patient outcomes and quality of life. This review aims at filling a critical gap by providing a comprehensive summary of the latest evidence on the complications and management of liver cirrhosis. Evidence-based therapies targeting both the etiologies and complications of cirrhosis are essential for improving outcomes. While liver transplantation is considered a definitive cure, advancements in pharmacological therapies offer promising avenues for halting and potentially reversing disease progression. This review summarizes the latest management strategies for cirrhosis and its associated complications, emphasizing the importance of early intervention and novel therapeutic options for improving outcomes and quality of life in affected individuals.

From Pathophysiology to Practice: Evolving Pharmacological Therapies, Clinical Complications, and Pharmacogenetic Considerations in Portal Hypertension

Background: Portal hypertension is a major complication of chronic liver diseases, leading to serious issues such as esophageal variceal bleeding. The increase in portal vein pressure is driven by both an organic component and a functional component, including tonic contraction of hepatic stellate cells. These processes result in a pathological rise in intrahepatic vascular resistance, stemming from partial impairment of hepatic microcirculation, which is further exacerbated by abnormalities in extrahepatic vessels, including increased portal blood flow. Objectives: This review aims to provide a comprehensive overview of the evolving pharmacological therapies for portal hypertension, with consideration and discussion of pathophysiological mechanisms, clinical complications, and pharmacogenetic considerations, highlighting potential directions for future research. Methods: A review of recent literature was performed to evaluate current knowledge and potential therapeutic strategies in portal hypertension. Results: For over 35 years, non-selective beta-blockers have been the cornerstone therapy for portal hypertension by reducing portal vein inflow as an extrahepatic target, effectively preventing decompensation and variceal hemorrhages. However, since not all patients exhibit an adequate response to non-selective beta-blockers (NSBBs), and some may not tolerate NSBBs, alternative or adjunctive therapies that enhance the effects of NSBBs on portal pressure are being investigated in preclinical and early clinical studies. Conclusions: A better understanding of pharmacogenetic factors and pathophysiological mechanisms could lead to more individualized and effective treatments for portal hypertension. These insights highlight potential directions for future research.

Stratified analysis of the correlation between wedged hepatic venous pressure and portal venous pressure in patients with portal hypertension

To evaluate the differences in the agreement between wedged hepatic venous pressure (WHVP) and portal venous pressure (PVP) at different hepatic venous pressure gradient (HVPG) levels to identify specific HVPG thresholds where WHVP can reliably estimate PVP, thus enhancing the accuracy of risk stratification and treatment decision-making for portal hypertension (PHT) patients. A multicenter study of 616 patients with PHT from three centers was stratified into five groups by their HVPG: HVPG < 12 (group A), 12 ≤ HVPG < 16 mmHg (group B), 16 ≤ HVPG < 20 mmHg (group C), 20 ≤ HVPG < 24 mmHg (group D), HVPG ≥ 24 mmHg (group E). Concordance was analyzed using Pearson's correlation coefficient (R), the intraclass correlation coefficient (ICC), and Bland‒Altman analysis in each HVPG stratum. Correlation and agreement between WHVP and PVP varied by HVPG group. Highest agreement was observed in the range of 20 ≤ HVPG < 24 mmHg. (R = 0.55, ICC = 0.68). The proportion of patients with a discrepancy between WHVP and PVP that was greater than 10% of the PVP value was highest in group A (95.7%) and lowest in group D (48.4%). Overestimation of PVP was more common in group E (44.5%), and underestimation of PVP was more common in group A (94.6%). This study does not confirm the usefulness of hepatic vein pressure measurements to predict the PVP and PPG. The means of WHVP and PVP were significantly different in ranges A, B, C, and E.

Efficacy and safety of variceal embolization for primary prophylaxis in cirrhosis patients with challenges in standard treatments: preliminary results

Objectives

Nonselective beta blockers (NSBBs) or endoscopic therapies are currently recommended by guidelines for preventing the first variceal bleed in patients with high-risk varices. However, there is a lack of detailed treatment strategies for patients who are intolerant to both NSBBs and endoscopic approaches. Our study aimed to assess the efficacy and safety of variceal embolization as a primary prophylaxis method in cirrhosis patients who are not suitable candidates for NSBBs or endoscopic treatments.

Methods

The study included 43 cirrhotic patients with high-risk varices who were candidates for primary prophylaxis against variceal bleeding. These patients underwent variceal embolization at the Xijing Hospital between January 2020 and June 2022. The primary endpoint was the occurrence of bleeding from varices, and the secondary endpoints were the recurrence of varices and the emergence of complications.

Results

The procedure of variceal embolization had a success rate of 93.0% (40 out of 43 patients). Over a 2-year follow-up period, the rate of variceal bleeding was 11.6% (5 out of 43 patients), the recurrence rate of varices was 14.0% (6 out of 43 patients), and the rate of severe complications was limited to 2.3% (1 out of 43 patients).

Conclusion

Variceal embolization is a viable primary prophylactic intervention for cirrhotic patients who are at risk of variceal bleeding when standard treatments, such as NSBBs or endoscopic therapies, are difficult to perform.

Influence of subcutaneous adipose tissue index on prognosis in cirrhotic patients following endoscopic therapy: a retrospective cohort study

BACKGROUND

The relation of adipose tissue depletion with prognostic outcome of variceal bleeding among cirrhotic patients is still inconclusive. The present work explored whether adipose tissue, which was measured based on computed tomography (CT), was valuable for analyzing rebleeding and mortality among patients with variceal bleeding who had undergone endoscopic therapy.

