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Mendizabal M, Cançado GGL, Albillos A. Evolving portal hypertension through Baveno VII recommendations. Ann Hepatol 2024; 29:101180. [PMID: 37984701 DOI: 10.1016/j.aohep.2023.101180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/08/2023] [Indexed: 11/22/2023]
Abstract
The Baveno VII consensus workshop has provided several novel recommendations regarding the management of patients with clinically significant portal hypertension (CSPH). The expert panel summarized the existing data into simple clinical rules to aid clinicians in their clinical practice. The use of non-invasive tests (NITs), especially liver stiffness measurement (LSM), have gain an important role in daily practice. The use of LSM alone or in combination with platelet count can be used to rule-in and rule-out compensated advanced chronic liver disease (cACLD) and CSPH. Further decompensation events were defined as a prognostic stage associated with an even higher mortality than that associated with first decompensation. Moreover, the term hepatic recompensation was introduced in Baveno VII consensus implying a partial or complete regression of the functional and structural changes of cirrhosis after the removal of the underlying etiology. This review will summarize the reader main aspects of Baveno VII consensus regarding the use of NITs in cACLD, analyze further decompensation events, and evaluate recent recommendations for prophylaxis and management of liver decompensation events.
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Affiliation(s)
- Manuel Mendizabal
- Unidad de Hígado y Trasplante Hepático, Hospital Universitario Austral, Pilar, Provincia de Buenos Aires, Argentina.
| | | | - Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Salud Carlos III, Madrid, Spain.
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2
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Segna D, Mendoza YP, Lange NF, Rodrigues SG, Berzigotti A. Non-invasive tools for compensated advanced chronic liver disease and portal hypertension after Baveno VII - an update. Dig Liver Dis 2023; 55:326-335. [PMID: 36369196 DOI: 10.1016/j.dld.2022.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/10/2022]
Abstract
Non-invasive tests (NITs) and liver stiffness measurement (LSM) in particular, have entered clinical practice over 20 years ago as point-of-care tests to diagnose liver fibrosis in patients with compensated chronic liver disease. Since then, NITs use has evolved thanks to a large number of studies in all major etiologies of liver disease, and they have become important tools to stratify the risk of portal hypertension and liver-related events. The Baveno VII consensus workshop provided several novel recommendations regarding the use of well-established and novel NITs in the specific setting of portal hypertension screening, diagnosis and follow-up. The Baveno VII expert panels paid special attention to summarizing the existing data into simple clinical rules able to guide clinicians in their practice. The "rule of five" for LSM is a tool to stratify the risk of liver-related events, and LSM alone or in combination with platelet count, can be used now to rule-in and rule-out compensated advanced chronic liver disease (cACLD) and clinically significant portal hypertension, as well as to rule-out high-risk varices. Use of NITs in obese subjects with non-alcoholic fatty liver disease (NAFLD) and patients with viral hepatitis C that has been successfully treated, require specific knowledge. This review will update the reader on these aspects.
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Affiliation(s)
- Daniel Segna
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland
| | - Yuly P Mendoza
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland
| | - Naomi F Lange
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland; Graduate School for Health Sciences (GHS), University of Bern, Switzerland
| | - Susana G Rodrigues
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland.
