Liver and spleen stiffness and other noninvasive methods to assess portal hypertension in cirrhotic patients: a review of the literature

Liver and spleen shear-wave elastography in the diagnosis and severity staging of myeloproliferative diseases and myelofibrosis

AIMS

Spleen and liver stiffness, investigated by VCTE (Vibration-Controlled Transient Elastography), have been associated with marrow fibrosis in patients with myeloproliferative neoplasms (MPNs). Tissue stiffness can be assessed by shear wave point (pSWE) and bidimensional elastography (2DSWE). Spleen stiffness (SS) values were higher in Myelofibrosis (MF) and Polycythemia Vera (PV) compared to Essential Thrombocythemia (ET). We aimed to identify SWE differences between MPN patients and healthy volunteers; to evaluate specific SWE features in patients with MF, PV and ET; to establish a correlation with bone marrow fibrosis in patients with myeloproliferative disease.

METHODS

Patients with myeloproliferative disease and healthy volunteers performed evaluation of spleen and liver stiffness (LS) by pSWE and 2DSWE.

RESULTS

A total of 218 subjects were included: 143 with myeloproliferative disease (64 MF, 29.4%, 33 PV, 15.1% and 46 ET, 21.1%), and 75 (34.4%) healthy volunteers. Compared to volunteers, MF patients had greater spleen (pSWE 40.9 vs. 26.3 kPa, p < 0.001; 2DSWE 34.9 vs. 20.1 kPa, p < 0.001), and liver stiffness (pSWE 7.72 vs. 5.52 kPa, p < 0.001; 2DSWE 6.96 vs. 5.01 kPa, p < 0.001). In low (0-1) (n = 81, 60.4%) versus high-grade bone marrow fibrosis (2-3) (n = 42, 39.6%), is evident a higher median stiffness in patients with higher grades of fibrosis both for liver (pSWE 5.2 vs. 6.65 kPa; 2DSWE 5.1 vs. 6.05 kPa) and spleen (pSWE 27.2 vs. 37.9 kPa, 2DSWE 21.7 vs 30.75 kPa-p < 0.001 in both).

CONCLUSION

SWE evaluation distinguishes MF patients from HV and ET/PV and may help in MPN diagnosis. LS and SS values are associated with bone marrow fibrosis grade.

Spleen stiffness determined by spleen-dedicated device accurately predicted esophageal varices in cirrhosis patients

Background

The advantages of spleen stiffness in prediction of high-risk varices (HRV) in cirrhosis patients have been confirmed. Recently, a new device utilizing a 100 Hz probe dedicated to spleen stiffness measurement (SSM) was developed.

Objectives

To validate the clinical applicability of SSM@100 Hz in predicting HRV by comparing it with other non-invasive tests (NITs).

Design

A prospective cohort study.

Methods

A total of 171 cirrhosis patients who underwent esophagogastroduodenoscopy (EGD) examination were included in this study. SSM using a 100 Hz probe and liver stiffness measurement using a 50 Hz probe were performed. Additionally, 22 healthy controls underwent spleen stiffness evaluation using the 100 Hz probe.

Results

The failure rates of spleen stiffness examination in patients with cirrhosis and in healthy controls were 2.9% and 4.5%, respectively. The means of SSM values were 56.4 ± 21.6 and 13.8 ± 6.7 kPa in cirrhosis and controls. SSM increased proportionally with the severity of esophageal varices. The area under receiver operating characteristic (ROC) for spleen stiffness in predicting HRV was 0.881 (95% confidence interval 0.829-0.934), with a cutoff value of 43.4 kPa. The accuracy, false negative rate and EGD spare rate were 86.5%, 2.5% and 24.3%, respectively. For HRV prediction, SSM was comparable to expanded Baveno VI and VII and superior to other NITs. As to viral versus non-viral cirrhosis and compensated versus decompensated cirrhosis, the cut-off and performance of SSM were different.

Conclusion

SSM@100 Hz demonstrates high accuracy in predicting HRV with a low missed HRV rate. Our findings suggest that SSM@100 Hz can be used independently due to its simplicity and effectiveness. However, further studies are needed to determine appropriate cutoff values based on the cause of cirrhosis and liver function.

Trail Registration

ChiCTR2300070270.

Is it possible to achieve an acceptable disease control by dietary therapy alone in Berardinelli Seip type 1? Experience from a case report

Background and objective

Severe metabolic complications generally manifest at an early age in Berardinelli - Seip congenital lipodystrophy (BSCL) and their management is especially challenging. Nutritional intervention with low lipid diets is considered by experts to be fundamental in treating the disease when associated with medical therapy, however little is known about the beneficial effects of dietary interventions alone.

Aim

To underline the importance of a well-structured low-fat diet in BSCL patients.

Methods and results

A BSCL male patient strictly followed a hypocaloric hypolipemic diet (60% carbohydrates, 22% fats and 18% proteins) since clinical diagnosis at the age of one year. Interestingly, pharmacological interventions were not required at any point during the follow-up. Aged 16 years the patient was referred to our center. Biochemistry, hormonal evaluation, 75 mg oral glucose tolerance test, cardiac evaluation and abdominal ultrasound were performed, revealing no abnormalities. Genetic analysis and leptin dosage were carried out, confirming the diagnosis of BSCL type 1 (homozygosity for c.493-1G>C pathogenic variant in AGPAT2 gene) and showing undetectable circulating levels of leptin (< 0.2 mcg/L). Diet therapy alone was therefore maintained, scheduling follow-up visits every six months, with acceptable disease control ever since.

Conclusions

This report proves how a low-fat diet is of great help in the management of BSCL and its complications. In addition, a specific hypolipemic diet could be used alone as an effective treatment in selected cases with high compliance and, probably, a milder phenotype.

The evaluation of portal hypertension in cirrhotic patients with spectral computed tomography

BACKGROUND

Iodine concentrations measured using dual-energy spectral CT (DESCT) have been recently proposed as providing good performance for examining tissues hemodynamics.

PURPOSE

To evaluate the diagnostic efficacy of DESCT-derived parameters in evaluating portal venous pressure in patients with liver cirrhosis.

MATERIAL AND METHODS

A total of 71 patients with liver cirrhosis who underwent percutaneous transhepatic portal vein puncture procedures were included in this study. All participants underwent DESCT and gastrointestinal endoscopy within one month before the operation. The direct portal venous pressure of each participant was measured preoperatively.

RESULTS

Stepwise multivariate linear regression analysis showed that the iodine concentrations in the portal vein and hepatic parenchyma during the portal venous phase and the platelet count were independently correlated with the direct portal venous pressure (P < 0.001, P < 0.001, and P = 0.030, respectively). Receiver operating characteristic analysis revealed that the normalized iodine concentration of the hepatic parenchyma had the best performance for identifying clinically significant portal hypertension (≥10 mmHg), esophageal varices, and high-risk esophageal varices (the area under the curve values were 0.951, 0.932, and 0.960, respectively).

CONCLUSION

The normalized iodine concentration of the hepatic parenchyma is a reliable parameter to non-invasively assess portal venous pressure in patients with liver cirrhosis.