METHODS

The study encompassed cirrhotic patients who underwent endoscopic therapy to prevent variceal rebleeding between January 2016 and October 2022. The L3-level CT images were obtained. Besides, impacts of subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI), as well as total adipose tissue index (TATI) on rebleeding and mortality among cirrhotic patients following endoscopic therapy were examined.

RESULTS

In this work, our median follow-up period was 31 months. Among those adipose tissue indexes, only SATI exhibited an independent relation to higher rebleeding (HR 0.981, 95% CI, 0.971-0.991, p < 0.001) and mortality (HR 0.965, 95% CI, 0.944-0.986, p = 0.001) risks. Upon multivariate Cox regression, low SATI (male < 30.15 cm2/m2, female < 39.82 cm2/m2) was independently linked to higher rebleeding risk (HR 2.511, 95% CI, 1.604-3.932, p < 0.001) and increased mortality risk (HR 3.422, 95% CI, 1.489-7.864, p = 0.004) after adjusting for other predictors. Furthermore, subgroups were created based on using nonselective β-blockers (NSBBs), demonstrating that quantitatively assessing SATI exerts a vital role in evaluating rebleeding incidence in patients with or without NSBB therapy.

CONCLUSION

This study underscores the potential of quantifying SATI as a means for achieving a more accurate risk classification for individual patients and identifying patients that can gain more benefits from nutritional intervention.

Guidelines for the Management of Esophagogastric Variceal Bleeding in Cirrhotic Portal Hypertension

To standardize the diagnosis, treatment, and management of esophagogastric variceal bleeding (EVB) in patients with cirrhotic portal hypertension, the Chinese Society of Hepatology, the Chinese Society of Gastroenterology, and the Chinese Society of Digestive Endoscopy of the Chinese Medical Association brought together relevant experts, reviewed the latest national and international progress in clinical research on EVB in cirrhotic portal hypertension, and followed evidence-based medicine to update the Guidelines on the Management of EVB in Cirrhotic Portal Hypertension. The guidelines provide recommendations for the diagnosis, treatment, and management of EVB in cirrhotic portal hypertension and with the aim to improve the level of clinical treatment of EVB in patients with cirrhotic portal hypertension.

Close Relationship between Systemic Arterial and Portal Venous Pressure in an Animal Model with Healthy Liver

It is unclear to what extent systemic arterial blood pressure influences portal pressure. This relationship is clinically important as drugs, which are conventionally used for therapy of portal hypertension, may also influence systemic arterial blood pressure. This study investigated the potential correlation between mean arterial (MAP) and portal venous pressure (PVP) in rats with healthy livers. In a rat model with healthy livers, we investigated the effect of manipulation of MAP on PVP. Interventions consisted of 0.9% NaCl (group 1), 0.1 mg/kg body weight (bw) Sildenafil (low dose), an inhibitor of phosphodiesterase-5 (group 2), and 1.0 mg/kg bw Sildenafil (high dose, group 3) in 600 µL saline injected intravenously. Norepinephrine was used to increase MAP in animals with circulatory failure while PVP was monitored. Injection of the fluids induced a transient drop in MAP and PVP, probably due to a reversible cardiac decompensation. The drop in MAP and drop in PVP are significantly correlated. The time lag between change in MAP and change in PVP by 24 s in all groups suggests a cause-and-effect relationship. Ten minutes after the injection of the fluid, cardiac function was normalized. Thereafter, MAP gradually decreased. In the NaCl group, PVP decreases by 0.485% for a 1% drop of MAP, by 0.550% in the low-dose sildenafil group, and by 0.651% in the high-dose sildenafil group (p < 0.05 for difference group two vs. group one, group three vs. group one, and group three vs. group two). These data suggest that Sildenafil has an inherent effect on portal pressure that exceeds the effect of MAP. Injection of norepinephrine led to a sudden increase in MAP followed by an increase in PVP after a time lag. These data show a close relationship between portal venous pressure and systemic arterial pressure in this animal model with healthy livers. A change in MAP is consequently followed by a change in PVP after a distinct time lag. This study, furthermore, suggests that Sildenafil influences portal pressure. Further studies should be performed in a model with cirrhotic livers, as these may be important in the evaluation of vasoactive drugs (e.g., PDE-5-inhibitors) for therapy of portal hypertension.

Immune changes over time and survival in patients with cirrhosis treated with non-selective beta-blockers: A prospective longitudinal study

BACKGROUND

Treatment with non-selective beta-blockers (NSBB) has been associated with anti-inflammatory and anti-cancer effects in patients with cirrhosis. This study aims to analyze the impact of chronic NSBB treatment on immune activation and disease progression in stable outpatients with cirrhosis.

METHODS

In this prospective follow-up of 150 patients with cirrhosis, 39 received treatment with NSBB. Blood samples were taken every 6-9 months, and immune and adrenergic variables were measured. Mixed linear models were used to assess the effect of NSBB on these variables over time. Multivariate Cox regression was used to study associations with adverse clinical events (hepatocellular carcinoma, death, or liver transplant).

RESULTS

Median follow-up was 1635 days. NSBB treatment was associated with significantly lower levels of IL-6 (β - 4.7; 95% confidence interval [CI] -6.9, -2.6) throughout the study. During follow-up, 11 patients developed hepatocellular carcinoma, 32 died, and 4 underwent liver transplant. Patients with higher concentrations of IL-10, IL-6 and IFN-γ developed more clinical events. Event-free survival was significantly better in patients treated with NSBB (hazard ratio 0.36, 95% CI 0.18, 0.71) in a multivariate Cox regression adjusted for Child-Pugh-Score, esophageal varices, and platelets.