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3
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Zhou H, Zhang Z, Zhang J, Sang L, Liu L, Gong X, Sun Y, Zheng Y, Yu M. Performance of spleen stiffness measurement by 2D-shear wave elastography in evaluating the presence of high-risk varices: comparative analysis of idiopathic portal hypertension versus hepatitis B virus. BMC Med Imaging 2023; 23:30. [PMID: 36759764 PMCID: PMC9909910 DOI: 10.1186/s12880-023-00977-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Noninvasive assessment of high-risk varices (HRV) in idiopathic portal hypertension (IPH) is rare. The purpose of this study was to investigate the performance of spleen stiffness (SS) for evaluating the presence of HRV in IPH patients as compared the measurements in patients with hepatitis B virus (HBV). METHODS A retrospective single-center study was performed to evaluate the performance of SS for assessing HRV in IPH and HBV-infected patients, in comparison with liver stiffness (LS), spleen stiffness-to-liver stiffness ratio (SS/LS), LS spleen-diameter-to-platelet-ratio score (LSPS), portal hypertension risk score (PH risk score) and varices risk score, by using upper gastrointestinal endoscopy (UGE) as the gold standard. Finally, 86 IPH and 102 HBV-infected patients were enrolled. UGE, two-dimensional shear wave elastography (2D-SWE) and laboratory data were collected, and noninvasive parameters were calculated. Analysis of receiver operating characteristic (ROC) curves was conducted to acquire the optimal area under the ROC curve (AUC) and cutoff value for predicting the presence of HRV. RESULTS In patients with HRV, the significantly different parameters between IPH (34.9%) and HBV-infected patients (46.1%) were as follows: spleen size (diameter 18.5 ± 3.9 cm vs. 20.8 ± 2.7 cm), SS (50.2 kPa vs. 42.9 kPa), LS (11.1 kPa vs. 18.3 kPa) and PT (prothrombin time 15.1 s vs. 16.7 s). No statistically significant differences were found in liver function, platelet counts, spleen thickness and flow volumes in the portal venous system (p > 0.05). The AUCs of SS were 0.98 and 0.96 for predicting the presence of HRV in IPH (44.0 kPa cutoff value; 0.93 sensitivity; 0.96 specificity) and HBV-infected patients (35.2 kPa cutoff value; 1.00 sensitivity; 0.82 specificity), respectively, which were significantly better than other parameters. CONCLUSION SS shows the optimal overall performance for predicting the presence of HRV in IPH and HBV-infected patients, in comparison with other noninvasive parameters.
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Affiliation(s)
- Huihui Zhou
- grid.417295.c0000 0004 1799 374XDepartment of Ultrasonic Medicine, The First Affiliated Hospital of Fourth Military Medical University, Xi’an, 710032 Shaanxi China
| | - Zhilin Zhang
- grid.417295.c0000 0004 1799 374XDepartment of Ultrasonic Medicine, The First Affiliated Hospital of Fourth Military Medical University, Xi’an, 710032 Shaanxi China
| | - Jun Zhang
- grid.417295.c0000 0004 1799 374XDepartment of Ultrasonic Medicine, The First Affiliated Hospital of Fourth Military Medical University, Xi’an, 710032 Shaanxi China
| | - Lin Sang
- grid.417295.c0000 0004 1799 374XDepartment of Ultrasonic Medicine, The First Affiliated Hospital of Fourth Military Medical University, Xi’an, 710032 Shaanxi China
| | - Lina Liu
- grid.417295.c0000 0004 1799 374XDepartment of Ultrasonic Medicine, The First Affiliated Hospital of Fourth Military Medical University, Xi’an, 710032 Shaanxi China
| | - Xue Gong
- grid.417295.c0000 0004 1799 374XDepartment of Ultrasonic Medicine, The First Affiliated Hospital of Fourth Military Medical University, Xi’an, 710032 Shaanxi China
| | - Yuanyuan Sun
- grid.417295.c0000 0004 1799 374XDepartment of Ultrasonic Medicine, The First Affiliated Hospital of Fourth Military Medical University, Xi’an, 710032 Shaanxi China
| | - Yu Zheng
- Department of Ultrasound, Xi'an Central Hospital, Xi'an, 710003, Shaanxi, China.
| | - Ming Yu
- Department of Ultrasonic Medicine, The First Affiliated Hospital of Fourth Military Medical University, Xi'an, 710032, Shaanxi, China.
