1
|
Wang J, Cui Y, Osipov A, Gong J, Pandol S, Lo S, Nissen N, Abbas A, Levi A, Hendifar A. Ascites Is a Poor Prognostic Factor in Advanced Pancreatic Adenocarcinoma and May Be Undertreated: A Prospective Cohort Study. Clin Transl Gastroenterol 2024; 15:e00719. [PMID: 38822798 PMCID: PMC11272255 DOI: 10.14309/ctg.0000000000000719] [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: 01/23/2024] [Accepted: 05/21/2024] [Indexed: 06/03/2024] Open
Abstract
INTRODUCTION Pancreatic ductal adenocarcinoma is associated with significant morbidity and mortality as most patients present with advanced disease. The development of ascites has been associated with poor outcomes and further characterization and contemporary management strategies are needed. METHODS A total of 437 patients enrolled in the Gastrointestinal Biobank at Cedars-Sinai Medical Center who had epithelial pancreatic malignancy were included in the prospective cohort group. Overall, 41.7% of patients included in this study developed ascites. Most patients with ascites (>80%) had high serum-ascites albumin gradient ascites. In both univariate and multivariate analysis, a history of ≥1 form of chemotherapy was significantly associated with ascites. Estimated median overall survival in patients with ascites was significantly lower than in patients without ascites, 473 days vs 573 days, and ascites had a hazard ratio of 1.37. RESULTS Patients with ascites who received diuretics and indwelling peritoneal catheter had an estimated median survival of 133 days from diagnosis of ascites, and those who received only the indwelling peritoneal catheter without diuretics had an estimated median survival of only 54 days. The estimated median survival from the diagnosis of ascites was 92 days, and the median time to puncture was 7 days. The median time from first tap to death was 45 days. DISCUSSION The use of diuretics is lower than would be expected for patients with pancreatic ductal adenocarcinoma with elevated serum-ascites albumin gradient. Other therapies such as beta blockers should be investigated in this subset of patients. The etiology of ascites in these patients is poorly understood, and further research is needed to establish treatment guidelines and improve outcomes.
Collapse
Affiliation(s)
- Justin Wang
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yujie Cui
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Arsen Osipov
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jun Gong
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stephen Pandol
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Simon Lo
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Anser Abbas
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Abrahm Levi
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | |
Collapse
|
2
|
Cromer M, Wilcox CM, Shoreibah M. Beta-blockers and cirrhosis: Striking the right balance. Am J Med Sci 2024; 367:228-234. [PMID: 38262558 DOI: 10.1016/j.amjms.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 01/16/2024] [Indexed: 01/25/2024]
Abstract
Decompensated cirrhosis is associated with a significantly increased risk of mortality. Variceal hemorrhage (VH) further increases the risk of mortality, and of future variceal bleed events. Non-selective beta-blockers (NSBBs) are effective therapy for primary and secondary prophylaxis of VH and have become the cornerstone of pharmacologic therapy in cirrhosis. Beta-blockers are associated with reduced overall mortality and GI-bleeding related mortality in patients with decompensated cirrhosis; they may also confer hemodynamically independent beneficial effects. Long-term treatment with beta-blockers may improve decompensation-free survival in compensated cirrhosis with clinically significant portal hypertension (CSPH). Carvedilol more effectively lowers the hepatic vein portal gradient than traditional NSBBs and has been shown to improve survival in compensated cirrhosis. Treatment goals in compensated cirrhosis with CSPH should focus on early utilization of beta-blockers to prevent decompensation and reduce mortality.
Collapse
Affiliation(s)
- Mark Cromer
- Division of General Internal Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - C Mel Wilcox
- Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Mohamed Shoreibah
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
3
|
Qaqish F, Dimachkie R, Sasso R, Loeffler J, Hasan M, Deghani S, Abou Yassine A, Deeb L. Safety of Nonselective Beta-Blockers in Decompensated Liver Cirrhosis and Their Role in Inducing Hepatorenal Syndrome. Cureus 2024; 16:e58296. [PMID: 38752039 PMCID: PMC11094662 DOI: 10.7759/cureus.58296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
Background Nonselective beta-blockers (NSBBs) have been used in the management of portal hypertension and the prevention of initial and recurrent variceal bleeding in patients with liver cirrhosis. However, there is controversy regarding the use of NSBBs in patients with decompensated cirrhosis (DC) due to concerns over potential adverse effects, such as worsening of hepatic function and risk of hepatorenal syndrome (HRS). HRS is a serious complication of DC characterized by acute kidney injury (AKI) and progressive renal failure, and its development can lead to significant morbidity and mortality in this setting. Therefore, using NSBBs in patients with DC remains an area of ongoing research and debate. Our study aims to investigate the potential effect of NSBBs on HRS development. Methodology A retrospective chart review of 404 patients with cirrhosis was performed across all Northwell Health institutions between January 01, 2019, and December 31, 2020. An analysis was done on 516 patient encounters. Inclusion criteria included patients with an established International Classification of Diseases 10th Revision code of cirrhosis and AKI. After adjusting for clinical predictors, the Student's t-test or Mann-Whitney U-test was used to compare variables between the two outcome groups (HRS vs. no HRS) for the continuous variables. Pearson's chi-square test or Fisher's exact test was used for the categorical variables to test if an association existed between the use of NSBBs at home and HRS. A two-sided p-value <0.05 was considered statistically significant. SAS 9.4 (SAS Institute Inc., Cary, NC, USA) was used for statistical analysis. Results The primary outcome was the development of HRS during the hospital stay. With a total of 109 visits with HRS, we had 21 (23.60%) reported HRS in the 89 visits where NSBBs were used at home before the hospitalization, while 88 (20.61%) HRS were observed in the 427 visits with no NSBB use at home. The use of NSBBs at home was not significantly associated with the development of HRS (odds ratio = 1.1, 95% confidence interval = 0.6-1.9, p = 0.7321). We also found that higher serum albumin on admission is associated with lower odds of HRS. In contrast, increased serum creatinine, bilirubin, presence of ascites, and use of pressors were associated with a higher risk of HRS. Conclusions Our study highlights the relevant safety of NSBB use in end-stage liver disease. Their use did not appear to increase the risk of developing HRS during hospitalization with DC. Further randomized controlled trials are warranted to shed more light on the efficacy, dose tolerance limits, and safety of NSBBs in decompensated end-stage liver disease.