High reproducibility of spleen stiffness measurement by vibration-controlled transient elastography with a spleen-dedicated module

Spleen stiffness measurement (SSM) by vibration-controlled transient elastography (VCTE) is a noninvasive technique for estimating portal hypertension in patients with chronic liver disease (CLD), with its reproducibility yet to be established and its feasibility still unknown beyond CLD. We have studied 420 participants from two tertiary referral centers for liver diseases (Novara, Milan): 297 patients with CLD (32% with cirrhosis) of different etiology (Group A), 63 Philadelphia-negative myeloproliferative neoplasms (Group B), and 60 heathy volunteers (Group C). All underwent SSM by VCTE with a spleen-dedicated module (SSM@100 Hz) and liver stiffness measurement (LSM), blindly performed by 2 different operators. In total, 1680 VCTE examinations for SSM were performed (1000 in Novara, 680 in Milan), with an overall 3.2% failure rate. Median SSM was 26.5 kPa (interquartile range [IQR] 20.0-42.3) in Group A, 26.3 kPa (IQR 22.3-33.6) in Group B, and 16.1 kPa (IQR 14.6-18.7) in Group C. In Group A, the median LSM was 6.8 kPa (IQR 4.9-11.3) in Novara and 8.3 kPa (IQR 7.1-10.8) in Milan, the proportion of patients with cirrhosis being 34% in Novara and 31% in Milan. The Group A interobserver agreement ICC was 0.90 (0.88-0.92), significantly lower in the absence of splenomegaly (ICC 0.87 vs. 0.91) and in absence of cirrhosis (ICC 0.84 vs. 0.90); overweight slightly, but not significantly reduced the interobserveragreement. The intra-observer agreement ICC ranged from 0.91 to 0.96 for the four operators. The Group B interobserver agreement ICC was 0.90 (0.83-0.94). In conclusion, SSM measured by the new spleen-dedicated VCTE module is a feasible, reliable, and highly reproducible tool in patients with CLD and hematological disorders, and in healthy volunteers.

A strategy for varices screening based on acoustic radiation force impulse combined with platelet (CHESS2001): An alternative of Baveno VI criteria

Few studies have reported on acoustic radiation force impulse (ARFI) for varices screening. Our study aimed to identify a strategy based on liver stiffness measurement (LSM) and spleen stiffness measurement (SSM) by ARFI combined with platelet count (PLT), named the ARP strategy, for ruling out high-risk varices (HRV) and avoiding unnecessary esophagogastroduodenoscopy (EGD) in patients with compensated cirrhosis. We retrospectively reviewed patients who underwent ARFI from a previous cohort (NCT04307264). Of them, patients between 2017 and 2019 composed the training cohort to develop the ARP strategy. The validation cohort consisted of others between 2015 and 2016 to validate and compare it with Baveno VI criteria about the performance for varices screening. Primary outcomes were the rates of spared EGDs and HRV missed. A total of 741 consecutive patients were included in the final analysis. Of them, 576 patients were included in the training cohort and 165 patients in the validation cohort. In the training cohort, ARP strategy was defined as LSM < 1.805 m/s or SSM < 2.445 m/s and PLT > 110 × 109 /L. ARP strategy could spare 234 (40.6%) EGDs with a missed HRV rate of 3.4% (8 of 234). In the validation cohort, compared with Baveno VI criteria, the ARP strategy improved the proportion of avoided EGDs (49.7% vs. 34.5%; p < 0.001) and lowered the rate of misclassified HRV (1.2% vs. 3.5%; p < 0.001). Conclusion: The ARP strategy was an efficient and safe tool for varices screening in compensated cirrhosis, and it might be an auxiliary or even alternative to Baveno VI criteria.

Non-invasive diagnosis and follow-up of portal hypertension

Compensated advanced chronic liver disease (cACLD) describes the spectrum of advanced fibrosis/cirrhosis in asymptomatic patients at risk of developing clinically significant portal hypertension (CSPH, defined by a hepatic venous pressure gradient (HVPG) ≥10 mmHg). Patients with cACLD are at high risk of liver-related morbidity and mortality. In patients at risk of chronic liver disease, cACLD is strongly suggested by a liver stiffness (LSM) value >15 kPa or clinical/biological/radiological signs of portal hypertension, and ruled out by LSM <10 kPa, or Fibrotest® ≤0.58, or Fibrometer® ≤0.786. Patients with chronic liver disease (excluding vascular diseases) with a LSM <10 kPa are at low risk of developing portal hypertension complications. The presence of CSPH can be strongly suspected when LSM is ≥20 kPa. In a patient without clinical, endoscopic or radiological features of portal hypertension, measurement of the HVPG is recommended before major liver or intra-abdominal surgery, before extra-hepatic transplantation and in patients with unexplained ascites. Endoscopic screening for oesophageal varices can be avoided in patients with LSM <20 kPa and a platelet count >150 G/L (favourable Baveno VI criteria) at the time of diagnosis. There is no non-invasive method alternative for oeso-gastroduodenal endoscopy in patients with unfavourable Baveno criteria (liver stiffness ≥20 kPa or platelet count ≤50 G/l). Platelet count and liver stiffness measurements must be performed once a year in patients with cACLD with favourable Baveno VI criteria at the time of diagnosis. A screening oeso-gastroduodenal endoscopy is recommended if Baveno VI criteria become unfavourable.

Valsalva Maneuver Decreases Liver and Spleen Stiffness Measured by Time-Harmonic Ultrasound Elastography

Ultrasound elastography quantitatively measures tissue stiffness and is widely used in clinical practice to diagnose various diseases including liver fibrosis and portal hypertension. The stiffness of soft organs has been shown to be sensitive to blood flow and pressure-related diseases such as portal hypertension. Because of the intricate coupling between tissue stiffness of abdominal organs and perfusion-related factors such as vascular stiffness or blood volume, simple breathing maneuvers have altered the results of liver elastography, while other organs such as the spleen are understudied. Therefore, we investigated the effect of a standardized Valsalva maneuver on liver stiffness and, for the first time, on spleen stiffness using time-harmonic elastography (THE). THE acquires full-field-of-view stiffness maps based on shear wave speed (SWS), covers deep tissues, and is potentially sensitive to SWS changes induced by altered abdominal pressure in the hepatosplenic system. SWS of the liver and the spleen was measured in 17 healthy volunteers under baseline conditions and during the Valsalva maneuver. With the Valsalva maneuver, SWS in the liver decreased by 2.2% (from a median of 1.36 m/s to 1.32 m/s; p = 0.021), while SWS in the spleen decreased by 5.2% (from a median of 1.63 m/s to 1.51 m/s; p = 0.00059). Furthermore, we observed that the decrease was more pronounced the higher the baseline SWS values were. In conclusion, the results confirm our hypothesis that the Valsalva maneuver decreases liver and spleen stiffness, showing that THE is sensitive to perfusion pressure-related changes in tissue stiffness. With its extensive organ coverage and high penetration depth, THE may facilitate translation of pressure-sensitive ultrasound elastography into clinical routine.

Nomogram for predicting the risk of gastroesophageal varices after primary endoscopic prophylaxis for variceal hemorrhage in patients with cirrhosis

BACKGROUND AND AIMS

The aim of this study was to identify predictors of non-high-risk gastroesophageal varices and evaluate the probability of the residual high-risk varices in cirrhosis patients after the primary endoscopic treatment.

PATIENTS AND METHODS

Medical records of the patients with cirrhosis admitted for primary endoscopic prophylaxis gastroesophageal varices hemorrhage were retrospectively analyzed. The patients were divided into high-risk varices and non-high-risk varices groups according to the endoscopy. A nomogram was developed based on the results of multivariate Cox analyses. Accuracy of this model was validated by the concordance index (Harrell's c-index) and calibration curve.

RESULTS

Altogether 117 patients were enrolled between March 2014 and April 2018. The multivariate Cox analyses identified spleen length <140 mm [odds ratio (OR) = 2.715; P = 0.037), small or medium size of esophageal varices (OR = 4.412; P = 0.017), unaccompanied with gastric varices (OR = 7.025; P = 0.003) and frequency of endoscopic variceal ligation ≥one time per 4 months (OR = 3.834; P = 0.034) as independent factors of non-high-risk varices. All significant predictors were incorporated into a nomogram to predict the residual high-risk varices, which showed a notable accuracy with the concordance index (0.833).

CONCLUSION

The nomogram-based prediction of residual high-risk varices can be used for risk stratification in cirrhosis patients with gastroesophageal varices.