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Hari A. Ultrasound-Based Diagnostic Methods: Possible Use in Fatty Liver Disease Area. Diagnostics (Basel) 2022; 12:diagnostics12112822. [PMID: 36428882 PMCID: PMC9689357 DOI: 10.3390/diagnostics12112822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
Liver steatosis is a chronic liver disease that is becoming one of the most important global health problems, due to its direct connection with metabolic syndrome, its significant impact on patients' socioeconomic status and frailty, and the occurrence of advanced chronic liver disease. In recent years, there has been rapid technological progress in the ultrasound-based diagnostics field that can help us to quantitatively assess liver steatosis, including continuous attenuation parameters in A and B ultrasound modes, backscatter coefficients (e.g., speed of sound) and ultrasound envelope statistic parametric imaging. The methods used in this field are widely available, have favorable time and financial profiles, and are well accepted by patients. Less is known about their reliability in defining the presence and degree of liver steatosis. Numerous study reports have shown the methods' favorable negative and positive predictive values in comparison with reference investigations (liver biopsy and MRI). Important research has also evaluated the role of these methods in diagnosing and monitoring non-alcoholic fatty liver disease (NAFLD). Since NAFLD is becoming the dominant global cause of liver cirrhosis, and due to the close but complex interplay of liver steatosis with the coexistence of liver fibrosis, knowledge regarding NAFLD's influence on the progression of liver fibrosis is of crucial importance. Study findings, therefore, indicate the possibility of using these same diagnostic methods to evaluate the impact of NAFLD on the patient's liver fibrosis progression risk, metabolic risk factors, cardiovascular complications, and the occurrence of hepatocellular carcinoma. The mentioned areas are particularly important in light of the fact that most of the known chronic liver disease etiologies are increasingly intertwined with the simultaneous presence of NAFLD.
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Affiliation(s)
- Andrej Hari
- Oddelek za Bolezni Prebavil, Splošna Bolnišnica Celje, Oblakova Cesta 3, 3000 Celje, Slovenia
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5
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Yu Q, Xu C, Li Q, Ding Z, Lv Y, Liu C, Huang Y, Zhou J, Huang S, Xia C, Meng X, Lu C, Li Y, Tang T, Wang Y, Song Y, Qi X, Ye J, Ju S. Spleen volume-based non-invasive tool for predicting hepatic decompensation in people with compensated cirrhosis (CHESS1701). JHEP Rep 2022; 4:100575. [PMID: 36204707 PMCID: PMC9531280 DOI: 10.1016/j.jhepr.2022.100575] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/14/2022] [Accepted: 08/16/2022] [Indexed: 11/30/2022] Open
Abstract
Background & Aims Non-invasive stratification of the liver decompensation risk remains unmet in people with compensated cirrhosis. This study aimed to develop a non-invasive tool (NIT) to predict hepatic decompensation. Methods This retrospective study recruited 689 people with compensated cirrhosis (median age, 54 years; 441 men) from 5 centres from January 2016 to June 2020. Baseline abdominal computed tomography (CT), clinical features, and liver stiffness were collected, and then the first decompensation was registered during the follow-up. The spleen-based model was designed for predicting decompensation based on a deep learning segmentation network to generate the spleen volume and least absolute shrinkage and selection operator (LASSO)-Cox. The spleen-based model was trained on the training cohort of 282 individuals (Institutions I–III) and was validated in 2 external validation cohorts (97 and 310 individuals from Institutions IV and V, respectively) and compared with the conventional serum-based models and the Baveno VII criteria. Results The decompensation rate at 3 years was 23%, with a 37.6-month median (IQR 21.1–52.1 months) follow-up. The proposed model showed good performance in predicting decompensation (C-index ≥0.84) and outperformed the serum-based models (C-index comparison test p <0.05) in both the training and validation cohorts. The hazard ratio (HR) for decompensation in individuals with high risk was 7.3 (95% CI 4.2–12.8) in the training and 5.8 (95% CI 3.9–8.6) in the validation (log-rank test, p <0.05) cohorts. The low-risk group had a negligible 3-year decompensation risk (≤1%), and the model had a competitive performance compared with the Baveno VII criteria. Conclusions This spleen-based model provides a non-invasive and user-friendly method to help predict decompensation in people with compensated cirrhosis in diverse healthcare settings where liver stiffness is not available. Lay summary People with compensated cirrhosis with larger spleen volume would have a higher risk of decompensation. We developed a spleen-based model and validated it in external validation cohorts. The proposed model might help predict hepatic decompensation in people with compensated cirrhosis when invasive tools are unavailable. Spleen volume is a predictor for decompensation by rapid risk increasement after spleen volume >364 cm3. The spleen-based model revealed incremental prognostic improvement (C-index >0.84). Low-risk patients identified by the spleen-based model had a negligible 3-year risk (≤1%) of decompensation.