CONCLUSION

Chronic treatment with NSBB in patients with stable cirrhosis gives rise to a different state of immune activation, characterized by lower concentrations of IL-6 over time, and it is associated with a reduced risk of adverse event (death, hepatocellular carcinoma, or transplant), after controlling for disease severity.

Gastroesophageal variceal hemorrhage in patients with chronic liver diseases attending university of Gondar Specialized comprehensive hospital in Ethiopia: Institutional based cross-sectional study

Introduction

Rupture and bleeding from Gastroesophageal Varices (GEVs) are major complications among patients with chronic liver disease (CLD) and are associated with a high mortality rate. Hence, identifying factors of Gastroesophageal Variceal Hemorrhage (GEVH) is essential for the management and prevention of this fatal outcome.

Objective

To assess the prevalence of GEVH and its associated factors among patients with CLD in Northwest Ethiopia.

Methods

An institutional based cross-sectional study design was employed on a total of 262 patients. The data was entered into Epi-Data version 3.1, and then exported and analyzed using STATA version 14. The distribution of variables was checked using kolmogorov-smirnov test. Bivariable logistic regression model was fitted to select variables for multivariable analysis. In the final model, adjusted odds ratio with 95% confidence level and P-value less than 0.05 were used to assess degree of association.

Results

The mean age of the study subjects was found to be 37.76 years (SD ± 11.62). The prevalence of GEVH was found to be 52% (95% CI: 49.6-54.2). Patients with grade F2 and F3 varices have 3.41 times (AOR: 3.41, 95% CI: 2.33-4.74) and 3.33 times (AOR: 3.33, 95% CI: 2.55-4.12) higher odds of bleeding, respectively. Patients not taking beta blocker have 2.38 times (AOR: 2.38, 95% CI: 1.82-3.90) increased odds of bleeding. Patients with more than three years of duration of illness have 2 times (AOR: 2.19, 95% CI: 1.39-3.99) increased odds of bleeding. Patients with platelet number less than 50,000/μl have 3.46 times (AOR: 3.46, 95% CI: 2.55-4.17) higher odds of bleeding.

Conclusion

GEVH is found to be high in patients with CLD seen at university of Gondar Hospital. Higher grade of varices, non-use of beta blockers, presence of infection, platelet number and age are associated with higher occurrence of bleeding, pointing the possibility of averting this fatal complication, for most of the identified factors are preventable.

A novel model based on liver/spleen volumes and portal vein diameter on MRI to predict variceal bleeding in HBV cirrhosis

OBJECTIVE

To develop a novel logistic regression model based on liver/spleen volumes and portal vein diameter measured on magnetic resonance imaging (MRI) for predicting oesophagogastric variceal bleeding (OVB) secondary to HBV cirrhosis.

METHODS

One hundred eighty-five consecutive cirrhotic patients with hepatitis B undergoing abdominal contrast-enhanced MRI were randomly divided into training cohort (n = 130) and validation cohort (n = 55). Spleen volume, total liver volume, four liver lobe volumes, and diameters of portal venous system were measured on MRI. Ratios of spleen volume to total liver and to individual liver lobe volumes were calculated. In training cohort, univariate analyses and binary logistic regression analyses were to determine independent predictors. Performance of the model for predicting OVB constructed based on independent predictors from training cohort was evaluated by receiver operating characteristic (ROC) analysis, and was validated by Kappa test in validation cohort.

RESULTS

OVB occurred in 42 and 18 individuals in training and validation cohorts during the 2 years' follow-up, respectively. An OVB prediction model was constructed based on the independent predictors including right liver lobe volume (RV), left gastric vein diameter (LGVD) and portal vein diameter (PVD) (odds ratio = 0.993, 2.202 and 1.613, respectively; p-values < 0.001 for all). The logistic regression model equation (-0.007 × RV + 0.79 × LGVD + 0.478 × PVD-6.73) for predicting OVB obtained excellent performance with an area under ROC curve of 0.907. The excellent performance was confirmed by Kappa test with K-value of 0.802 in validation cohort.

CONCLUSION

The novel logistic regression model can be reliable for predicting OVB.

KEY POINTS

• Patients with oesophagogastric variceal bleeding are mainly characterized by decreased right lobe volume, and increased spleen volume and diameters of portal vein system. • The right liver lobe volume, left gastric vein diameter and portal vein diameter are the independent predictors of oesophagogastric variceal bleeding. • The novel model developed based on the independent predictors performed well in predicting oesophagogastric variceal bleeding with an area under the receiver operating characteristic curve of 0.907.

Emerging Therapeutic Targets for Portal Hypertension

Purpose of Review

Portal hypertension is responsible of the main complications of cirrhosis, which carries a high mortality. Recent treatments have improved prognosis, but this is still far from ideal. This paper reviews new potential therapeutic targets unveiled by advances of key pathophysiologic processes.

Recent Findings

Recent research highlighted the importance of suppressing etiologic factors and a safe lifestyle and outlined new mechanisms modulating portal pressure. These include intrahepatic abnormalities linked to inflammation, fibrogenesis, vascular occlusion, parenchymal extinction, and angiogenesis; impaired regeneration; increased hepatic vascular tone due to sinusoidal endothelial dysfunction with insufficient NO availability; and paracrine liver cell crosstalk. Moreover, pathways such as the gut-liver axis modulate splanchnic vasodilatation and systemic inflammation, exacerbate liver fibrosis, and are being targeted by therapy. We have summarized studies of new agents addressing these targets.

Summary

New agents, alone or in combination, allow acting in complementary mechanisms offering a more profound effect on portal hypertension while simultaneously limiting disease progression and favoring regression of fibrosis and of cirrhosis. Major changes in treatment paradigms are anticipated.