The role of endoscopic ultrasound for portal hypertension in liver cirrhosis

Chronic liver disease is still a major problem because disease progression will ultimately lead to liver cirrhosis. Portal hypertension is the hallmark in advanced liver disease management. By establishing portal vein access, endoscopic ultrasound (EUS) has been utilized in various clinical applications. In comparison to standard upper gastrointestinal endoscopy, EUS-Doppler has been shown to be a better modality for detecting esophageal and gastric varices along with peri-esophageal collateral veins, para-esophageal collateral veins, and perforating veins, and may be used to objectively predict the recurrence of bleeding. EUS-guided portal vein catheterization has also been proposed to overcome the limitations of trans-jugular approaches. The combination of EUS-elastography and azygos vein evaluation can also enhance the diagnostic accuracy of each modality. Another well-known implementation of EUS-guided procedures is in the management of ascites; particularly in paracentesis and ascitic fluid analysis. In addition, the most common clinical application of EUS in the treatment of portal hypertension is through vascular therapy or creation of intrahepatic portosystemic shunts. Major drawbacks of EUS mainly revolve around technical difficulties, the high cost of the procedure, as well as the requirement of more studies in humans to evaluate EUS-guided advanced therapeutic modalities in portal hypertension.

Stiffer Spleen Predicts Higher Bone Marrow Fibrosis and Higher JAK2 Allele Burden in Patients With Myeloproliferative Neoplasms

A total of 63 myeloproliferative neoplasms [MPN; 9 polycythemia vera (PV), 32 essential thrombocythemia (ET), and 22 myelofibrosis (MF)] underwent spleen stiffness (SS) measurement by vibration-controlled transient elastography equipped with a novel spleen-dedicated module. Higher SS values significantly correlated with grade 2-3 bone marrow (BM) fibrosis (p=0.035), with hemoglobin level <10 g/dl (p=0.014) and with white blood cells ≥10,000/μl (p=0.008). Median SS was significantly higher in MF patients compared to ET and PV (p=0.015). SS also correlated with higher JAK2 variant allele frequency (p=0.02). This study identifies SS as a potential noninvasive tool that reflects BM fibrosis and the mutational burden in MPN.

Portal Hypertension in Non-alcoholic Fatty Liver Disease in the Era of Non-invasive Assessment

Non-alcoholic fatty liver disease (NAFLD) is one of the emerging global health problems due to an increase of burden worldwide. It has been known that NAFLD is strongly associated with metabolic syndrome. The progression of NAFLD is a complex and multifactorial mechanism. Portal hypertension is still the main key in liver disease progression management. In NAFLD, portal hypertension might occur in the non-cirrhotic condition. Hepatic vein pressure gradient measurement has been considered as the gold standard for portal pressure assessment; however, due to its invasiveness and the need for a high-expertise centre, it is considered a non-practical measurement tool in clinical practice. Many other non-invasive parameters have been developed to replace the invasive measurement; however, there are still some limitations with regard to the technical issue, patient’s condition, and its accuracy in the different stages of the disease. Therefore, the authors review portal hypertension related to the clinical course of NAFLD, and the development of portal pressure evaluation in patients with NAFLD.

A novel radiomics-platelet nomogram for the prediction of gastroesophageal varices needing treatment in cirrhotic patients

BACKGROUND AND AIMS

Highly accurate noninvasive methods for predicting gastroesophageal varices needing treatment (VNT) are desired. Radiomics is a newly emerging technology of image analysis. This study aims to develop and validate a novel noninvasive method based on radiomics for predicting VNT in cirrhosis.

METHODS

In this retrospective-prospective study, a total of 245 cirrhotic patients were divided as the training set, internal validation set and external validation set. Radiomics features were extracted from portal-phase computed tomography (CT) images of each patient. A radiomics signature (Rad score) was constructed with the least absolute shrinkage and selection operator algorithm and tenfold cross-validation in the training set. Combined with independent risk factors, a radiomics nomogram was built with a multivariate logistic regression model.

RESULTS

The Rad score, consisting of 14 features from the gastroesophageal region and 5 from the splenic hilum region, was effective for VNT classification. The diagnostic performance was further improved by combining the Rad score with platelet counts, achieving an AUC of 0.987 (95% CI 0.969-1.00), 0.973 (95% CI 0.939-1.00) and 0.947 (95% CI 0.876-1.00) in the training set, internal validation set and external validation set, respectively. In efficacy and safety assessment, the radiomics nomogram could spare more than 40% of endoscopic examinations with a low risk of missing VNT (< 5%), and no more than 8.3% of unnecessary endoscopic examinations still be performed.

CONCLUSIONS

In this study, we developed and validated a novel, diagnostic radiomics-based nomogram which is a reliable and noninvasive method to predict VNT in cirrhotic patients.

CLINICAL TRIALS REGISTRATION

NCT04210297.

Noninvasive Detection of Clinically Significant Portal Hypertension in Compensated Advanced Chronic Liver Disease

Patients with compensated advanced chronic liver disease have different prognoses depending on the presence of portal hypertension. Current non-invasive diagnostic methods allow identification of clinically significant portal hypertension. Portosystemic collaterals on imaging or liver stiffness of more than 20 to 25 kPa by using transient elastography identifies patients with clinically significant portal hypertension. Patients with liver stiffness of less than 20 kPa and platelet count of greater than 150 g/L can avoid endoscopy. This rule could be expanded using spleen stiffness. Methods to risk stratify for portal hypertension in compensated advanced chronic liver disease and successfully treated chronic hepatitis C and B are subject of research.

The role of liver and spleen elastography in advanced chronic liver disease

Portal hypertension is the main driver of complications in patients with advanced chronic liver disease (ACLD). In the last decade, many non-invasive tests, such us liver and spleen elastography, have been proposed and validated for the identification of patients with clinically significant portal hypertension (CSPH) and its complications, mainly hepatic decompensation and liver-related morbidity and mortality. Moreover, elastography accurately stratifies for the risk of HCC development, HCC recurrence and decompensation after liver surgery. Recent studies suggest a role of SSM in monitoring response to treatments and interventions in ACLD, such as viral eradication, non-selective beta-blockers and transjugular intrahepatic portosystemic shunt placement. However, one of the most indications to perform elastography in ACLD still remains the screening for esophageal varices. In fact, according to the Baveno VI consensus, liver stiffness measurement (LSM) <20 kPa and platelet count >150,000/mm³ can safely identify patients at low risk of varices requiring treatment (VNT) and could therefore avoid invasive upper invasive endoscopy; LSM>20-25 kPa can accurately rule-in CSPH in patients with viral etiology. Spleen stiffness measurement (SSM) is a direct surrogate of portal hypertension and has been demonstrated more accurate in predicting portal hypertension severity and VNT. A combined model including Baveno VI Criteria and SSM (≤46 kPa) can significantly increase the number of spared endoscopies (>40-50%), maintaining a low (<5%) of missed VNT.

Diffusion tensor imaging of the spleen in prediction and grading of esophageal varices in cirrhotic children with portal hypertension

PURPOSE

To assess diffusion tensor imaging (DTI) of spleen in prediction and grading of esophageal varices (OV) in cirrhotic children.

METHODS

This prospective study was conducted upon 30 children with cirrhotic children with OV and 10 age-gender matched controls that underwent DTI of abdomen. Mean diffusivity (MD) and fractional anisotropy (FA) of spleen were calculated and matched with the grading of OV at endoscopy and laboratory biomarkers of portal hypertension.

RESULTS

Mean ADC of spleen in patient was significantly different (p = 0.001) from that of controls by both reviewers respectively. The cutoff ADC measurement of the spleen used for prediction of OV was ≥ 0.75 and ≥ 0.76 × 10^-3mm²/s with AUC was 0.993 and 0.997 for both reviewers respectively. The FA of the spleen in patient was different (p = 0.01) from of controls of both reviewers respectively. Cutoff FA of spleen used for prediction of OV was ≤ 0.35 and ≤ 0.36 for both observers respectively. ADC and FA of spleen was correlated with platelets count (r =  - 0.713, 0.392; p = 0.001, 0.012) and prothrombin time (r = 0.518, - 0.380; p = 0.001, 0.016).