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Affiliation(s)
- Qian Yu
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Chuanjun Xu
- Department of Radiology, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Qinyi Li
- Department of Radiology, The Affiliated Third Hospital of Jiangsu University, Zhenjiang, China
| | - Zhimin Ding
- Department of Radiology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Yan Lv
- Department of Medical Imaging, Subei People’s Hospital, Medical School of Yangzhou University, Yangzhou, China
| | - Chuan Liu
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yifei Huang
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Jiaying Zhou
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Shan Huang
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Cong Xia
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiangpan Meng
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Chunqiang Lu
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yuefeng Li
- Department of Radiology, The Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Tianyu Tang
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yuancheng Wang
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yang Song
- MR Scientific Marketing, Siemens Healthineers Ltd., Shanghai, China
| | - Xiaolong Qi
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jing Ye
- Department of Medical Imaging, Subei People’s Hospital, Medical School of Yangzhou University, Yangzhou, China
| | - Shenghong Ju
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Corresponding author. Address: Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China. Tel.: +86-83272121.
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Mendoza YP, Shengir M, Bosch J, Sebastiani G, Berzigotti A. FIB-4 Improves LSM-Based Prediction of Complications in Overweight or Obese Patients With Compensated Advanced Chronic Liver Disease. Clin Gastroenterol Hepatol 2022; 20:2396-2398.e3. [PMID: 33716139 DOI: 10.1016/j.cgh.2021.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/01/2021] [Accepted: 03/05/2021] [Indexed: 02/07/2023]
Abstract
Liver stiffness measurement (LSM) by transient elastography (TE) is able to stratify the risk of decompensation in patients with compensated advanced chronic liver disease (cACLD).1 Recently, we demonstrated that this holds true also in overweight or obese patients with cACLD due to nonalcoholic steatohepatitis (NASH) studied by the XL probe. An LSM cutoff of ≥21 kPa remained associated with a high risk of complications in this population.2.
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Affiliation(s)
- Yuly P Mendoza
- University Clinic for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Mohamed Shengir
- Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Jaime Bosch
- August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain; Hepatology Group, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Giada Sebastiani
- Division of Experimental Medicine, McGill University, Montreal, Canada; Division of Gastroenterology and Hepatology, McGill University Health Centre, Royal Victoria Hospital, Montreal, Canada
| | - Annalisa Berzigotti
- University Clinic for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland; Hepatology Group, Department of Biomedical Research, University of Bern, Bern, Switzerland.
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7
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ABC: a novel algorithm to stratify decompensation risk in patients with compensated advanced chronic liver disease (CHESS2108): an international, multicenter cohort study. Hepatol Int 2022; 16:1105-1115. [PMID: 35606627 DOI: 10.1007/s12072-022-10345-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/16/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Liver-related death is preceded by clinical decompensation; therefore, the risk stratification of decompensation in compensated advanced chronic liver disease (cACLD) is extraordinary significant. METHODS The international, multicenter study included three cohorts from January 2009 to August 2021. In training cohort, the unfavorable Baveno VI criteria patients were used to develop the novel CHESS criteria to stratify decompensation risk. The Algorithm based on Baveno VI criteria plus CHESS criteria (ABC model) was validated in validation cohort, and used to diagnose clinically significant portal hypertension (CSPH) in hepatic venous pressure gradient (HVPG)-performed cohort. RESULTS A total of 1377 cACLD patients were enrolled. In training cohort, multivariate analysis revealed that liver stiffness measurement (LSM), platelet count (PLT), albumin, alanine aminotransferase (ALT) and varices were the independent risk factors for hepatic decompensation. The novel CHESS criteria was produced (0.036 × LSM [kPa]) + (- 0.013 × PLT [109/L]) + (- 0.068 × Albumin [g/L])) + (- 0.016 × ALT [U/L]) + (0.651 × Varices [present: 1, absent: 0]), and < - 4.4, - 4.4 to - 3.1 and > - 3.1 indicated the low risk, medium risk, and high risk of decompensation, with a 3 year-time-dependent area under the curve (tAUC) of 0.851 (0.800-0.901). In validation cohort, the 3 year-tAUC of ABC model was 0.843 (0.742-0.943). Notably, in HVPG cohort, the high risk group was used to rule in CSPH with a positive predictive value of 93.0%. CONCLUSIONS The ABC model can stratify the risk of decompensation in cACLD. HVPG evaluation can be waived in both low risk and high risk cACLD patients as they can be managed by Baveno VI criteria and non-selective β-blockers intervention, respectively, and the remaining medium risk patients need further HVPG evaluation.