Development and validation of a prognostic nomogram for decompensated liver cirrhosis

BACKGROUND

Decompensated liver cirrhosis (DLC) is a stage in the progression of liver cirrhosis and has a high mortality.

AIM

To establish and validate a novel and simple-to-use predictive nomogram for evaluating the prognosis of DLC patients.

METHODS

A total of 493 patients with confirmed DLC were enrolled from The First Affiliated Hospital of Nanchang University (Nanchang, Jiangxi Province, China) between December 2013 and August 2019. The patients were divided into two groups: a derivation group (n = 329) and a validation group (n = 164). Univariate and multivariate Cox regression analyses were performed to assess prognostic factors. The performance of the nomogram was determined by its calibration, discrimination, and clinical usefulness.

RESULTS

Age, mechanical ventilation application, model for end-stage liver disease (MELD) score, mean arterial blood pressure, and arterial oxygen partial pressure/inhaled oxygen concentration were used to construct the model. The C-indexes of the nomogram in the derivation and validation groups were 0.780 (95%CI: 0.670-0.889) and 0.792 (95%CI: 0.698-0.886), respectively. The calibration curve exhibited good consistency with the actual observation curve in both sets. In addition, decision curve analysis indicated that our nomogram was useful in clinical practice.

CONCLUSION

A simple-to-use novel nomogram based on a large Asian cohort was established and validated and exhibited improved performance compared with the Child-Turcotte-Pugh and MELD scores. For patients with DLC, the proposed nomogram may be helpful in guiding clinicians in treatment allocation and may assist in prognosis prediction.

Performance of machine learning techniques on prediction of esophageal varices grades among patients with cirrhosis

OBJECTIVES

All patients with cirrhosis should be periodically examined for esophageal varices (EV), however, a large percentage of patients undergoing screening, do not have EV or have only mild EV and do not have high-risk characteristics. Therefore, developing a non-invasive method to predict the occurrence of EV in patients with liver cirrhosis as a non-invasive method with high accuracy seems useful. In the present research, we compared the performance of several machine learning (ML) methods to predict EV on laboratory and clinical data to choose the best model.

METHODS

Four-hundred-and-ninety data from the Liver and Gastroenterology Research Center of Shahid Beheshti University of Medical Sciences in the period 2014-2021, were analyzed applying models including random forest (RF), artificial neural network (ANN), support vector machine (SVM), and logistic regression.

RESULTS

RF and SVM had the best results in general for all grades of EV. RF showed remarkably better results and the highest area under the curve (AUC). After that, SVM and ANN had the AUC of 98%, for grade 3, the SVM algorithm had the highest AUC after RF (89%).

CONCLUSIONS

The findings may help to better predict EV with high precision and accuracy and also can help reduce the burden of frequent visits to endoscopic centers. It can also help practitioners to manage cirrhosis by predicting EV with lower costs.

Simvastatin is Efficacious in Treating Cirrhosis: A Meta-analysis

BACKGROUND

Statins can improve prognosis of patients with liver cirrhosis by suppressing inflammation and lowering portal pressure. Here, we performed a meta-analysis to evaluate the clinical efficacy of simvastatin in liver cirrhosis patients.

METHODS

We searched PubMed, EMBASE, and Cochrane library databases for randomized controlled trials targeting simvastatin in patients with liver cirrhosis. The primary and secondary outcomes were the efficacy of simvastatin on clinical outcomes and its safety, respectively.

RESULTS

A total of 554 relevant articles were downloaded, of which 9 (comprising 648 participants) were eligible and were finally included in the analysis. Four studies revealed the impact of simvastatin on patient mortality, with the overall death rate found to be significantly lower in the simvastatin relative to the control group [risk ratio (RR): 0.46; 95% confidence interval (CI), 0.29 to 0.73; P <0.01]. Further analysis of the cause of death showed that simvastatin significantly reduces incidence of fatal bleeding (RR: 0.35; 95% CI, 0.13 to 0.95; P =0.04), as well as cholesterol [mean difference (MD): -31.48; 95% CI, -52.80 to -10.15; P <0.01] and triglyceride (MD: -25.88; 95% CI, -49.90 to -1.86; P =0.03) levels. At the same time, simvastatin did not significantly elevate levels of alanine aminotransferase (ALT) (MD: 2.34; 95% CI, -31.00 to 35.69; P =0.89) and was not associated with incidence of other side effects.

CONCLUSIONS

The use of simvastatin in cirrhotic patients lowers mortality rates by suppressing incidences of fatal bleeding.

The Role of von Willebrand Factor Antigen in Predicting Survival of Patients with HBV-Related Cirrhosis

OBJECTIVE

The model for end-stage liver disease (MELD) scoring system cannot be used to assess the deterioration of patients with liver cirrhosis caused by infection and portal hypertension. Elevated von Willebrand factor antigen (vWF-Ag) in plasma is associated with portal pressure and complications in patients with liver cirrhosis. We aimed to evaluate whether the addition of vWF-Ag can improve the risk prediction ability of the MELD scoring system.

METHODS

A total of 228 patients with hepatitis B virus (HBV)-related liver cirrhosis were eligible for inclusion in this retrospective study. The vWF-Ag level was assessed by enzyme-linked immunosorbent assay (ELISA). The endpoint of this study was defined as the time to liver transplantation or death. Univariate and multivariate analyses were performed to assess the risk factors associated with transplant-free mortality. Receiver operating characteristic (ROC) curve analysis was used to assess potential discriminatory variables for transplant-free mortality.