CONCLUSION

DTI metrics of spleen can predict and grade OV and correlated with laboratory biomarkers of portal hypertension.

Approaches to the Diagnosis of Portal Hypertension: Non-Invasive or Invasive Tests?

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.

Baveno VI criteria and spleen stiffness measurement rule out high-risk varices in virally suppressed HBV-related cirrhosis

BACKGROUND & AIMS

There are no data validating the performance of spleen stiffness measurement in ruling out high-risk varices in patients with HBV-related cirrhosis under maintained viral suppression. Thus, we aimed to prospectively validate the performance of spleen stiffness measurement (cut-off 46 kPa) combined with Baveno VI criteria in ruling out high-risk varices in these patients.

METHODS

Patients with cirrhosis were enrolled from April to December 2019 at the hepatology unit of the Nanfang Hospital, China. Liver and spleen transient elastography and esophagogastroduodenoscopy were performed at enrollment. Antiviral regimen(s) and virological responses, evaluated every 3-6 months, were recorded.

RESULTS

Overall 341 patients with HBV-related cirrhosis under maintained viral suppression were enrolled, and the prevalence of high-risk varices was 20.5% (70/341). Baveno VI criteria spared 37.0% (126/341) esophagogastroduodenoscopies and no high-risk varices were missed (0/70). Eight cases of high-risk varices (8/70, 11.4%) were misclassified in patients (208/341, 61.0%) within the expanded Baveno VI criteria. The spleen stiffness measurement cut-off (≤46.0 kPa) was shown to safely rule out high-risk varices in these patients (the percentage of missed high-risk varices was 4.3%). Over half (61.6%, 210/341) of patients met the combined model (Baveno VI criteria and spleen stiffness measurement cut-off ≤46 kPa) and 4.3% (3/70) of high-risk varices cases were misclassified. This combined model exhibited a sensitivity of 95.71%, specificity of 76.38%, negative predictive value of 98.57%, and negative likelihood ratio of 0.06 for ruling out high-risk varices.

CONCLUSIONS

We validated the excellent performance of Baveno VI criteria combined with spleen stiffness measurement (cut-off 46 kPa) for safely ruling out high-risk varices in patients with HBV-related cirrhosis under viral suppression; more than half of esophagogastroduodenoscopy procedures were spared using this combination.

CLINICAL TRIAL NUMBER

NCT04123509 LAY SUMMARY: Esophageal varices have important prognostic implications in patients with cirrhosis. Thus, their timely identification is important so that treatment can be initiated early. Herein, we validated the excellent performance of the combination of Baveno VI criteria with spleen stiffness measurement (cut-off 46 kPa) for ruling out high-risk esophageal varices in patients with HBV-related cirrhosis under maintained viral suppression (with antiviral treatment). This combined model was able to safely rule out high-risk varices (missed/total <5%) and over half (61.6%) of esophagogastroduodenoscopy procedures were spared.

Liver and spleen elastography of dogs affected by brachycephalic obstructive airway syndrome and its correlation with clinical biomarkers

The purpose of this study is to determine whether the brachycephalic obstructive airway syndrome (BOAS) is correlated to alterations in liver and spleen elasticity. Forty-eight brachycephalic and 22 mesocephalic dogs were submitted to a BOAS functional assessment, laboratory tests, abdominal ultrasound and liver and spleen Acoustic Radiation Force Impulse (ARFI) elastography. Dogs clinically affected by BOAS had higher values of liver stiffness (p < 0.001) than healthy dogs: medial lobes (1.57 ± 0.37 m/s), left and right lateral lobes (1.54 ± 0.50 m/s, 1.23 ± 0.28 m/s, respectively) and caudate lobe (1.28 ± 0.42 m/s). Compared to the mesocephalic group, the brachycephalic group (BOAS clinically affected and unaffected dogs) had higher spleen (2.51 ± 0.45 m/s; p < 0.001) and liver stiffness (p < 0.001): medial lobes (1.53 ± 0.37 m/s), left and right lateral lobes (1.47 ± 0.47 m/s, 1.20 ± 0.30 m/s, respectively) and caudate lobe (1.23 ± 0.40 m/s). Principal component analysis explained 70% of the variances composed by liver stiffness increase, erythrocytes and alanine aminotransferase reduction. Brachycephalic dogs had higher spleen and liver stiffness and a subacute inflammatory state, which represent another BOAS systemic effect. Consequently, these dogs can be at higher risk of hepatic disorders compared with mesocephalic dogs, similarly to humans affected by sleep apnea syndrome.

Non-invasive tests for the prediction of primary hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies in the world and it is one of the main complications of cirrhosis and portal hypertension. Even in the presence of a well-established follow-up protocol for cirrhotic patients, to date poor data are available on predictive markers for primary HCC occurrence in the setting of compensated advanced chronic liver disease patients (cACLD). The gold standard method to evaluate the prognosis of patients with cACLD, beyond liver fibrosis assessed with histology, is the measurement of the hepatic venous pressure gradient (HVPG). An HVPG ≥10 mmHg has been related to an increased risk of HCC in cACLD patients. However, these methods are burdened by additional costs and risks for patients and are mostly available only in referral centers. In the last decade increasing research has focused on the evaluation of several, simple, non-invasive tests (NITs) as predictors of HCC development. We reviewed the currently available literature on biochemical and ultrasound-based scores developed for the non-invasive evaluation of liver fibrosis and portal hypertension in predicting primary HCC. We found that the most reliable methods to assess HCC risk were the liver stiffness measurement, the aspartate aminotransferase to platelet ratio index score and the fibrosis-4 index. Other promising NITs need further investigations and validation for different liver disease aetiologies.

Spleen stiffness measurement for assessing the response to β-blockers therapy for high-risk esophageal varices patients

BACKGROUND

Non-selective β-blocker (NSBB) therapy is the treatment of choice for primary prophylaxis of cirrhotic patients with high-bleeding risk esophageal varices (HRV). The hemodynamic response to NSBB is assessed by the measurement of the hepatic venous pressure gradient (HVPG). Recently, liver and spleen stiffness measurements (LSM and SSM) were proposed as non-invasive surrogates of HVPG. We aimed to evaluate LSM and SSM changes for assessing hemodynamic response in these patients.

METHODS

Cirrhotic patients with HRV were prospectively enrolled and evaluated at our Department before starting NSBB and after 3 months. Correlation between changes (delta) of HVPG after NSBB treatment and those of LSM or SSM by transient elastography was performed.

RESULTS

From the initial 59 patients considered for the study, 20 were finally included in the analysis. Fifteen (15) patients reached hemodynamic response to NSBB according to HVPG. Changes in LSM did not correlate with changes in HVPG (r = 0.107, p value = 0.655), unlike changes in SSM (r = 0.784, p value < 0.0001). Delta SSM presented excellent accuracy in identifying HVPG responders (AUROC 0.973; 95% CI 0.912-1). The best cut-off for delta SSM to identify responders was -10% (sensitivity 100%, specificity 60%, NPV 100% and PPV 90%).

CONCLUSIONS

SSM could be a reliable non-invasive test for the assessment of hemodynamic response to NSBB therapy as primary prophylaxis for HRV. Similar to HVPG, SSM reduction ≥ 10% is able to assess hemodynamic response.

Spleen volumetry and liver transient elastography: Predictors of persistent posthepatectomy decompensation in patients with hepatocellular carcinoma

BACKGROUND

Posthepatectomy decompensation remains a frequent and poor outcome after hepatectomy, but its prediction is still inaccurate. Liver stiffness measurement can predict posthepatectomy decompensation, but there is a so-called "gray zone" that requires another predictor. Because splenomegaly is an objective sign of portal hypertension, we hypothesized that spleen volumetry could improve the identification of patients at risk.