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8
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Liver stiffness can predict decompensation and need for beta-blockers in compensated cirrhosis: a step beyond Baveno-VI criteria. Hepatol Int 2022; 16:89-98. [DOI: 10.1007/s12072-021-10280-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/12/2021] [Indexed: 11/30/2022]
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9
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Tamaki N, Ajmera V, Loomba R. Non-invasive methods for imaging hepatic steatosis and their clinical importance in NAFLD. Nat Rev Endocrinol 2022; 18:55-66. [PMID: 34815553 PMCID: PMC9012520 DOI: 10.1038/s41574-021-00584-0] [Citation(s) in RCA: 98] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 01/27/2023]
Abstract
Hepatic steatosis is a key histological feature of nonalcoholic fatty liver disease (NAFLD). The non-invasive quantification of liver fat is now possible due to advances in imaging modalities. Emerging data suggest that high levels of liver fat and its temporal change, as measured by quantitative non-invasive methods, might be associated with NAFLD progression. Ultrasound-based modalities have moderate diagnostic accuracy for liver fat content and are suitable for screening. However, of the non-invasive imaging modalities, MRI-derived proton density fat fraction (MRI-PDFF) has the highest diagnostic accuracy and is used for trial enrolment and to evaluate therapeutic effects in early-phase clinical trials in nonalcoholic steatohepatitis (NASH). In patients with NAFLD without advanced fibrosis, high levels of liver fat are associated with rapid disease progression. Furthermore, changes on MRI-PDFF (≥30% decline relative to baseline) are associated with NAFLD activity score improvement and fibrosis regression. However, an inverse association exists between liver fat and complications of cirrhosis. Liver fat decreases as liver fibrosis progresses towards cirrhosis, and the clinical importance of quantitative measurements of liver fat differs by NAFLD status. As such, patients with NAFLD should be stratified by fibrosis severity to investigate the utility of quantitative measurements of liver fat for assessing NAFLD progression and prognosis.
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Affiliation(s)
- Nobuharu Tamaki
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Veeral Ajmera
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, USA.
- The Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA.
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10
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D'Amico G, Bernardi M, Angeli P. Towards a new definition of decompensated cirrhosis. J Hepatol 2022; 76:202-207. [PMID: 34157322 DOI: 10.1016/j.jhep.2021.06.018] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/09/2021] [Accepted: 06/14/2021] [Indexed: 12/13/2022]
Abstract
There is a universal agreement that the occurrence of clinical complications, such as ascites, hepatic encephalopathy, gastrointestinal bleeding, and jaundice mark the transition from the compensated to the decompensated stage of cirrhosis. Decompensation is associated with a substantial worsening of patient prognosis and is therefore considered the most important stratification variable for the risk of death. However, this classification is an oversimplification, as it does not discriminate between the prognostic subgroups that characterise the course of decompensation, which depends on the type and number of decompensating events. A deeper insight into the clinical course of decompensated cirrhosis is provided by observational studies characterising acute decompensation (AD), which occurs mostly in patients who have already experienced decompensating events. Decompensation presents as AD in a portion of patients while in many others it presents as a slow development of ascites or mild grade 1 or 2 hepatic encephalopathy, or jaundice, not requiring hospitalisation. Thus, we propose that decompensation of cirrhosis occurs through 2 distinct pathways: a non-acute and an acute (which includes acute-on-chronic liver failure) pathway. Moreover, while non-acute decompensation is the most frequent pathway of the first decompensation, AD mostly represents further decompensation.
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Affiliation(s)
- Gennaro D'Amico
- Gastroenterology Unit, Ospedale V. Cervello, Clinica La Maddalena, Palermo, Italy
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Paolo Angeli
- Department of Medicine, Unit of Internal Medicine and Hepatology (UIMH), University of Padova, Italy.