RESULTS

During a median follow-up interval of 30.23 months, 124 patients (54.4%) reached the endpoint of this study. Patients who died or underwent liver transplantation had elevated levels of MELD and vWF-Ag. Moreover, vWF-Ag and MELD showed comparable predictive potential for transplant-free survival (area under the curve [AUC], vWF-Ag = 0.71; AUC, MELD = 0.73). Ultimately, vWF-Ag can significantly improve the predictive potential of MELD in determining transplant-free mortality (AUC, MELD-vWF-Ag = 0.79, P = 0.006).

CONCLUSION

An elevated vWF-Ag level was independently associated with transplant-free mortality in patients with liver cirrhosis. The inclusion of vWF-Ag in the MELD scoring system can improve mortality predictions in patients with liver cirrhosis.

Experimental model of portal hypertension and esophagogastric varices in minipigs: pressure and endoscopic pilot study

INTRODUCTION

Portal hypertension still represents an important health problem worldwide. In the search for knowledge regarding this syndrome, experimental studies with animal models have proven to be useful to point the direction to be taken in future randomized clinical trials.

PURPOSE

To validate the experimental model of portal hypertension and esophagogastric varices in a medium-sized animal.

METHODS

This study included five minipigs br1. Midline laparotomy with dissection of the portal vein and production of a calibrated stenosis of this vein was performed. Measurement of pressure in the portal venous and digestive endoscopic were performed before and five weeks after the production of a stenosis.

RESULTS

All animals were 8 months old, average weight of 17 ± 2.5 kg. The mean pressure of the portal vein immediately before the partial ligation of the portal vein was 8.9 + 1.6 mm Hg, with 26.6 + 5.4 mm Hg in the second measurement five weeks later (p < 0.05). No gastroesophageal varices or hypertensive portal gastropathy were seen at endoscopy procedures in our sample at any time in the study.

CONCLUSION

Portal vein ligation in minipigs has been validated in the production of portal hypertension, but not in the formation of esophageal varices.

Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies

Patients with cirrhosis and esophageal varices bleed at a yearly rate of 5%-15%, and, when variceal hemorrhage develops, mortality reaches 20%. Patients are deemed at high risk of bleeding when they present with medium or large-sized varices, when they have red signs on varices of any size and when they are classified as Child-Pugh C and have varices of any size. In order to avoid variceal bleeding and death, individuals with cirrhosis at high risk of bleeding must undergo primary prophylaxis, for which currently recommended strategies are the use of traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a NSBB with additional alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL). The superiority of one of these alternatives over the others is controversial. While EVL might be superior to pharmacological therapy regarding the prevention of the first bleeding episode, either traditional NSBBs or carvedilol seem to play a more prominent role in mortality reduction, probably due to their capacity of preventing other complications of cirrhosis through the decrease in portal hypertension. A sequential strategy, in which patients unresponsive to pharmacological therapy would be submitted to endoscopic treatment, or the combination of pharmacological and endoscopic strategies might be beneficial and deserve further investigation.

The Hepatic Sinusoid in Chronic Liver Disease: The Optimal Milieu for Cancer

Simple Summary

During the development of chronic liver disease, the hepatic sinusoid undergoes major changes that further compromise the hepatic function, inducing persistent inflammation and the formation of scar tissue, together with alterations in liver hemodynamics. This diseased background may induce the formation and development of hepatocellular carcinoma (HCC), which is the most common form of primary liver cancer and a major cause of mortality. In this review, we describe the ways in which the dysregulation of hepatic sinusoidal cells—including liver sinusoidal cells, Kupffer cells, and hepatic stellate cells—may have an important role in the development of HCC. Our review summarizes all of the known sinusoidal processes in both health and disease, and possible treatments focusing on the dysregulation of the sinusoid; finally, we discuss how some of these alterations occurring during chronic injury are shared with the pathology of HCC and may contribute to its development.

Abstract

The liver sinusoids are a unique type of microvascular beds. The specialized phenotype of sinusoidal cells is essential for their communication, and for the function of all hepatic cell types, including hepatocytes. Liver sinusoidal endothelial cells (LSECs) conform the inner layer of the sinusoids, which is permeable due to the fenestrae across the cytoplasm; hepatic stellate cells (HSCs) surround LSECs, regulate the vascular tone, and synthetize the extracellular matrix, and Kupffer cells (KCs) are the liver-resident macrophages. Upon injury, the harmonic equilibrium in sinusoidal communication is disrupted, leading to phenotypic alterations that may affect the function of the whole liver if the damage persists. Understanding how the specialized sinusoidal cells work in coordination with each other in healthy livers and chronic liver disease is of the utmost importance for the discovery of new therapeutic targets and the design of novel pharmacological strategies. In this manuscript, we summarize the current knowledge on the role of sinusoidal cells and their communication both in health and chronic liver diseases, and their potential pharmacologic modulation. Finally, we discuss how alterations occurring during chronic injury may contribute to the development of hepatocellular carcinoma, which is usually developed in the background of chronic liver disease.