Collapse
Affiliation(s)
- Faris Qaqish
- Internal Medicine, Staten Island University Hospital, Staten Island, USA
| | - Reem Dimachkie
- Internal Medicine, Staten Island University Hospital, Staten Island, USA
| | - Roula Sasso
- Internal Medicine, Staten Island University Hospital, Staten Island, USA
| | - Jeffrey Loeffler
- Internal Medicine, Staten Island University Hospital, Staten Island, USA
| | - Mohammed Hasan
- Internal Medicine, Staten Island University Hospital, Staten Island, USA
| | - Shabnam Deghani
- Internal Medicine, Staten Island University Hospital, Staten Island, USA
| | - Ahmad Abou Yassine
- Internal Medicine, Staten Island University Hospital, Staten Island, USA
| | - Liliane Deeb
- Gastroenterology, Staten Island University Hospital, Staten Island, USA
| |
Collapse
|
4
|
Gaspar R, Silva M, Cardoso P, Goncalves R, Andrade P, Macedo G. Spleen stiffness: a new tool to predict high-risk varices in cirrhotic patients. J Gastroenterol Hepatol 2023; 38:1840-1846. [PMID: 37655720 DOI: 10.1111/jgh.16344] [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: 01/29/2023] [Revised: 07/23/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
INTRODUCTION Cirrhosis is one of the major causes of morbidity and mortality worldwide. Portal hypertension is the major contributor of cirrhosis-related complications and is defined as a hepatic venous pressure gradient (HVPG) > 5 mmHg. Measurement of HVPG is an invasive, difficult, and costly procedure. Therefore, it is only performed in specialized centers. Liver stiffness measured with transient elastography is one of the most studied noninvasive markers of portal hypertension, and spleen elastography has recently emerged as an important adjuvant tool. The development of a new probe (100 Hz) that more reliably reflect the grade of portal hypertension evaluated by spleen stiffness measurement has improved the accuracy of this technique. The aim of this work was to evaluate the accuracy of spleen stiffness with the new dedicated probe to predict the presence of high-risk varices, as well as to determine the ideal cutoff to predict it. METHODS Prospective study of cirrhotic patients admitted to upper endoscopy that were also submitted to liver and spleen elastography with the 100-Hz probe by the same blinded operator in a tertiary center. RESULTS We included 209 cirrhotic patients, with mean age of 61.9 years (±9.9), 77.0% male. The most common etiology was alcoholic liver disease (72.7%). The median value of liver elastography was 25.3 [4.5-75] kPa, and the median value of spleen elastography was 42.4 [7.6-100] kPa. At the cutoff of 53.25 kPa, we obtained sensitivity of 100% and specificity of 72.6% to predict high-risk varices, and, according to this cutoff, 133/175 of esophagogastroduodenoscopy could have been spared (76.0%), while according to Baveno guidelines, only 51/175 would have been spared (29.1%). CONCLUSION In the era of noninvasive exams, spleen elastography with the 100-Hz probe emerges as an excellent tool for prediction of presence of high-risk varices. At the cutoff of 53.25 kPa, spleen elastography avoids upper endoscopy for screening for high-risk varices, promising to be become part of the hepatologists' daily routine.