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11
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Ferraioli G, Berzigotti A, Barr RG, Choi BI, Cui XW, Dong Y, Gilja OH, Lee JY, Lee DH, Moriyasu F, Piscaglia F, Sugimoto K, Wong GLH, Wong VWS, Dietrich CF. Quantification of Liver Fat Content with Ultrasound: A WFUMB Position Paper. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:2803-2820. [PMID: 34284932 DOI: 10.1016/j.ultrasmedbio.2021.06.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/19/2021] [Accepted: 06/07/2021] [Indexed: 06/13/2023]
Abstract
New ultrasound methods that can be used to quantitatively assess liver fat content have recently been developed. These quantitative ultrasound (QUS) methods are based on the analysis of radiofrequency echoes detected by the transducer, allowing calculation of parameters for quantifying the fat in the liver. In this position paper, after a section dedicated to the importance of quantifying liver steatosis in patients with non-alcoholic fatty liver disease and another section dedicated to the assessment of liver fat with magnetic resonance, the current clinical studies performed using QUS are summarized. These new methods include spectral-based techniques and techniques based on envelope statistics. The spectral-based techniques that have been used in clinical studies are those estimating the attenuation coefficient and those estimating the backscatter coefficient. Clinical studies that have used tools based on the envelope statistics of the backscattered ultrasound are those performed by using the acoustic structure quantification or other parameters derived from it, such as the normalized local variance, and that performed by estimating the speed of sound. Experts' opinions are reported.
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Affiliation(s)
- Giovanna Ferraioli
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Medical School University of Pavia, Pavia, Italy
| | - Annalisa Berzigotti
- Hepatology Dept., University Clinic for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, Switzerland
| | - Richard G Barr
- Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio, USA
| | - Byung I Choi
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Xin Wu Cui
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Odd Helge Gilja
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, and Department of Clinical Medicine, University of Bergen, Norway
| | - Jae Young Lee
- Departments of Health and Science and Technology and Medical Device Management and Research, Samsung Advanced Institute for Health Science and Technology, Sungkyunkwan University, Seoul, Korea
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Fuminori Moriyasu
- Department of Gastroenterology and Hepatology, International University of Health and Welfare, Sanno Hospital, Tokyo, Japan
| | - Fabio Piscaglia
- Unit of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, Department of Medical and Surgical Sciences, University of Bologna S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Katsutoshi Sugimoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Grace Lai-Hung Wong
- Medical Data Analytic Centre and Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permancence, Bern, Switzerland.
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EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update. J Hepatol 2021; 75:659-689. [PMID: 34166721 DOI: 10.1016/j.jhep.2021.05.025] [Citation(s) in RCA: 752] [Impact Index Per Article: 250.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 02/07/2023]
Abstract
Non-invasive tests are increasingly being used to improve the diagnosis and prognostication of chronic liver diseases across aetiologies. Herein, we provide the latest update to the EASL Clinical Practice Guidelines on the use of non-invasive tests for the evaluation of liver disease severity and prognosis, focusing on the topics for which relevant evidence has been published in the last 5 years.
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Tamaki N, Kurosaki M, Yasui Y, Tsuchiya K, Izumi N. Attenuation coefficient (ATT) measurement for liver fat quantification in chronic liver disease. J Med Ultrason (2001) 2021; 48:481-487. [PMID: 34165645 DOI: 10.1007/s10396-021-01103-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
Liver fat is one of the main clinical features in chronic liver disease, and the number of fatty liver patients is increasing as the prevalence of obesity and metabolic syndrome increases globally. Noninvasive and quantitative assessment of liver fat content was made possible by recent technological advances. Attenuation coefficient (ATT) measurement is a noninvasive and quantitative liver fat measurement method used in clinical practice. The ATT value is significantly associated with histological steatosis grade. The diagnostic accuracy of ATT for histological steatosis grade is equivalent to controlled attenuation parameter (CAP), and ATT has a lower measurement failure rate than CAP because ATT can be measured on a B-mode image with the exact location of the region of interest. Furthermore, ATT measurement has high interobserver reproducibility. Since ATT measurement and other ultrasound-based modalities for liver fat quantification are easy to perform and inexpensive, these modalities are suitable for point-of-care and screening. Although emerging data suggest that quantitative liver fat content and its changes over time may be associated with disease progression in nonalcoholic fatty liver disease, the association between ATT and disease progression has not been evaluated yet. Therefore, further investigation and validation studies are necessary to strengthen the clinical significance of ATT measurement in chronic liver disease.