Liver Stiffness Is a Predictor of Rebleeding in Patients With Hepatitis B-Related Cirrhosis: A Real-World Cohort Study

Background: Esophageal vein rebleeding is a life-threatening complication of liver cirrhosis. However, the role of non-invasive methods that were developed to evaluate the severity of chronic liver disease, especially in rebleeding, remains unclear. Aims: To evaluate the performance of liver stiffness and non-invasive fibrosis scores in predicting esophageal vein rebleeding in hepatitis B virus (HBV) cirrhotic patients. Methods: A prospective analysis of 194 HBV patients between 2017 and 2021 was performed. Receiver operating characteristic (ROC) curves and time-dependent ROC curves were used to assess the power for predicting rebleeding with non-invasive fibrosis score and liver stiffness. Results: During the median follow-up time of 68.28 weeks, 55 patients experienced rebleeding. In the entire cohort, the area under the ROC curve for liver stiffness measurement (LSM) predicting for rebleeding was 0.837, with a cut-off value of 17.79 kPa, and the time-dependent ROC curve also showed stable prediction performance of LSM. The predictive ability of the non-invasive fibrosis score was less than that of LSM, and there were statistical differences. Moreover, patients using non-selective beta-blockers and HBV DNA-negative patients experienced significantly reduced rebleeding. Conclusions: Compared with non-invasive fibrosis scores, LSM can more simply and accurately predict rebleeding events of hepatitis B liver cirrhosis.

The longitudinal outcomes of applying non-selective beta-blockers in portal hypertension: real-world multicenter study

BACKGROUND/AIM

We investigated the effect of non-selective β-blockers (NSBB) in real-world situations and whether low-dose NSBB is beneficial compared to maximally tolerated doses.

METHODS

We performed a retrospective study of 740 patients with cirrhosis requiring prophylactic treatment of esophageal varices: 473 primary prophylaxis (PP: NSBB = 349, non-NSBB = 124) and 267 secondary prophylaxis (SP: NSBB = 200, non-NSBB = 67). The NSBB group was divided into low-dose (≤ 80 mg/day) and high-dose (> 80 mg/day).

RESULTS

In the PP group, NSBB treatment reduced mortality and showed the most pronounced effect in patients with moderate/severe ascites (hazard ratio [HR], 0.46; p < 0.01), HVPG ≥ 16 mmHg (HR, 0.53; p = 0.04), or CTP class B/C (HR, 0.46; p < 0.01) but not in those with no/mild ascites, HVPG < 16 mmHg, or CTP class A. Low-dose NSBB group showed a significant reduction in mortality compared with non-NSBB (moderate/severe ascites: HR, 0.61; p = 0.02 and CTP class B/C: HR, 0.41; p < 0.01) and the effect size was stronger than the high-dose NSBB. NSBB was associated with a reduced risk of infection (HR, 0.36; p = 0.01). In the SP group, NSBB prolonged survival in patients with moderate/severe ascites (HR, 0.56; p = 0.02), HVPG ≥ 16 mmHg (HR, 0.42; p < 0.01), or CTP class B/C (HR, 0.52; p < 0.01). Low-dose NSBB was more beneficial with 56% risk reduction (p < 0.01) of mortality compared with 33% risk reduction in the high-dose NSBB (p = 0.05).

CONCLUSION

NSBB therapy was associated with longer survival in PP and SP groups who had an advanced stage of cirrhosis. Moreover, low-dose NSBB exhibited a better benefit than a standard-titrated high-dose NSBB with better tolerability.

Co-Medication and Nutrition in Hepatocellular Carcinoma: Potentially Preventative Strategies in Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death worldwide, with about 841,000 new cases and 782,000 deaths annually. Given the clearly defined population at risk, mostly patients with liver cirrhosis, prevention of HCC could be highly effective.

SUMMARY

Besides regular ultrasound surveillance, numerous publications have suggested protective effects of diverse drugs and nutrients. However, none of those preventive options has made it into clinical routine or practice guidelines. We therefore summarize the current status of preventive effects of drugs such as statins, acetylsalicylic acid (ASA), and metformin, but also dietary aspects and nutrients such as coffee, tea, and vitamin D supplementation. A successful implementation of some of these strategies may potentially lead to improved prevention of HCC development in patients with liver cirrhosis. Key Messages: Accumulating data suggest that particularly ASA, antidiabetic therapies, and statins may substantially decrease HCC incidence in patients at risk.

Primary prevention of bleeding from esophageal varices in patients with liver cirrhosis: An update and review of the literature

All patients with liver cirrhosis and portal hypertension should be stratified by risk groups to individualize different therapeutic strategies to increase the effectiveness of treatment. In this regard, the development of primary prophylaxis of variceal bleeding and its management according to the severity of portal hypertension may be promising. This paper is to describe the modern principles of primary prophylaxis of esophageal variceal bleeding in patients with liver cirrhosis. The PubMed and EMbase databases, Web of Science, Google Scholar, and the Cochrane Database of Systematic Reviews were used to search for relevant publications from 1999 to 2019. The results suggested that depending on the severity of portal hypertension, patients with cirrhosis should be divided into those who need preprimary prophylaxis, which aims to prevent the formation of esophageal varices, and those who require measures that aim to prevent esophageal variceal bleeding. In subclinical portal hypertension, therapy should be etiological and pathogenetic. Cirrhosis with clinically significant portal hypertension should receive nonselective β-blockers if they have small esophageal varices and risk factors for variceal bleeding. Nonselective β-blockers are the first-line drugs for the primary prevention of bleeding from medium to large-sized esophageal varices. Endoscopic band ligation is indicated for the patients who are intolerant to nonselective β-blockers or in the case of contraindications to pharmacological therapy. In summary, the stratification of cirrhotic patients by the severity of portal hypertension and an individual approach to the choice of treatment may increase the effectiveness of therapy as well as improve survival rate of these patients.