Collapse
Affiliation(s)
- Rui Gaspar
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Marco Silva
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Pedro Cardoso
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Raquel Goncalves
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Patrícia Andrade
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| |
Collapse
|
5
|
Mattos AAD, Mattos AZD, Sartori GDP, Both GT, Tovo CV. THE ROLE OF ELASTOGRAPHY IN CLINICALLY SIGNIFICANT PORTAL HYPERTENSION. ARQUIVOS DE GASTROENTEROLOGIA 2023; 60:525-535. [PMID: 38018555 DOI: 10.1590/s0004-2803.230402023-64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/08/2023] [Indexed: 11/30/2023]
Abstract
• In compensated cirrhosis, using non-invasive methods would exempt the patient from the need of an endoscopy. • The Baveno VII presented the "rule of 5" for Vibration-Controlled Transient Elastography; liver stiffness measurement ≤15 kPa and platelets >150.000/mm3 exclude clinically significant portal hypertension (CSPH), while when ≥25 kPa is highly suggestive of CSPH. • Spleen stiffness measurement has been proposed as a more specific technique to predict the presence of CSPH. • Elastography has gained prestige in the non-invasive evaluation of patients with advanced chronic liver disease by allowing prophylactic measures to be taken when suggesting the presence of CSPH. This is a narrative review that aims to discuss the importance of elastographic methods in the evaluation of clinically significant portal hypertension (CSPH) in cirrhotic patients, where the authors propose an algorithm for evaluating these patients. In compensated advanced chronic liver disease, the goal is to prevent the development of CSPH and, in those already with CSPH, prevent the appearance of gastroesophageal varices (GEV) and other complications of portal hypertension. In compensated cirrhosis, the prevalence of GEV is 30-40%, of which 10-20% are at risk of bleeding. Therefore, using non-invasive methods would exempt the patient from the need of an endoscopy. Hepatic Elastography is a non-invasive, safe, reproducible method, available through many techniques: Vibration-Controlled Transient Elastography (VCTE), Shear Wave Elastography (SWE) and Magnetic Resonance Elastography (MRE). The Baveno VII presented the "rule of 5" for VCTE: liver stiffness measurement (LSM) ≤15 kPa and platelets >150.000/mm3 exclude CSPH, while an LSM ≥25 kPa is highly suggestive of CSPH. Also, the "rule of 4" for SWE has been proposed: patients with ≥17 kPa could be considered as having CSPH. At last, spleen stiffness measurement (SSM) has been proposed as a more specific technique to predict the presence of CSPH. In conclusion, elastography has gained prestige in the non-invasive evaluation of patients with advanced chronic liver disease by allowing prophylactic measures to be taken when suggesting the presence of CSPH.
Collapse
Affiliation(s)
- Angelo Alves de Mattos
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Clínica Médica, Porto Alegre, RS, Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | - Angelo Zambam de Mattos
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Clínica Médica, Porto Alegre, RS, Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | - Giovana Dal Pozzo Sartori
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | - Gustavo Tovo Both
- Universidade Luterana do Brasil, Departamento de Clínica Médica, Canoas, RS, Brasil
| | - Cristiane Valle Tovo
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Clínica Médica, Porto Alegre, RS, Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| |
Collapse
|
6
|
Dajti E, Ravaioli F, Zykus R, Rautou PE, Elkrief L, Grgurevic I, Stefanescu H, Hirooka M, Fraquelli M, Rosselli M, Chang PEJ, Piscaglia F, Reiberger T, Llop E, Mueller S, Marasco G, Berzigotti A, Colli A, Festi D, Colecchia A. Accuracy of spleen stiffness measurement for the diagnosis of clinically significant portal hypertension in patients with compensated advanced chronic liver disease: a systematic review and individual patient data meta-analysis. Lancet Gastroenterol Hepatol 2023; 8:816-828. [PMID: 37478880 DOI: 10.1016/s2468-1253(23)00150-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/06/2023] [Accepted: 05/10/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND The diagnosis of clinically significant portal hypertension is crucial for prognosis and treatment guidance in patients with compensated advanced chronic liver disease (ACLD). Spleen stiffness measurement (SSM) might improve the non-invasive diagnosis of clinically significant portal hypertension, but previous studies have reported heterogeneous SSM cutoffs. We aimed to evaluate the accuracy of SSM and SSM-based algorithms in this setting. METHODS In this systematic review and individual patient data meta-analysis, we searched PubMed, Embase, Scopus, Web of Science, and the Cochrane Library from database inception to Dec 31, 2022, for articles, abstracts, and letters, with no restrictions on language. Cross-sectional studies reporting hepatic venous pressure gradient and SSM by different techniques (transient elastography; two-dimensional shear-wave elastography [2D-SWE]; point shear-wave elastography [p-SWE]) in adults (≥18 years) with compensated ACLD were eligible for inclusion. The main outcome was the diagnostic performance of two SSM-based algorithms, with the Baveno VII model as a reference, evaluating sensitivity and specificity, as well as summary negative predictive values (NPVs) and positive predictive values (PPVs). In the Baveno VII model, clinically significant portal hypertension was ruled out if patients had a liver stiffness measurement (LSM) of 15 kPa or less and a platelet count of 150 × 109 platelets per L or higher and ruled in if they had an LSM of greater than 25 kPa. The two SSM-based models combined these same cutoffs with additional criteria. In the Baveno VII-SSM single cutoff model, clinically significant portal hypertension was ruled out if at least two of the following were present: LSM of 15 kPa or less, platelet count of 150 × 109 platelets per L or higher, and SSM of 40 kPa or less; and ruled in if at least two were present: LSM of greater than 25 kPa, platelet count of less than 150 × 109 platelets per L, and SSM of greater than 40 kPa. The Baveno VII-SSM dual cutoff