1
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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
|
4
|
Lu Q, Leong S, Lee KA, Patel A, Chua JME, Venkatanarasimha N, Lo RH, Irani FG, Zhuang KD, Gogna A, Chang PEJ, Tan HK, Too CW. Hepatic venous-portal gradient (HVPG) measurement: pearls and pitfalls. Br J Radiol 2021; 94:20210061. [PMID: 34106779 DOI: 10.1259/bjr.20210061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Hepatic venous pressure gradient (HVPG) is the gold-standard for measurement of portal hypertension, a common cause for life-threatening conditions such as variceal bleeding and hepatic encephalopathy. HVPG also plays a crucial role in risk stratification, treatment selection and assessment of treatment response. Thus recognition of common pitfalls and unusual hepatic venous conditions is crucial. This article aims to provide a radiographical and clinical guide to HVPG with representative clinical cases.
Collapse
Affiliation(s)
- Qiqi Lu
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Sum Leong
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Kristen Alexa Lee
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Ankur Patel
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Jasmine Ming Er Chua
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Nanda Venkatanarasimha
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Richard Hg Lo
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Farah Gillan Irani
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Kun Da Zhuang
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Apoorva Gogna
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Pik Eu Jason Chang
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Hiang Keat Tan
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Chow Wei Too
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| |
Collapse
|
6
|
Tey TT, Gogna A, Irani FG, Too CW, Lo HGR, Tan BS, Tay KH, Lui HF, Chang PEJ. Application of a standardised protocol for hepatic venous pressure gradient measurement improves quality of readings and facilitates reduction of variceal bleeding in cirrhotics. Singapore Med J 2017; 57:132-7. [PMID: 26996384 DOI: 10.11622/smedj.2016054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Hepatic venous pressure gradient (HVPG) measurement is recommended for prognostic and therapeutic indications in centres with adequate resources and expertise. Our study aimed to evaluate the quality of HVPG measurements at our centre before and after introduction of a standardised protocol, and the clinical relevance of the HVPG to variceal bleeding in cirrhotics. METHODS HVPG measurements performed at Singapore General Hospital from 2005-2013 were retrospectively reviewed. Criteria for quality HVPG readings were triplicate readings, absence of negative pressure values and variability of ≤ 2 mmHg. The rate of variceal bleeding was compared in cirrhotics who achieved a HVPG response to pharmacotherapy (reduction of the HVPG to < 12 mmHg or by ≥ 20% of baseline) and those who did not. RESULTS 126 HVPG measurements were performed in 105 patients (mean age 54.7 ± 11.4 years; 55.2% men). 80% had liver cirrhosis and 20% had non-cirrhotic portal hypertension (NCPH). The mean overall HVPG was 13.5 ± 7.2 mmHg, with a significant difference between the cirrhosis and NCPH groups (p < 0.001). The proportion of quality readings significantly improved after the protocol was introduced. HVPG response was achieved in 28 (33.3%, n = 84) cirrhotics. Nine had variceal bleeding over a median follow-up of 29 months. The rate of variceal bleeding was significantly lower in HVPG responders compared to nonresponders (p = 0.025). CONCLUSION The quality of HVPG measurements in our centre improved after the introduction of a standardised protocol. A HVPG response can prognosticate the risk of variceal bleeding in cirrhotics.
Collapse
Affiliation(s)
- Tze Tong Tey
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Apoorva Gogna
- Interventional Radiology Centre, Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Farah Gillan Irani
- Interventional Radiology Centre, Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Chow Wei Too
- Interventional Radiology Centre, Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Hoau Gong Richard Lo
- Interventional Radiology Centre, Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Bien Soo Tan
- Interventional Radiology Centre, Department of Diagnostic Radiology, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore
| | - Kiang Hiong Tay
- Interventional Radiology Centre, Department of Diagnostic Radiology, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore
| | | | - Pik Eu Jason Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore
| |
Collapse
|
8
|
Chang PEJ, Cheng CL, Asok K, Fong KY, Chee SP, Tan CK. Visual disturbances in dengue fever: an answer at last? Singapore Med J 2007; 48:e71-3. [PMID: 17342274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Visual disturbances in dengue infection are uncommon but may result in permanent visual impairment. We report a 32-year-old Chinese woman with dengue infection and she developed retinal haemorrhage, retinal vasculitis and macular detachment. Autoimmune screen revealed a low C4 complement level, possibly due to partial C4 complement deficiency. The patient was treated with steroids and there was significant improvement in her vision. Partial C4 deficiency predisposes to autoimmune disease, and patients with pre-existing low C4 levels may be susceptible to ocular complications in dengue infection. Interestingly, previous case reports of ophthalmic complications of dengue infection occurred in young female patients, who are likewise predisposed to autoimmune disease. In conclusion, in individuals predisposed to autoimmune disease (females and patients with partial C4 deficiency), dengue infection may provide the antigenic trigger for immune complex deposition and retinal vasculitis. Steroids may have an important role in the treatment of this condition.
Collapse
Affiliation(s)
- P E J Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Outram Road, Singapore 169608.
| | | | | | | | | | | |
Collapse
|