METHODS

Patients with hepatocellular carcinoma who underwent hepatectomy in our tertiary center between August 2014 and December 2017 were reviewed. The primary endpoint was to determine if the spleen volumetry and liver stiffness measurement were independent predictors of posthepatectomy decompensation, and secondarily, to determine if they were synergistic through a theoretic predictive model.

RESULTS

One hundred and seven patients were included. The median follow-up time was 3 months (3-5). Postoperative 90-day mortality was 4.7%. By multivariate analysis, liver stiffness measurement and spleen volumetry predicted posthepatectomy decompensation. The liver stiffness measurement had a cutoff point of 11.6 kPa (area under receiver operating curve = 0.71 confidence interval 95% 0.71-0.88, sensitivity: 89%, specificity: 47%). The spleen volumetry cutoff point was 381.1 cm³ (area under receiver operating curve = 0.78, 95% confidence interval 0.77-0.93, sensitivity: 55%, specificity: 91%). The spleen volumetry improved prediction of posthepatectomy decompensation, because use of the spleen volumetry increased sensitivity (from 62% to 97%) and the negative predictive value (from 96% to 100%) along with a negligible decrease in specificity (from 96.7 to 93.4) and positive predictive value (from 64% to 59%) (P = .003).

CONCLUSION

Spleen volumetry (>380 cm³) and liver stiffness measurement (>12 kPa) are non-invasive, independent, and synergistic tools that appear to be able to predict posthepatectomy decompensation. The importance of this finding is that these measurements may help to anticipate posthepatectomy decompensation and may possibly be used to direct alternative treatments to resection.

Combined effect of hepatic venous pressure gradient and liver stiffness on long-term mortality in patients with cirrhosis

BACKGROUND/AIMS

Both hepatic venous pressure gradient (HVPG) and liver stiffness (LS) are useful tools for predicting mortality in patients with cirrhosis. We investigated the combined effect of HVPG and LS on long-term mortality in patients with cirrhosis.

METHODS

We retrospectively collected data from 103 patients with cirrhosis, whose HVPG and LS were measured between November 2009 and September 2013. The patients were divided into four groups according to the results of the HVPG and LS measurements. Long-term mortality and the risk factors for mortality were analyzed.

RESULTS

Of the 103 patients, 35 were in group 1 (low HVPG and low LS), 16 in group 2 (high HVPG and low LS), 24 in group 3 (low HVPG and high LS), and 28 in group 4 (high HVPG and high LS). Over a median follow-up of 47.3 months, 18 patients died. The mortality rate of patients in group 4 was significantly higher than in the other three groups (vs. group 1, p = 0.005; vs. group 2, p = 0.049; vs. group 3, p = 0.004), but there were no significant differences in survival between groups 1, 2, and 3. In multivariable analyses, both HVPG and LS were identified as independent risk factors for mortality (hazard ratio [HR], 1.127, p = 0.018; and HR, 1.062, p = 0.009, respectively).

CONCLUSION

In patients with cirrhosis, those with concurrent elevation of HVPG and LS had the highest long-term mortality rates. However, when either HVPG or LS alone was elevated, mortality did not increase significantly.

A novel spleen-dedicated stiffness measurement by FibroScan® improves the screening of high-risk oesophageal varices

BACKGROUND & AIMS

Several non-invasive tests (NITs) have been developed to diagnose oesophageal varices (EV), including the recent Baveno VI criteria to rule out high-risk varices (HRV). Spleen stiffness measurement (SSM) with the standard FibroScan® (SSM@50Hz) has been evaluated. However, the EV grading could be underestimated because of a ceiling threshold (75 kPa) of the SSM@50Hz. The aims were to evaluate SSM by a novel spleen-dedicated FibroScan® (SSM@100Hz) for EV diagnosis compared with SSM@50Hz, other validated NITs and Baveno VI criteria.

METHODS

This prospective multicentre study consecutively enrolled patients with chronic liver disease; blood data, endoscopy, liver stiffness measurement (LSM), SSM@50Hz and SSM@100Hz were collected.

RESULTS

Two hundred and sixty patients met inclusion criteria. SSM@100Hz success rate was significantly higher than that of SSM@50Hz (92.5% vs 76.0%, P < .001). SSM@100Hz accuracy for the presence of EV (AUC = 0.728) and HRV (AUC = 0.756) was higher than in other NITs. SSM@100Hz AUC for large EV (0.782) was higher than SSM@50Hz (0.720, P = .027). AUC for HRV with SSM@100Hz (0.780) was higher than with LSM (0.615, P < .001). The spared endoscopy rate of Baveno VI criteria (8.1%) was significantly increased by the combination to SSM@50Hz (26.5%) or SSM@100Hz (38.9%, P < .001 vs others). The missed HRV rate was, respectively, 0% and 4.7% for combinations.

CONCLUSIONS

SSM@100Hz is a new performant non-invasive marker for EV and HRV providing a higher accuracy than SSM@50Hz and other NITs. The combination of Baveno VI criteria and SSM@100Hz significantly increased the spared endoscopy rate compared to Baveno VI criteria alone or combined with SSM@50Hz. Clinical trial number: NCT02180113.

Spleen and Liver Stiffness to Detect Esophageal Varices in Children with Biliary Atresia

OBJECTIVES

The aim of the study was to determine the accuracy of noninvasive parameters, such as liver (LS) and spleen stiffness (SS) to detect esophageal varices (EV) in children with biliary atresia (BA).

METHODS

Children with BA between 2000 and 2015 were recruited. All underwent esophagogastroduodenoscopy and transient elastography. Demographic data, laboratory investigations, alanine transferase-to-platelet ratio index (APRI), and Varices Prediction Rule (VPR) score were collected.

RESULTS

A total of 51 children (mean age 10.63 years, standard deviation (SD) = 6.08 years; 53% boys) were enrolled. There were differences in onset and outcome of portoenterostomy, spleen palpablility, platelet count, albumin, LS, SS, and VPR between the varice and varice-free groups (P < 0.05). In the varice group, the median LS was 18.12 (interquartile ratio, IQR 13.15-19.12) and the median SS was 46.85 (IQR 25.95-54.55) kPa. In the varice-free group, the median LS was 7.85 (IQR 5.88-16.75) and the median SS was 16.54 (IQR 11.75-21.75) kPa. Both LS and SS were higher in the varice than the varice-free group (P < 0001). The area under the receiver operating characteristic curve of LS, SS, spleen palpability, platelet count, APRI, and VPR were 0.734, 0.870, 0.817, 0.810, 0.751, and 0.794, respectively. Using a cut-off value of 12.5 kPa for LS, the sensitivity and specificity were 80 and 70%, respectively. Using a cut-off value of 28.9 kPa for SS, the sensitivity and specificity were 75 and 87%, respectively. Combination of LS and SS to diagnose varices increased the specificity to 93%.

CONCLUSIONS

SS as a single marker had the best diagnostic value to predict esophageal varices in children with BA. The combination of SS and LS furthermore, increased the diagnostic yield.

Noninvasive Assessment of Portal Hypertension Using Spectral Computed Tomography

BACKGROUND

Early diagnosis of portal hypertension is imperative for timely treatment to reduce the mortality rate. However, there is still no adequate method to noninvasively and accurately assess the portal hypertension in routine clinical practice.

PURPOSE

We aimed to evaluate the accuracy of parameters measured using dual energy spectral computed tomography (LightSpeed CT750 HD) in assessing portal venous pressure in patients with liver cirrhosis.

STUDY

Forty-five patients with liver cirrhosis who underwent percutaneous transhepatic portal vein puncture as part of their treatment for liver disease were enrolled in this study. Measurement of direct portal venous pressure was performed preoperatively. All patients underwent dual energy spectral computed tomography within 3 days before their operations.