Phosphodiesterases in the Liver as Potential Therapeutic Targets of Cirrhotic Portal Hypertension

Liver cirrhosis is a frequent condition with high impact on patients' life expectancy and health care systems. Cirrhotic portal hypertension (PH) gradually develops with deteriorating liver function and can lead to life-threatening complications. Other than an increase in intrahepatic flow resistance due to morphological remodeling of the organ, a functional dysregulation of the sinusoids, the smallest functional units of liver vasculature, plays a pivotal role. Vascular tone is primarily regulated by the nitric oxide-cyclic guanosine monophosphate (NO-cGMP) pathway, wherein soluble guanylate cyclase (sGC) and phosphodiesterase-5 (PDE-5) are key enzymes. Recent data showed characteristic alterations in the expression of these regulatory enzymes or metabolite levels in liver cirrhosis. Additionally, a disturbed zonation of the components of this pathway along the sinusoids was detected. This review describes current knowledge of the pathophysiology of PH with focus on the enzymes regulating cGMP availability, i.e., sGC and PDE-5. The results have primarily been obtained in animal models of liver cirrhosis. However, clinical and histochemical data suggest that the new biochemical model we propose can be applied to human liver cirrhosis. The role of PDE-5 as potential target for medical therapy of PH is discussed.

Use of Nonselective β-Blockers in Patients With End-Stage Liver Disease and Select Complications

Objective: To review the literature and recommendations for nonselective β-blockers (NSBBs) in the setting of variceal bleeding prophylaxis and decompensated liver disease. Data Sources: Literature search of MEDLINE was performed (1988 to October 2019) using the following search terms: cirrhosis, advanced cirrhosis, β-blocker, decompensation, prophylaxis. Abstracts, peer-reviewed publications, clinical practice guidelines, and product monographs were reviewed. Study Selection and Data Extraction: Relevant English language studies and those conducted in humans were considered for analysis and inclusion. Data Synthesis: Evidence that suggests that NSBBs are harmful in advanced cirrhosis is overshadowed by confounding variables and small patient populations. The majority of the available evidence suggests neutral or beneficial effects on mortality with continuation of NSBBs despite liver disease progression. Based on the available literature, guidelines, and expert consensuses, NSBBs can be considered within this patient population and may have a positive impact on the majority of these patients. Relevance to Patient Care and Clinical Practice: This review summarizes current place in therapy for NSBBs in the setting of cirrhosis and variceal bleeding prophylaxis. It also includes a discussion of the literature for use of NSBBs within the setting of different acute decompensations in which the data and recommendations for use are less clear. Conclusions: Recent evidence shows neutral or positive results for NSBB use in particular decompensation subgroups, which suggests that NSBBs can be used cautiously with close monitoring in patients with advanced cirrhosis. Questions still remain regarding optimal agent and dose and whether agents can be safely restarted after an acute decompensation episode.

Comparison of drugs facilitating endoscopy for patients with acute variceal bleeding: a systematic review and network meta-analysis

BACKGROUND

We aimed to compare the efficacy of different drugs facilitating endoscopy in patients with acute variceal bleeding.

METHODS

Databases were searched to identify randomized controlled trials which compared the efficacy of vasoactive drugs (vasopressin, terlipressin, octreotide, somatostatin) with placebo or each other. The primary outcomes were 6-week and 5-day mortality. Secondary outcomes were 5-day rebleeding, control of initial bleeding and adverse events. Pairwise and network meta-analysis were performed.

RESULTS

We identified 14 RCTs involved 2,187 patients. Four drugs had comparable clinical efficacy in all involving outcomes, except for adverse events. However, we do exhibit a superiority when vasopressin (OR, 4.40; 95% CI: 1.04-19.57), terlipressin (OR, 4.58; 95% CI: 1.63-13.63), octreotide (OR, 5.79; 95% CI: 2.41-16.71) and somatostatin (OR, 5.15; 95% CI: 1.40-27.39) were compared to placebo respectively as for initial hemostasis. In addition, only octreotide was more effective than placebo in decreasing 5-day rebleeding (OR, 0.44; 95% CI: 0.22-0.90). Meanwhile, octreotide was shown to have the highest probability ranking the best to improve initial hemostasis (mean rank =1.8) and carries a lowest risk of adverse events (9.1%) and serious adverse events (0.0%) compared to other drugs.

CONCLUSIONS

Balanced with curative effect and tolerability, octreotide may be the preferred vasoactive drug facilitating endoscopy.

Predicting gastro-oesophageal variceal bleeding in hepatitis B-related cirrhosis by CT radiomics signature

AIM

To develop liver a computed tomography (CT) radiomics model to predict gastro-oesophageal variceal bleeding (GVB) secondary to hepatitis B-related cirrhosis.

MATERIALS AND METHODS

Electronic medical records and image data of liver triple-phase contrast-enhanced CT examinations of 295 patients with hepatitis B-related cirrhosis were collected retrospectively from two hospitals. Two hundred and thirty-six and 59 patients were enrolled randomly into the training and validation cohorts, respectively; and 75 in the training cohort and 16 in the validation cohort endured GVB while the others did not during follow-up period. Radiomics features of the liver were extracted from the portal venous phase images, and clinical features came from medical records. The tree-based method and univariate feature selection were used to select useful features. The radiomics model, clinical model, and integration of radiomics and clinical models were built using the useful image features and/or clinical features. Predicting performance of three models was evaluated with the area under receiver-operating characteristic curve (AUC), accuracy, and F-1 score.

RESULTS

Twenty-one useful radiomics features and/or three clinical features were selected to build prediction models that correlated with GVB. AUC of integration of radiomics and clinical models was larger than of clinical or radiomics models for the training cohort (0.83±0.09 versus 0.64±0.08 or 0.82±0.10) and the validation cohort (0.64 versus 0.61 or 0.61). Integration of radiomics and clinical models obtained good performance in predicting GVB for both the training and validation cohorts (accuracy: 0.76±0.07 and 0.73, and F-1 score: 0.77±0.09 and 0.72, respectively).