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Affiliation(s)
- Nobuharu Tamaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, 1-26-1 Kyonan-cho, Musashino-shi, Tokyo, 180-8610, Japan
| | - Masayuki Kurosaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, 1-26-1 Kyonan-cho, Musashino-shi, Tokyo, 180-8610, Japan
| | - Yutaka Yasui
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, 1-26-1 Kyonan-cho, Musashino-shi, Tokyo, 180-8610, Japan
| | - Kaoru Tsuchiya
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, 1-26-1 Kyonan-cho, Musashino-shi, Tokyo, 180-8610, Japan
| | - Namiki Izumi
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, 1-26-1 Kyonan-cho, Musashino-shi, Tokyo, 180-8610, Japan.
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14
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Dajti E, Alemanni LV, Marasco G, Montagnani M, Azzaroli F. Approaches to the Diagnosis of Portal Hypertension: Non-Invasive or Invasive Tests? Hepat Med 2021; 13:25-36. [PMID: 33776492 PMCID: PMC7987277 DOI: 10.2147/hmer.s278077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/19/2021] [Indexed: 12/15/2022] Open
Abstract
Portal hypertension is the main driver of complications in patients with advanced chronic liver disease (ACLD) and is defined by values of hepatic venous pressure gradient measurement (HVPG) >5 mmHg. Values of HVPG ≥10 mmHg determine the presence of clinically significant portal hypertension (CSPH), the main predictor of the risk of variceal bleeding, hepatic decompensation, and mortality. However, its measurement is invasive and requires high expertise, so its routine use outside third level centers or clinical trials is limited. In the last decades, several non-invasive tests (NITs) have been developed and validated for the diagnosis of portal hypertension. Among these, liver (LSM) and spleen stiffness measurement (SSM) are the most promising tools available, as they have been proven accurate to predict CSPH, high-risk esophageal varices, decompensation, and mortality in patients with ACLD. In the last Baveno VI Consensus proceedings, LSM evaluation was recommended for the first time for diagnosis of CSPH (LSM >20-25 kPa) and the screening of patients with a low probability of having high-risk varices (LSM <20 kPa and platelet count >150.000/mm3). In this review, we aimed to summarize the growing evidence supporting the use of non-invasive tests for the evaluation of portal hypertension in patients with chronic liver disease.
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Affiliation(s)
- Elton Dajti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luigina Vanessa Alemanni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Giovanni Marasco
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Marco Montagnani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Francesco Azzaroli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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15
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Quantitative assessment of liver steatosis using ultrasound controlled attenuation parameter (Echosens). J Med Ultrason (2001) 2021; 48:489-495. [PMID: 34132934 PMCID: PMC8578057 DOI: 10.1007/s10396-021-01106-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/27/2021] [Indexed: 01/01/2023]
Abstract
Controlled attenuation parameter (CAP) is the algorithm available on the FibroScan system (Echosens, France) for quantification of liver steatosis. It assesses the ultrasound beam attenuation, which is directly related to liver fat content. The inter-observer reproducibility of the technique is high, with a reported concordance correlation coefficient of 0.82. Specific quality criteria for CAP measurements are not clearly defined yet, and there are conflicting results in the literature. Using liver biopsy as the reference standard, several studies have assessed the CAP performance in grading liver steatosis, and have reported that values are not affected by liver fibrosis. The cutoff for detection of liver steatosis reported in the literature ranges from 222 decibels per meter (dB/m) in a cohort of patients with chronic hepatitis C to 294 dB/m in a meta-analysis of nonalcoholic fatty liver disease (NAFLD) patients. CAP has been used as a tool to noninvasively evaluate the prevalence of NAFLD in groups at risk or in the general population; however, it should be underscored that different CAP cutoffs for steatosis detection (S > 0) were used in different studies, and this limits the robustness of the findings. CAP, alone or combined with other noninvasive indices or biomarkers, has been proposed as a tool for assessing nonalcoholic steatohepatitis or as a noninvasive predictor of prognosis in patients with chronic liver disease. CAP is easy to perform and has become a point-of-care technique. However, there is a large overlap of values between consecutive grades of liver steatosis, and cutoffs are not clearly defined.
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