RESULTS

The iodine concentrations of portal vein and hepatic parenchyma during the portal venous phase and the alanine aminotransferase level were found to be independently correlated with the direct portal venous pressure according to stepwise multivariate linear regression analysis (P<0.001, 0.004, and 0.024, respectively). In a receiver operating characteristic analysis, the area under the receiver operating characteristic of iodine concentrations of the portal vein (ICPV) for identifying clinically significant portal hypertension (≥10 mm Hg) was significantly higher than that of iodine concentrations of hepatic parenchyma (ICliver) and the alanine aminotransferase level (0.944, 0.825, and 0.301, respectively). The threshold ICPV of 58.27 yielded a sensitivity of 93.8%, specificity of 69.2%, positive predictive value of 88.2%, and negative predictive value of 81.8%, respectively.

CONCLUSIONS

ICPV values may be a useful tool in noninvasively assessing the portal venous pressure and identifying clinically significant portal hypertension in liver cirrhosis.

Role of Spleen Stiffness Measurement by 2D-Shear Wave Elastography in Ruling Out the Presence of High-Risk Varices in Cirrhotic Patients

BACKGROUND AND AIM

To evaluate if spleen stiffness measurement (SSM) can rule out the presence of high-risk varices in patients with cirrhosis, avoiding an upper gastrointestinal endoscopy (UGE).

METHODS

We enrolled 71 cirrhotic patients irrespective of liver disease's etiology. 2D shear wave elastography (SWE) of spleen and UGE was performed. High-risk varices (HRV) were defined as esophageal varices ≥ 5 mm and/or red spots and any gastric varices.

RESULTS

Esophageal varices were documented in 37 (52.1%) and HRV in 25 (35.2%) patients. SSM was not technically feasible in 7/71 patients (9.8%). From the remaining 64 patients, when those with cholestatic liver disease were excluded (n = 17), SSM < 35.8 kPa was found to exclude well the existence of HRV offering an AUROC of 0.854 (p < 0.001), sensitivity 88.9%, negative predictive value (NPV) 91.3%, specificity 72.4%, and positive predictive value (PPV) 66.7%. Only 2/47 patients (4.3%) were misclassified, and 23 (48.9%) could avoid endoscopy. In the total cohort of 64 patients, SSM < 33.7 kPa was found to exclude well the presence of HRV offering AUROC 0.792 (p < 0.001), sensitivity 91.7%, specificity 60%, NPV 92.3%, and PPV 57.9%. The misclassification rate was 3.1% (2/64), while 26/64 (40.6%) could avoid endoscopy.

CONCLUSIONS

2D-SWE of spleen is a reliable method for ruling out the presence of HRV in cirrhotic patients. If larger studies confirm our results, a large number of endoscopies could be avoided.

Evaluation of liver and spleen stiffness of healthy dogs by use of two-dimensional shear wave elastography

OBJECTIVE

To assess liver and spleen stiffness in healthy dogs by use of a novel 2-D shear wave elastography (SWE) technique and to investigate the repeatability and reproducibility of the technique.

ANIMALS

8 healthy adult Beagles.

PROCEDURES

2-D SWE was performed on each dog to assess liver and spleen stiffness. Repeatability (intraday variability) and reproducibility (interday variability) of 2-D SWE were investigated. For all 8 dogs, 2-D SWE was performed 3 times in 1 day (4-hour intervals) and on 3 separate days (1-week interval). Data were expressed as mean ± SD values for shear wave velocity and the Young modulus in the liver and spleen. Intraday and interday coefficients of variation were assessed for all variables.

RESULTS

Mean ± SD shear wave velocity obtained for the liver and spleen was 1.51 ± 0.08 m/s and 2.18 ± 0.27 m/s, respectively. Mean value for the Young modulus obtained for the liver and spleen was 6.93 ± 0.79 kPa and 14.66 ± 3.79 kPa, respectively. Elasticity values were significantly higher for the spleen than for the liver. Intraday and interday coefficients of variation for all variables were < 25% (range, 3.90% to 20.70%).

CONCLUSIONS AND CLINICAL RELEVANCE

2-D SWE was a feasible technique for assessing liver and spleen stiffness of healthy dogs. Future studies on the application of 2-D SWE for dogs with chronic hepatitis, cirrhosis, and portal hypertension are needed to evaluate the clinical applicability of 2-D SWE.

Role of liver and spleen stiffness in predicting the recurrence of hepatocellular carcinoma after resection

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) is a frequent complication of liver disease. When feasible, hepatic resection is the first-choice therapy. However, tumor recurrence complicates at least 2/3 hepatic resections at 5 years. Early recurrences are mainly tumor or treatment-related, but predictors of late recurrences are undefined. We aimed to evaluate the factors related to HCC recurrence after curative resection, with liver and spleen stiffness measurement (LSM and SSM) as markers of severity and duration of the underlying liver disease.

METHODS

We enrolled patients with chronic liver disease and primary HCC suitable for hepatic resection. We followed up patients for at least 30 months or until HCC recurrence. We performed uni- and multivariate analyses to evaluate the predictive role of tumor characteristics, laboratory data, LSM and SSM for both early and late recurrence of HCC.

RESULTS

We prospectively enrolled 175 patients. Early HCC recurrence at multivariate analysis was associated with viral etiology, HCC grading (3 or 4), resection margins <1 cm and being beyond the Milan criteria. HCC late recurrence at univariate analysis was associated with esophageal varices (hazard ratio [HR] 3.321, 95% CI 1.564-7.053), spleen length (HR 3.123, 95% CI 1.377-7.081), platelet/spleen length ratio if <909 (HR 2.170, 95% CI 1.026-4.587), LSM (HR 1.036, 95% CI 1.005-1.067), SSM (HR 1.046, 95% CI 1.020-1.073). HCC late recurrence at multivariate analysis was independently associated only with SSM (HR 1.046, CI 1.020-1.073). Late HCC recurrence-free survival was significantly different according to the SSM cut-off of 70 kPa (p = 0.0002).

CONCLUSIONS

SSM seems to be the only predictor of late HCC recurrence, since it is directly correlated with the degree of liver disease and portal hypertension, both of which are involved in carcinogenesis.

LAY SUMMARY

The main result of this study is that spleen stiffness measurement, evaluated by transient elastography, seems to be the only predictor of the late recurrence of hepatocellular carcinoma, defined as recurrence after 24 months from liver resection. Indeed, spleen stiffness measurement is directly correlated with the degree of liver disease and portal hypertension, which are both involved in carcinogenesis.

Liver Stiffness Measurement Allows Early Diagnosis of Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome in Adult Patients Who Undergo Hematopoietic Stem Cell Transplantation: Results from a Monocentric Prospective Study

Veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), is a life-threatening complication affecting patients undergoing hematopoietic stem cell transplantation (HSCT). The survival rate is higher when specific therapy is initiated early; thus, improving early, noninvasive diagnosis of VOD/SOS is an important need. In an adult population undergoing HSCT, we aimed to assess the role of liver stiffness measurement (LSM), evaluated by transient elastography (TE), for diagnosing VOD/SOS. Between April 2016 and March 2018, 78 consecutive adult patients with indications for allogeneic HSCT were prospectively included. LSM was performed before HSCT and at days +9/10, +15/17, and +22/24 post-HSCT. New European Society for Blood and Marrow Transplantation criteria were used to establish VOD/SOS diagnosis. Four patients developed VOD/SOS (5.1%) during the study period, with a median time of +17 days post-HSCT. A sudden increase in LSM compared with previously assessed values and pre-HSCT values, was seen in all patients who developed VOD/SOS. LSM increases occurred from 2 to 12 days before clinical SOS/VOD appearance. The VOD/SOS diagnostic performance of increased LSM over pre-HSCT assessment showed an area under the receiver operating characteristic curve of 0.997 (sensitivity 75%; specificity 98.7%). LSM gradually decreased following successful VOD/SOS-specific treatment. Interestingly, LSM values did not increase significantly in patients experiencing hepatobiliary complications (according to the Common Terminology Criteria) other than VOD/SOS. LSM by TE can be considered a promising method to perform an early, preclinical diagnosis and follow-up of VOD/SOS.