model used the same criteria, but with a cutoff of SSM of less than 21 kPa to rule out, and greater than 50 kPa to rule in, clinically significant portal hypertension. This study is registered with PROSPERO, CRD42019127164. FINDINGS Of the 44 records assessed for eligibility, 17 studies (with 1245 patients) were included in the meta-analysis. In the transient elastography cohort (n=600), the Baveno VII algorithm was validated for both ruling out (NPV 100%, 95% CI 64-100; sensitivity 100%, 95% CI 70-100) and ruling in (PPV 95%, 85-98; specificity 94%, 95% CI 87-97) clinically significant portal hypertension, but the proportion of patients with indeterminate results (grey zone) was 48% (95% CI 44-52); 57% (95% CI 52-62) of patients with clinically significant portal hypertension were included in the rule-in zone. The Baveno VII-SSM dual cutoff model had adequate NPV (98%, 95% CI 58-100; sensitivity 100%, 95% CI 91-100) and PPV (93%, 95% CI 84-97; specificity 89%, 95% CI 84-93), with 32% (95% CI 28-36) of patients in the grey zone; 76% (95% CI 72-80) of the patients with clinically significant portal hypertension were in the rule-in zone. The Baveno VII-SSM single cutoff model had a sensitivity of 93% (95% CI 85-97) and a NPV of 85% (95% CI 60-96) for ruling out, and a specificity of 86% (95% CI 80-91) and a PPV of 92% (95% CI 83-95) for ruling in, clinically significant portal hypertension. 88% (95% CI 84-91) of patients with clinically significant portal hypertension were included in the rule-in zone and 9% (95% CI 7-12) of patients were in the grey zone. In the 2D-SWE cohort (n=225), all three algorithms could safely rule in clinically significant portal hypertension with adequate PPV (≥90%), but NPV was inadequate for ruling out clinically significant portal hypertension. Insufficient data were available to evaluate the performance of SSM assessed by p-SWE. Heterogeneity was low (I2<25%) for most estimates. INTERPRETATION Algorithms combining Baveno VII criteria with SSM showed good performance and reduced the diagnostic grey zone for clinically significant portal hypertension compared with Baveno VII criteria alone. Future studies should evaluate whether SSM-based diagnosis allows for the identification of patients who would benefit from non-selective β-blocker treatment. FUNDING None.
Collapse
Affiliation(s)
- Elton Dajti
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, European Reference Network on Hepatological Diseases, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Department of Medical Specialities, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Romanas Zykus
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Pierre-Emmanuel Rautou
- Centre de Recherche sur l'Inflammation, Inserm, Université Paris-Cité, Paris, France; Service d'Hépatologie, Hôpital Beaujon, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, European Reference Network on Hepatological Diseases, Clichy, France
| | - Laure Elkrief
- Hepatogastroenterology Unit, Hôpital Trousseau, CHRU de Tours, Tours, France
| | - Ivica Grgurevic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, University of Zagreb School of Medicine and Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
| | - Horia Stefanescu
- Hepatology Department, Octavian Fodor Regional Institute of Gastroenterology and Hepatology, luliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Masashi Hirooka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Rosselli
- Department of Internal Medicine, Ospedale San Giuseppe, Empoli, Italy; Division of Medicine, Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, UK
| | - Pik Eu Jason Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Fabio Piscaglia
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, European Reference Network on Hepatological Diseases, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Thomas Reiberger
- Department of Internal Medicine III, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Elba Llop
- Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Madrid, Spain
| | - Sebastian Mueller
- Department of Internal Medicine, Center for Alcohol Research, University of Heidelberg, Heidelberg, Germany
| | - Giovanni Marasco
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, European Reference Network on Hepatological Diseases, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Antonio Colecchia
- Department of Medical Specialities, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy.
| |
Collapse
|
7
|
Ravaioli F, Berger A, Farcau O, Colecchia A, Stefanescu H, Candillier C, Nahon P, Bureau C, Ganne-Carriè N, Berzigotti A, de Ledinghen V, Petta S, Calès P. Individual and population screening of varices needing treatment by a simple, safe and accurate test. Clin Res Hepatol Gastroenterol 2023; 47:102123. [PMID: 37061034 DOI: 10.1016/j.clinre.2023.102123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/08/2023] [Accepted: 04/12/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND Several tests have been developed to screen VNT in different screening settings. We aimed to develop simple estimators to quantify VNT risk and spare endoscopy while missing <5% of VNT, adapted to different screenings in the main etiologies. METHODS 2,368 patients with chronic liver disease were included. The main VNT predictors were platelets, prothrombin index (PI) and LSM. Their interactions led to score construction, LIP: (LSM*45)/(PI*platelets), and BLIP: BMI-adjusted LIP in NAFLD. Scores were categorized either for population (VNT sensitivity ≥95%) or individual (negative predictive value ≥95%) VNT screening. RESULTS 1) Scores diagnosing VNT. AUROCs were, PLER: 0.767 Anticipate: 0.773 (p=0.059 vs previous), LIP: 0.779 (p=0.136), PLEASE: 0.789 (p=0.196). 2) Population screening performance was in increasing order (with missed VNT rate), Baveno6 criteria: 23.9% (2.5%), Anticipate 24.5%, p=0.367 vs previous (3.3%), PLER 27.3%, p<0.001 (3.6%), LIP 33.4%, p<0.001 (4.2%), PLEASE 35.2%, p=0.006 (3.6%). In NAFLD, LIP 38.6%, BLIP 40.8%, p=0.038. 3) Individual screening performance was, expanded Baveno6 criteria: 42.7%, LIP 54.1%, p<0.001. In NAFLD, performance was, NAFLD-cirrhosis criteria: 66.7%, BLIP 74.6%, p<0.001. CONCLUSION LIP combined simplicity, performance and safety in each etiology. In NAFLD, BMI-adjusted LIP outperformed other tests.