CONCLUSION

Integration of the radiomics and clinical models may be a non-invasive method to predict GVB.

Pharmacologic Management of Portal Hypertension

Terlipressin, somatostatin, or octreotide are recommended as pharmacologic treatment of acute variceal hemorrhage. Nonselective β-blockers decrease the risk of variceal hemorrhage and hepatic decompensation, particularly in those 30% to 40% of patients with good hemodynamic response. Carvedilol, statins, and anticoagulants are promising agents in the management of portal hypertension. Recent advances in the pharmacologic treatment of portal hypertension have mainly focused on modifying an increased intrahepatic resistance through nitric oxide and/or modulation of vasoactive substances. Several novel pharmacologic agents for portal hypertension are being evaluated in humans.

Systematic review: role of elevated plasma von-Willebrand factor as predictor of mortality in patients with chronic liver disease

In this systematic review, we aimed to assess role of plasma von-Willebrand factor (vWF), an endothelial activation marker, as prognostic marker in patients with chronc liver disease [cirrhosis and acute-on-chronic liver failure (ACLF)]. We searched published databases using predefined keywords to identify all studies up to June 2018, in which plasma vWF (antigen or activity assay) was used as prognostic marker predicting mortality in patients with chronic liver disease. Relevant extracted data from selected studies were narratively summarized. The individual study's area under ROC curve for plasma vWF as a predictor of mortality was pooled and meta-analyzed. Six studies (cirrhosis: 5; ACLF: 1) with an aggregate data of 765 patients (cirrhosis: 715 patients; ACLF: 50 patients) were included. Baseline plasma vWF-antigen was an independent predictor of medium-term mortality in patients with cirrhosis (summary area under the curve: 0.74; 95% confidence interval: 0.70-0.79) with an optimal cutoff of 318% (216-390%; median, range) over a period of 25.6 months (23.6-33 months). Plasma vWF also predicted short-term (over 7 days) mortality in patients with ACLF. Plasma vWF levels correlated with Child's score, model for end-stage liver disease (MELD) score and hepatic venous pressure gradient and performed as well as MELD score in predicting mortality in patients with cirrhosis and ACLF. Baseline plasma vWF level predicts mortality over a medium term (1-3 years) in cirrhosis and over a short term (1 week) in ACLF patients. The marked elevation of baseline plasma vWF levels in ACLF patients was associated with drastic truncation of survival when compared with cirrhosis patients.

Antiviral therapy reduces rebleeding rate in patients with hepatitis B-related cirrhosis with acute variceal bleeding after endotherapy

Background

The preventive effects of antiviral therapy to reduce rebleeding rate in patients with hepatitis B-related cirrhosis undergoing endoscopic treatment have not yet been reported.

Methods

In this retrospective cohort study, 1139 patients with chronic hepatitis B with first acute variceal bleeding after endoscopic therapy from September 2008 to December 2017 were included. Among them, 923 who received and 216 who did not receive antiviral therapy were followed up for rebleeding. Cumulative rebleeding rate was calculated using the Kaplan-Meier method. Univariate and multivariate logistic regression analyses were performed to estimate the effects of antiviral therapy on rebleeding risk. The propensity score matched method and inverse probability of treatment weighting analysis were used to calculate the rebleeding rate between the antiviral and non-antiviral groups.

Results

The rebleeding rates were 40.5, 60.7, 72.6, and 89.2% in antiviral group at 1, 2, 3, and 5 years, respectively. The corresponding rebleeding rates in the non-antiviral group were 54.2, 72.4, 84.4, and 93.3%, respectively. The multivariate logistic regression analysis revealed that antiviral therapy was an independent protective factor associated with rebleeding.

Conclusion

Antiviral treatment significantly reduced rebleeding rate in patients with HBV-related cirrhosis who received endoscopic treatment after the first variceal bleeding.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-1020-2) contains supplementary material, which is available to authorized users.

Carvedilol for prevention of variceal bleeding: a systematic review and meta-analysis

Background

Beta-blockers are used for prophylaxis of variceal bleeding. Our aim was to assess the efficacy and safety of carvedilol for primary or secondary prevention of variceal bleeding in patients with cirrhosis.

Methods

We searched Medline, Embase, CENTRAL and gray literature sources for randomized controlled trials (RCTs) comparing carvedilol with placebo or any active intervention. We synthesized data using random effects models. We summarized the strength of evidence using GRADE criteria.

Results

We included 13 trials with 1598 patients. Carvedilol was as efficacious as endoscopic variceal ligation (EVL) (4 RCTs, risk ratio [RR] 0.74, 95% confidence interval [CI] 0.37-1.49) or propranolol (3 RCTs, RR 0.76, 95%CI 0.27-2.14) for primary prevention of variceal bleeding. Likewise, carvedilol was as efficacious as EVL (3 RCTs, RR 1.10, 95%CI 0.75-1.61), non-selective beta-blockers (NSBBs) plus isosorbide-5-mononitrate (2 RCTs, RR 1.02, 95%CI 0.70-1.51) or propranolol (2 RCTs, RR 0.39, 95%CI 0.15-1.03) for secondary prevention of variceal bleeding. Carvedilol was associated with lower all-cause mortality compared to EVL (3 RCTs, RR 0.51, 95%CI 0.33-0.79). There was no difference in any other efficacy outcome. Finally, there were no significant differences in the safety profiles compared with EVL and NSBBs. Our confidence in the effect estimates for all outcomes was very low.

Conclusion

Carvedilol is as efficacious and safe as standard-of-care interventions for the primary and secondary prevention of variceal bleeding.