Spleen and liver stiffness for noninvasive assessment of portal hypertension in cirrhotic patients with large esophageal varices

PURPOSE

Noninvasive evaluation of portal hypertension is needed for cirrhotic patients with large esophageal varices. This study was aimed at assessing the diagnostic value of liver/spleen stiffness in predicting hepatic vein pressure gradient (HVPG) in this special population.

METHODS

In the present prospective cohort study, liver/spleen stiffness was measured by transient elastography. Patients also underwent HVPG assessment, upper gastrointestinal endoscopy, and other noninvasive serum models.

RESULTS

Ninety-nine cirrhotic patients with large esophageal varices were enrolled. Liver/spleen stiffness strongly correlated with HVPG. In regards to significant portal hypertension, area under receiver operating characteristic curves (AUROCs) for liver/spleen stiffness were 0.74 and 0.91. Accuracy for detecting significant portal hypertension was 79% for spleen stiffness of 48.9 kPa (sensitivity: 76%, specificity: 100%, positive predictive value: 100%, negative predictive value: 38%) and 75% for liver stiffness of 16.0 kPa (sensitivity: 78%, specificity: 54%, positive predictive value: 92%, negative predictive value: 27%). Similarly, spleen stiffness had significant higher AUROCs for predicting HVPG ≥16 and ≥20 mm Hg than that of liver stiffness and other noninvasive serum models.

CONCLUSION

In cirrhotic patients with large esophageal varices, liver stiffness and spleen stiffness correlate with HVPG, and spleen stiffness is superior to liver stiffness in predicting portal hypertension.

A Novel FibroScan Examination Dedicated to Spleen Stiffness Measurement

Esophageal varices (EVs) are among the most severe complications of cirrhosis, with a prevalence of 50% to 60% among cirrhotic patients. International guidelines therefore recommend that cirrhotic patients should be screened for the presence of EVs. The main objective of this study was to introduce a new spleen-dedicated FibroScan (Echosens, Paris, France) examination and to assess its performance in detecting large EVs (grade 2 and 3). This novel examination has been validated in simulation and phantom studies and has been used in a population of patients with chronic liver disease. The study described here suggests that the novel spleen-dedicated FibroScan examination performs better than the standard FibroScan for the detection of large EVs (area under the curve = 0.70 for the standard examination and 0.79 [p <0.01] for the spleen examination), but further clinical studies are needed to investigate the role of spleen stiffness in the management of cirrhotic patients.

A combined model based on spleen stiffness measurement and Baveno VI criteria to rule out high-risk varices in advanced chronic liver disease

BACKGROUND & AIMS

Recently, Baveno VI guidelines suggested that esophagogastroduodenoscopy (EGD) can be avoided in patients with compensated advanced chronic liver disease (cACLD) who have a liver stiffness measurement (LSM) <20 kPa and platelet count >150,000/mm³. We aimed to: assess the performance of spleen stiffness measurement (SSM) in ruling out patients with high-risk varices (HRV); validate Baveno VI criteria in a large population and assess how the sequential use of Baveno VI criteria and SSM could safely avoid the need for endoscopy.

METHODS

We retrospectively analyzed 498 patients with cACLD who had undergone LSM/SSM by transient elastography (TE) (FibroScan®), platelet count and EGDs from 2012 to 2016 referred to our tertiary centre. The new combined model was validated internally by a split-validation method, and externally in a prospective multicentre cohort of 115 patients.

RESULTS

SSM, LSM, platelet count and Child-Pugh-B were independent predictors of HRV. Applying the newly identified SSM cut-off (≤46 kPa) or Baveno VI criteria, 35.8% and 21.7% of patients in the internal validation cohort could have avoided EGD, with only 2% of HRVs being missed with either model. The combination of SSM with Baveno VI criteria would have avoided an additional 22.5% of EGDs, reaching a final value of 43.8% spared EGDs, with <5% missed HRVs. Results were confirmed in the prospective external validation cohort, as the combined Baveno VI/SSM ≤46 model would have safely spared (0 HRV missed) 37.4% of EGDs, compared to 16.5% when using the Baveno VI criteria alone.

CONCLUSIONS

A non-invasive prediction model combining SSM with Baveno VI criteria may be useful to rule out HRV and could make it possible to avoid a significantly larger number of unnecessary EGDs compared to Baveno VI criteria only.

LAY SUMMARY

Spleen stiffness measurement assessed by transient elastography, the most widely used elastography technique, is a non-invasive technique that can help the physician to better stratify the degree of portal hypertension and the risk of esophageal varices in patients with compensated advanced chronic liver disease. Performing spleen stiffness measurement together with liver stiffness measurement during the same examination is simple and fast and this sequential model can identify a greater number of patients that can safely avoid endoscopy, which is an invasive and expensive examination.

Noninvasive Assessment of Portal Hypertension in Advanced Chronic Liver Disease: An Update

The assessment of portal hypertension is a relevant step in the evaluation of newly diagnosed advanced chronic liver disease (ACLD). The current gold standard includes the invasive evaluation of hepatic venous pressure gradient (HVPG) and endoscopy. However, noninvasive or minimally invasive techniques to assess portal hypertension have been proposed and well established. In the present manuscript, we review clinical studies on the use of noninvasive or minimally invasive techniques to assess portal hypertension in ACLD patients.

Hepatocellular carcinoma risk assessment by the measurement of liver stiffness variations in HCV cirrhotics treated with direct acting antivirals

BACKGROUND

Direct-acting antivirals (DAA) are an effective treatment for hepatitis C virus infection. However, sustained virologic response (SVR) after DAA treatment does not seem to reduce the risk of hepatocellular carcinoma (HCC) development in these patients. Liver stiffness measurement (LSM) may predict the risk of developing HCC in liver cirrhosis patients.

AIMS

The aim of our study was to evaluate the role of LSM variation as predictor of HCC development in patients treated with DAA.

METHODS

In 139 HCV-related cirrhotic patients, LSM and laboratory tests were carried out at baseline (BL) and at the end of DAA treatment (EOT). Patients were followed for at least 6 months after the EOT. LSM reduction was expressed as Delta LS (∆LS). Cox regression analysis was used to identify prognostic factors for HCC development after DAA.

RESULTS

Median LSM values were significantly reduced from BL to EOT (from 18.6 to 13.8 kPa; p < 0.001). The median ∆LS was -26.7% (IQR: -38.4% -13.6%). During a median follow-up of 15 months after DAA treatment, 20 (14.4%) patients developed HCC. Significant LSM reduction was observed both in patients who developed HCC and in those who did not, but this was significantly lower in the patients who developed HCC (-18.0% vs -28.9% p = 0.005). At multivariate analysis, ∆LS lower than -30%, Child-Turcotte-Pugh-B and history of HCC were independently associated with HCC development.

CONCLUSION

Our results indicate that ∆LS is a useful non-invasive marker for predicting HCC development after DAA treatment.

Clinical value of liver and spleen shear wave velocity in predicting the prognosis of patients with portal hypertension

AIM

To explore the relationship of liver and spleen shear wave velocity in patients with liver cirrhosis combined with portal hypertension, and assess the value of liver and spleen shear wave velocity in predicting the prognosis of patients with portal hypertension.

METHODS

All 67 patients with liver cirrhosis diagnosed as portal hypertension by hepatic venous pressure gradient in our hospital from June 2014 to December 2014 were enrolled into this study. The baseline information of these patients was recorded. Furthermore, 67 patients were followed-up at 20 mo after treatment, and liver and spleen shear wave velocity were measured by acoustic radiation force impulse at the 1^st week, 3^rd month and 9^th month after treatment. Patients with favorable prognosis were assigned into the favorable prognosis group, while patients with unfavorable prognosis were assigned into the unfavorable prognosis group. The variation and difference in liver and spleen shear wave velocity in these two groups were analyzed by repeated measurement analysis of variance. Meanwhile, in order to evaluate the effect of liver and spleen shear wave velocity on the prognosis of patients with portal hypertension, Cox’s proportional hazard regression model analysis was applied. The ability of those factors in predicting the prognosis of patients with portal hypertension was calculated through receiver operating characteristic (ROC) curves.