Collapse
Affiliation(s)
- Federico Ravaioli
- Gastroenterology and Hepatology Unit, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.
| | - Arthur Berger
- Hepato-Gastroenterology Department, University Hospital, Angers, France; HIFIH laboratory, UPRES 3859, UNIV Angers, France.
| | - Oana Farcau
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania.
| | - Antonio Colecchia
- Gastroenterology and Hepatology Unit, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; Hepato-Gastroenterology Department, University Hospital, Angers, France; HIFIH laboratory, UPRES 3859, UNIV Angers, France; Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania; Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy.
| | - Horia Stefanescu
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania.
| | - Camille Candillier
- Hepato-Gastroenterology Department, University Hospital, Angers, France; HIFIH laboratory, UPRES 3859, UNIV Angers, France.
| | - Pierre Nahon
- Hepatology Department, Avicenne Hospital, Bobigny, Paris hospitals; INSERM UMR-1162, Paris Sorbonne University, France.
| | - Christophe Bureau
- Hepato-Gastroenterology Department, Purpan University Hospital, Toulouse, France.
| | - Nathalie Ganne-Carriè
- Hepatology Department, Avicenne Hospital, Bobigny, Paris hospitals; INSERM UMR-1162, Paris Sorbonne University, France.
| | - Annalisa Berzigotti
- Hepatology, Swiss Liver Center, Visceral Surgery and Medicine Clinic (UVCM), Inselspital, University of Bern, Switzerland.
| | | | - Salvatore Petta
- Department of Gastroenterology and Hepatology, PROMISE, University of Palermo, Palermo, Italy.
| | - Paul Calès
- Hepato-Gastroenterology Department, University Hospital, Angers, France; HIFIH laboratory, UPRES 3859, UNIV Angers, France.
| |
Collapse
|
8
|
Ferral H, Schepis F, Gaba RC, Garcia-Tsao G, Zanetto A, Perez-Campuzano V, Haskal ZJ, Garcia-Pagan JC. Endovascular Assessment of Liver Hemodynamics in Patients with Cirrhosis Complicated by Portal Hypertension. J Vasc Interv Radiol 2023; 34:327-336. [PMID: 36516940 DOI: 10.1016/j.jvir.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/02/2022] [Accepted: 12/04/2022] [Indexed: 12/14/2022] Open
Abstract
The hepatic venous pressure gradient (HVPG) is currently considered the gold standard to assess portal hypertension (PH) in patients with cirrhosis. A meticulous technique is important to achieve accurate and reproducible results, and values obtained during measurement are applied in risk stratification of patients with PH, allocating treatment options, monitoring follow-up, and deciding management options in surgical patients. The use of portosystemic pressure gradients in patients undergoing placement of transjugular intrahepatic portosystemic shunts has been studied extensively and has great influence on decisions on shunt diameter. The purpose of this study was to describe the recommended technique to measure HVPG and portosystemic pressure gradient and to review the existing literature describing the importance of these hemodynamic measurements in clinical practice.
Collapse
Affiliation(s)
- Hector Ferral
- Section of Interventional Radiology, Department of Radiology, Louisiana State University, New Orleans, Louisiana
| | - Filippo Schepis
- Hepatic Hemodynamic Laboratory, Division of Gastroenterology, AOU of Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Ron C Gaba
- Division of Interventional Radiology, Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Guadalupe Garcia-Tsao
- Digestive Disease Section, Internal Medicine, Yale School of Medicine, New Haven, Connecticut; VA-Connecticut Healthcare System, West Haven, Connecticut
| | - Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Italy
| | - Valeria Perez-Campuzano
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders, Hamburg, Germany
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders, Hamburg, Germany.
| |
Collapse
|
9
|
Zimmermann HW, Trautwein C, Bruns T. [Current diagnostics and treatment of portal hypertension]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2022; 63:1257-1267. [PMID: 36374293 DOI: 10.1007/s00108-022-01427-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
In industrial nations portal hypertension is mostly a consequence of liver cirrhosis and is a prerequisite for complications, such as esophageal varices and ascites. The pathophysiology of portal hypertension is complex. It is defined as an increase in the hepatovenous pressure gradient to > 5 mm Hg, with complications to be expected at ≥ 10 mm Hg. Measurement of the pressure of the hepatic vein occlusion is the gold standard for estimating portal pressure but this is not very practical. Liver elastography, in particular, has proven to be an effective noninvasive tool to identify patients with clinically significant portal hypertension (CSPH). Current treatment concepts address the CSPH even before the onset of complications to reduce the likelihood of decompensation. In addition to beta blockers, a transjugular intrahepatic portosystemic shunt is the most important procedure to lower portal vein pressure and enables an improvement in the prognosis of selected patients.
Collapse
Affiliation(s)
- Henning W Zimmermann
- Medizinische Klinik III, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - Christian Trautwein
- Medizinische Klinik III, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland.
| |
Collapse
|
10
|
Rabiee A, Deng Y, Ciarleglio M, Chan JL, Pons M, Genesca J, Garcia-Tsao G. Noninvasive predictors of clinically significant portal hypertension in NASH cirrhosis: Validation of ANTICIPATE models and development of a lab-based model. Hepatol Commun 2022; 6:3324-3334. [PMID: 36214066 PMCID: PMC9701481 DOI: 10.1002/hep4.2091] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 01/21/2023] Open
Abstract
Clinically significant portal hypertension (CSPH), defined as hepatic venous pressure gradient (HVPG) ≥ 10 mm Hg, identifies patients with compensated cirrhosis at a high risk of decompensation. However, HVPG is an invasive and nuanced method. The ANTICIPATE models, which include liver stiffness measurements by transient elastography (TE) and platelet count ± body mass index, are robust noninvasive surrogates of CSPH but required external validation in patients with nonalcoholic steatohepatitis (NASH) cirrhosis. Additionally, TE is not widely available worldwide. The aims of the study were: (1) to externally validate the ANTICIPATE models using baseline data from patients with compensated NASH cirrhosis screened/enrolled in a multicenter international randomized controlled trial; and (2) to develop and externally validate a model using only laboratory values. Regarding aim 1, both ANTICIPATE models showed good calibration and discrimination (area under the curve [AUC] > 0.8) in our cohort (n = 222). Regarding aim 2, a new lab-based model using the Fibrosis-4 index (FIB-4 [age, aspartate aminotransferase, alanine aminotransferase, platelet count]) plus serum albumin was developed. The discrimination in the training cohort (n = 309) was good (AUC of 0.78 [95% confidence interval [CI]:0.72-0.83]). It was then externally validated in a separate cohort of 245 patients with compensated NASH cirrhosis (AUC of 0.8 [95% CI: 0.75-0.86]). Given the difference in the prevalence of CSPH between training (74%) and validation (39%) cohorts, the model required an update of the baseline risk to achieve a good calibration. The updated model was named FIB4+. In conclusion, both ANTICIPATE models performed well in predicting the presence of CSPH in NASH cirrhosis. A model using FIB-4 plus albumin (FIB4+) can be used to predict CSPH where TE is not available.
Collapse
Affiliation(s)
- Anahita Rabiee
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yanhong Deng
- Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Maria Ciarleglio
- Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Jean L Chan
- Conatus Pharmaceuticals at the time of study conduct, San Diego, California, USA
| | - Monica Pons
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Genesca
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA.,VA-CT Healthcare System, New Haven, Connecticut, USA
| |
Collapse
|
11
|
A Combined Baveno VII and Spleen Stiffness Algorithm to Improve the Noninvasive Diagnosis of Clinically Significant Portal Hypertension in Patients With Compensated Advanced Chronic Liver Disease. Am J Gastroenterol 2022; 117:1825-1833. [PMID: 35973171 DOI: 10.14309/ajg.0000000000001887] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/08/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION A noninvasive diagnosis of clinically significant portal hypertension (CSPH) has important prognostic and therapeutic implications for patients with compensated advanced chronic liver disease. We aimed to validate and improve the available algorithms for the CSPH diagnosis by evaluating spleen stiffness measurement (SSM) in patients with compensated advanced chronic liver disease. METHODS This is a retrospective study including patients with liver stiffness measurement (LSM) ≥10 kPa, no previous decompensation, and available measurements of hepatic venous pressure gradient, LSM, and SSM by transient elastography referring to our center in Bologna. The diagnostic algorithms were adequate if negative and positive predictive values were >90% when ruling out and ruling in CSPH, respectively; these models were validated in a cohort from Verona. The 5-year decompensation rate was reported. RESULTS One hundred fourteen patients were included in the derivation cohort. The Baveno VII diagnostic algorithm (LSM ≤15 kPa + platelet count ≥150 × 10 9 /L to rule out CSPH and LSM >25 kPa to rule in CSPH) was validated; however, 40%-60% of the patients remained in the gray zone. The addition of SSM (40 kPa) to the model significantly reduced the gray zone to 7%-15%, maintaining adequate negative and positive predictive values. The diagnostic algorithms were validated in a cohort of 81 patients from Verona. All first decompensation events occurred in the "rule-in" zone of the model including SSM. DISCUSSION The addition of SSM significantly improves the clinical applicability of the algorithm based on LSM and platelet count for CSPH diagnosis. Our models can be used to noninvasively identify candidates for nonselective beta-blocker treatment and patients at a high risk of decompensation.