RESULTS

The liver and spleen shear wave velocity in the favorable prognosis group revealed a clear decline, while those in the unfavorable prognosis group revealed an increasing tendency at different time points. Furthermore, liver and spleen shear wave velocity was higher in the unfavorable prognosis group, compared with the favorable prognosis group; the differences were statistically significant (P < 0.05). The prognosis of patients with portal hypertension was significantly affected by spleen hardness at the 3^rd month after treatment [relative risk (RR) = 3.481]. At the 9^th month after treatment, the prognosis was affected by liver hardness (RR = 5.241) and spleen hardness (RR = 7.829). The differences between these two groups were statistically significant (P < 0.05). The ROC analysis revealed that the area under the curve (AUC) of spleen hardness at the 3^rd month after treatment was 0.644, while the AUCs of liver and spleen hardness at the 9^th month were 0.579 and 0.776, respectively. These might predict the prognosis of patients with portal hypertension.

CONCLUSION

Spleen hardness at the 3^rd month and liver and spleen shear wave velocity at the 9^th month may be used to assess the prognosis of patients with portal hypertension. This is hoped to be used as an indicator of predicting the prognosis of patients with portal hypertension.

Fibrogenic/Angiogenic Linker for Non-Invasive Assessment of Hepatic Fibrosis Staging in Chronic Hepatitis C Among Egyptian Patients

Background and rationale for the study. Liver biopsy is the golden standard for staging liver fibrosis, but it may be accompanied by complications. Because of this complication, the aim of this study is to evaluate a simple noninvasive score to assess hepatic fibrosis in chronic hepatitis C genotype 4 patients which is very may have an important in diagnosis and therapeutic decision. This score [HA vascular (HAV) score] is a combination of direct markers [hyaluronic acid (HA) and vascular endothelial growth factor (VEGF)] and indirect markers [aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio (AAR)].

RESULTS

Samples were collected from 220 patients (F0-F4): an estimated group (n = 120) and a validated group (n = 100). HA and VEGF levels, HCV RNA, liver function tests, platelet counts were assayed, Fibroscan was done and liver biopsy was taken and the stage of liver fibrosis and the grade of inflammatory activity was calculated according to Metavir score system. HA vascular (HAV) score = -35.1 + 0.14 (HA) (ng/L) + 0.03 (VEGF) (pg/mL) + (-6.7) [AAR (AST/ALT ratio)]. The HAV score produced areas under curve of 0.979 and 0.994 for significant (F2-F4) and advanced fibrosis (F3-F4) (cut off = 0.583 and 6.3, respectively). Surprisingly, the validation study of this score gave very good values of AUCs i.e. 0.990, 0.996 and 0.995 for significant, advanced and liver cirrhosis.

CONCLUSIONS

Our developed score can not only help to assess liver fibrosis staging effectively but also avoid the invasiveness and the limitations of liver biopsy in Egyptian hepatitis C virus patients.

Diagnostic efficacy of noninvasive liver fibrosis indexes in predicting portal hypertension in patients with cirrhosis

Background

Recent data suggest that noninvasive liver fibrosis indexes could be useful for predicting esophageal varices (EV) in cirrhotic patients. However, thus far, the diagnostic efficacy of these indexes in predicting portal hypertension (PH) in cirrhotic patients has been poorly evaluated.

Aims

To evaluate the diagnostic efficacy of noninvasive liver fibrosis indexes in the diagnosis of PH.

Methods

A total of 238 cirrhotic patients underwent hepatic venous pressure gradient (HVPG) evaluation and relevant serum tests to analyze the variables associated with PH grade. Then, the diagnostic performances of seven fibrosis indexes, the aspartate aminotransferase (AST)-to-alanine aminotransferase (ALT) ratio (AAR), AST-to-platelet (PLT) ratio index (APRI), fibrosis index (FI), FIB-4, Forns index, King’s score and the Lok index, were evaluated to determine their efficacy in predicting clinically significant PH (CSPH) and severe PH (SPH). In addition, the performances of these fibrosis indexes in different subgroups were investigated.

Results

The results of a multivariate analysis of serum markers showed that AST values, platelet (PLT) count and albumin (ALB) were associated with PH grade. Among the seven—fibrosis indexes, King’s score, APRI and the Lok index showed modest diagnostic accuracy in predicting CSPH and SPH, as indicated by AUC of 0.755 and 0.742, 0.740 and 0.742, and 0.722 and 0.717, respectively. In addition, combination of King’s score (cutoff 23.47) and Lok index (cutoff 1.30) predicted presence of CSPH, with the highest PPV (95.38%) and +LR (5.49). A subgroup analysis indicated that the noninvasive screening model may be more applicable to patients with cirrhosis of viral etiology.

Conclusions

Serum liver fibrosis indexes exhibited modest diagnostic accuracy for PH in cirrhotic patients. These indexes may not be able to replace HVPG measurements for the diagnosis of PH but may be used as a first-line screening method for CSPH in liver cirrhosis patients.

Clinical role of non-invasive assessment of portal hypertension

Measurement of portal pressure is pivotal in the evaluation of patients with liver cirrhosis. The measurement of the hepatic venous pressure gradient represents the reference method by which portal pressure is estimated. However, it is an invasive procedure that requires significant hospital resources, including experienced staff, and is associated with considerable cost. Non-invasive methods that can be reliably used to estimate the presence and the degree of portal hypertension are urgently needed in clinical practice. Biochemical and morphological parameters have been proposed for this purpose, but have shown disappointing results overall. Splanchnic Doppler ultrasonography and the analysis of microbubble contrast agent kinetics with contrast-enhanced ultrasonography have shown better accuracy for the evaluation of patients with portal hypertension. A key advancement in the non-invasive evaluation of portal hypertension has been the introduction in clinical practice of methods able to measure stiffness in the liver, as well as stiffness/congestion in the spleen. According to the data published to date, it appears to be possible to rule out clinically significant portal hypertension in patients with cirrhosis (i.e., hepatic venous pressure gradient ≥ 10 mmHg) with a level of clinically-acceptable accuracy by combining measurements of liver stiffness and spleen stiffness along with Doppler ultrasound evaluation. It is probable that the combination of these methods may also allow for the identification of patients with the most serious degree of portal hypertension, and ongoing research is helping to ensure progress in this field.

Role of spleen elastography in patients with chronic liver diseases

The development of liver cirrhosis and portal hypertension (PH), one of its major complications, are structural and functional alterations of the liver, occurring in many patients with chronic liver diseases (CLD). Actually the progressive deposition of hepatic fibrosis has a key role in the prognosis of CLD patients. The subsequent development of PH leads to its major complications, such as ascites, hepatic encephalopathy, variceal bleeding and decompensation. Liver biopsy is still considered the reference standard for the assessment of hepatic fibrosis, whereas the measurement of hepatic vein pressure gradient is the standard to ascertain the presence of PH and upper endoscopy is the method of choice to detect the presence of oesophageal varices. However, several non-invasive tests, including elastographic techniques, are currently used to evaluate the severity of liver disease and predict its prognosis. More recently, the measurement of the spleen stiffness has become particularly attractive to assess, considering the relevant role accomplished by the spleen in splanchnic circulation in the course of liver cirrhosis and in the PH. Moreover, spleen stiffness as compared with liver stiffness better represents the dynamic changes occurring in the advanced stages of cirrhosis and shows higher diagnostic performance in detecting esophageal varices. The aim of this review is to provide an exhaustive overview of the actual role of spleen stiffness measurement as assessed by several elastographic techniques in evaluating both liver disease severity and the development of cirrhosis complications, such as PH and to highlight its potential and possible limitations.