Collapse
|
12
|
A Novel SAVE Score to Stratify Decompensation Risk in Compensated Advanced Chronic Liver Disease (CHESS2102): An International Multicenter Cohort Study. Am J Gastroenterol 2022; 117:1605-1613. [PMID: 35973168 PMCID: PMC9531993 DOI: 10.14309/ajg.0000000000001873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/12/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION In patients with compensated advanced chronic liver disease (cACLD), the invasive measurement of hepatic venous pressure gradient is the best predictor of hepatic decompensation. This study aimed at developing an alternative risk prediction model to provide a decompensation risk assessment in cACLD. METHODS Patients with cACLD were retrospectively included from 9 international centers within the Portal Hypertension Alliance in China (CHESS) network. Baseline variables from a Japanese cohort of 197 patients with cACLD were examined and fitted a Cox hazard regression model to develop a specific score for predicting hepatic decompensation. The novel score was validated in an external cohort (n = 770) from 5 centers in China, Singapore, Korea, and Egypt, and was further assessed for the ability of predicting clinically significant portal hypertension in a hepatic venous pressure gradient cohort (n = 285). RESULTS In the derivation cohort, independent predictors of hepatic decompensation were identified including Stiffness of liver, Albumin, Varices, and platElets and fitted to develop the novel score, termed "SAVE" score. This score performed significantly better (all P < 0.05) than other assessed methods with a time-dependent receiver operating characteristic curve of 0.89 (95% confidence interval [CI]: 0.83-0.94) and 0.83 (95% CI: 0.73-0.92) in the derivation and validation cohorts, respectively. The decompensation risk was best stratified by the cutoff values at -6 and -4.5. The 5-year cumulative incidences of decompensation were 0%, 24.9%, and 69.0% in the low-risk, middle-risk, and high-risk groups, respectively ( P < 0.001). The SAVE score also accurately predicted clinically significant portal hypertension (AUC, 0.85 95% CI: 0.80-0.90). DISCUSSION The SAVE score can be readily incorporated into clinical practice to accurately predict the individual risk of hepatic decompensation in cACLD.
Collapse
|
13
|
Calès P, Ravaioli F, Berger A, Farcau O, Festi D, Stefanescu H, Vitellius C, Nahon P, Bureau C, Ganne-Carriè N, Berzigotti A, de Ledinghen V, Petta S. Comparison of screening strategies with two new tests to score and diagnose varices needing treatment. Clin Res Hepatol Gastroenterol 2022; 46:101925. [PMID: 35470108 DOI: 10.1016/j.clinre.2022.101925] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/08/2022] [Accepted: 04/15/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS We aimed to improve non-invasive screening of varices needing treatment (VNT) and compare different screening strategies. METHODS 2,290 patients with chronic liver disease were included in a retrospective study. Etiologies were: virus: 50.0%, NAFLD: 29.5%, alcohol: 20.5%, VNT: 14.9%. Test descriptors were performance (spared endoscopy) and safety (missed VNT). VNT tests were evaluated according to their safety levels either for individual screening (95% negative predictive value (NPV)), population screening (95% sensitivity) or undifferentiated screening (100% sensitivity/NPV) without missed VNT. The tests provided three categories: missed VNT <5%, VNT 100% specificity (new category), both sparing endoscopies, and intermediate (endoscopy required). RESULTS Independent VNT predictors (etiology, sex, age, platelets, prothrombin index, albumin, ALT, liver stiffness) were included in two tests: VNT virus alcohol NAFLD test (VANT) and varice risk score (VARS). We report results of the whole population. Considering population screening, performances were, Baveno VI criteria: 24.1%, Anticipate: 24.7%, VariScreen: 35.3%, VANT: 40.2% (p<0.001 vs other tests). VANT spared 58.0% more endoscopies in the whole population than Baveno criteria in compensated advanced chronic liver diseases. Considering individual screening, VARS performance was, in all patients: 62.0% vs 42.9% for the expanded Baveno VI criteria (p<0.001), and, in NAFLD: 72.8% vs 65.1% for the NAFLD cirrhosis criteria (p<0.001). Considering undifferentiated screening, VARS performance was 12%. The VARS score estimated VNT probability from 0 to 100% (AUROC: 0.826). CONCLUSION VANT and VARS spared from 12% (undifferentiated screening) to 40% (population screening) or 62% (individual screening) of endoscopies in main-etiology patients without ascites.
Collapse
Affiliation(s)
- Paul Calès
- Hepato-Gastroenterology Department, University Hospital, Angers, France; HIFIH laboratory, UPRES 3859, UNIV Angers, France.
| | - Federico Ravaioli
- Gastroenterology and Hepatology Unit, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.
| | - Arthur Berger
- Hepato-Gastroenterology Department, University Hospital, Angers, France; HIFIH laboratory, UPRES 3859, UNIV Angers, France.
| | - Oana Farcau
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Davide Festi
- Gastroenterology and Hepatology Unit, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.
| | - Horia Stefanescu
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania.
| | - Carole Vitellius
- Hepato-Gastroenterology Department, University Hospital, Angers, France; HIFIH laboratory, UPRES 3859, UNIV Angers, France.
| | - Pierre Nahon
- Hepatology Department, Avicenne Hospital, Bobigny, Paris hospitals, INSERM UMR-1162, Paris Sorbonne University, France.
| | - Christophe Bureau
- Hepato-Gastroenterology Department, Purpan University Hospital, Toulouse, France.
| | - Nathalie Ganne-Carriè
- Hepatology Department, Avicenne Hospital, Bobigny, Paris hospitals, INSERM UMR-1162, Paris Sorbonne University, France.
| | - Annalisa Berzigotti
- Hepatology, Swiss Liver Center, Visceral Surgery and Medicine Clinic (UVCM), Inselspital, University of Bern, Switzerland.
| | | | - Salvatore Petta
- Department of Gastroenterology and Hepatology, PROMISE, University of Palermo, Palermo, Italy.
| |
Collapse
|
14
|
Propranolol vs. band ligation for primary prophylaxis of variceal hemorrhage in cirrhotic patients with ascites: a randomized controlled trial. Hepatol Int 2022; 16:944-953. [DOI: 10.1007/s12072-022-10361-4] [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: 03/02/2022] [Accepted: 05/07/2022] [Indexed: 11/04/2022]
|
15
|
Wong YJ, Li J, Liu C, Chen Z, Chan YH, Putera M, Teh KB, Ang TL, Zhao L, Yan Z, Kumar R, Li X, Qi X. CHESS-ALARM score to stratify decompensation risk in compensated advanced chronic liver disease patients: An international multicenter study. J Gastroenterol Hepatol 2022; 37:1043-1051. [PMID: 35253271 DOI: 10.1111/jgh.15819] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM A combination of platelet and elastography (PE criteria) was proposed to identify compensated advanced chronic liver disease (cACLD) patients at risk of liver decompensation. We aim to validate and refine PE criteria by developing a new predictive score to predict decompensation in Asian cACLD patients. METHODS An international cohort of 633 cACLD patients with liver stiffness measurement (LSM) and esophagogastroduodenoscopy performed were included. We validated PE criteria to predict first liver decompensation using competing risk analysis, with death and hepatocellular carcinoma as competing events. We developed a predictive model using proportional subdistribution hazard regression. Prognostic accuracy was compared with the model of end-stage liver disease (MELD), albumin-bilirubin (ALBI), and ALBI-FIB-4 score using time-dependent area under operative characteristic curve (tAUC). RESULTS Sixty patients developed decompensation over the median follow-up of 39 months. Favorable Baveno VI status ruled out cACLD patients at risk of liver decompensation. LSM > 25 kPa was suboptimal to predict cACLD patients who will develop liver decompensation. We developed CHESS-ALARM score by incorporating age, platelet, and gender into LSM. CHESS-ALARM score (tAUC = 0.86, 95% confidence interval [CI]: 0.79-0.94) has significantly higher accuracy than MELD (tAUC: 0.61), ALBI (tAUC: 0.62), ALBI-FIB-4 (tAUC: 0.70), and LSM > 25 kPa (tAUC: 0.54) to predict liver decompensation at 5 years (P < 0.05 for all). Patients with CHESS-ALARM score ≥ -0.37 had an 11-fold higher risk of decompensation (subdistribution hazard ratio = 11.2, 95% CI: 5.1-24.5). CONCLUSION CHESS-ALARM score can be readily incorporated into clinical practice of cACLD patients to estimate individual risk of liver decompensation; however, more data are required in morbidly obese cACLD patients of nonviral etiology.
Collapse
Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Program, SingHealth, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jia Li
- Department of Gastroenterology and Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Chuan Liu
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Zhaojin Chen
- Biostatistic Unit, Yong Loo Lin School of Medicine, Singapore
| | - Yiong Huak Chan
- Biostatistic Unit, Yong Loo Lin School of Medicine, Singapore
| | - Martin Putera
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kok Ban Teh
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Program, SingHealth, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lili Zhao
- Department of Gastroenterology and Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Zhongfang Yan
- Department of Radiology, Tianjin Second People's Hospital, Tianjin, China
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Program, SingHealth, Singapore
| | - Xin Li
- Department of Clinical Nutrition, Tianjin Second People's Hospital, Tianjin, China
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| |
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW In 2015, as a consequence of the high development in noninvasive tests, Baveno VI consensus recommended for the first time the use of a prediction rule (liver stiffness <20kPa and platelet count > 150000) to identify patients at low risk of having varices and that could circumvent endoscopy. These became known as the Baveno VI criteria. We review here the data validating Baveno VI criteria and we discuss the attempts of expanding these criteria. RECENT FINDINGS We report 28 studies assessing the performance of Baveno VI criteria showing a pooled 99% negative predictive value for ruling out high-risk varices. Performance is not affected by the cause of cirrhosis. Different attempts at expanding these criteria show suboptimal performance. Nonelastography-based criteria require further validation. SUMMARY Baveno VI criteria can be safely used to avoid endoscopy in a substantial proportion of patients with compensated cirrhosis. The progressive change in approach to the management of compensated cirrhosis, progressively focusing on treating portal hypertension with beta-blockers independently of the presence of varices, might render these criteria less relevant.
Collapse
|