Clinical significance of measuring hepatic venous pressure gradient on transjugular liver biopsy for patients with pre-cirrhotic bridging fibrosis liver disease

PURPOSE

To demonstrate that patients with pre-cirrhotic bridging fibrosis (Meta-analysis of Histological Data in Viral Hepatitis, METAVIR stage F3) and clinically significant portal hypertension (CSPH, Hepatic Venous Pressure Gradient ≥10 mmHg) experience a higher rate of clinical decompensation than patients without CSPH.

MATERIALS AND METHODS

128 consecutive patients with pathology proven bridging fibrosis without cirrhosis between 2012 and 2019 were reviewed. Inclusion criteria were patients with HVPG measurement obtained during the same outpatient transjugular liver biopsy and clinical follow up of at least two years. Primary endpoint included rate of overall complication related to portal hypertension including evidence of either ascites, presence of varices on imaging or endoscopy, or evidence of hepatic encephalopathy.

RESULTS

Among 128 patients with bridging fibrosis (67 females and 61 males; average age 56 years), 42 (33%) and 86 (67%) were with and without CSPH (HVPG ≥10 mmHg). Median follow-up time was 4 years. Rate of overall complication (either ascites, varices or hepatic encephalopathy) in patients with and without CSPH was 36/42 (86%) and 39/86 (45%) (p < .001) respectively. Rate of developing ascites, varices and hepatic encephalopathy in patients with and without CSPH was 21/42 (50%) vs 26/86 (30%) (p = .034), 32/42 (76%) vs 26/86 (30%) (p ≤ .001) and 18/42 (43%) vs 12/86 (14%) (p = .001) respectively.

CONCLUSION

Patients with pre-cirrhotic bridging fibrosis and CSPH were associated with higher rates of developing ascites, varices and hepatic encephalopathy. Measuring HVPG during transjugular liver biopsy provides additional prognostic value in anticipating clinical decompensation in patients with pre-cirrhotic bridging fibrosis.

Drug-eluting bead transarterial chemoembolization could improve the hepatic hemodynamics of patients with unresectable hepatocellular carcinoma: a retrospective cohort study

Background

Transarterial chemoembolization (TACE) is widely used for patients with unresectable hepatocellular carcinoma (HCC); however, previous studies have demonstrated that conventional TACE (cTACE) might affect hepatic hemodynamics, which both associate with liver cirrhosis and survival. Drug-eluting bead TACE (DEB-TACE) improves treatment efficacy and safety, but its effects on the hepatic hemodynamics of HCC patients with cirrhosis remain unknown.

Methods

This retrospective cohort study included unresectable HCC patients treated with DEB-TACE from April 2018 to September 2020, who had limited tumor burden and liver function. The hepatic hemodynamics was measured by hepatic venous pressure gradient (HVPG) using occlusion balloon catheter before and after treatment. Baseline characteristics of demography, laboratory (tumoral and liver-function) and hepatic hemodynamics were compared between patients with and without clinically significant portal hypertension (CSPH). Laboratory examination and imaging assessments were performed 4-6 weeks; overall survival (OS) was defined as the time from DEB-TACE initiation until death or last follow-up.

Results

Twenty-four eligible consecutive HCC patients were included, with a median age of 58.0 years and 54.2% in Child-Pugh A class. During a median follow-up of 9.8 months, median OS for the whole cohort of patients reached 10.0 months. Kaplan-Meier survival curves and Cox regression analyses demonstrated that age >60 years, ascites, Eastern Cooperative Oncology Group (ECOG) score of 1, Child-Pugh B class, Model for End-Stage Liver Disease (MELD) score >10, and albumin (ALB) <35 g/L were prognostic factors for decreased OS (P<0.05). Importantly, hepatic hemodynamics were significantly improved in patients after treatment with DEB-TACE (7.5 vs. 5.3 mmHg of HVPG, P<0.001), especially for those with CSPH (13.6 vs. 10.2 mmHg of HVPG, P=0.014).

Conclusions

DEB-TACE can improve hepatic hemodynamics in HCC patients, especially those with CSPH. Combing these findings with its effects on tumor, DEB-TACE might be more suitable for HCC patients with cirrhosis.

Network Meta-Analysis: Noninvasive Imaging Modalities for Identifying Clinically Significant Portal Hypertension

BACKGROUND

Although measurement of the hepatic venous pressure gradient (HVPG) is the current reference standard for obtaining portal venous pressures, several noninvasive imaging-based modalities have been proposed as alternatives.

AIMS

We performed a systematic review and meta-analysis to compare the diagnostic accuracy of noninvasive imaging approaches for identifying clinically significant portal hypertension (CSPH).

METHODS

Two independent reviewers conducted a literature search of PubMed, SCOPUS, and the Cochrane Library from inception until January 5, 2021. The following imaging modalities were compared to HVPG: computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance elastography, ultrasound, transient elastography (TE), shear wave elastography (SWE), acoustic radiation force impulse (ARFI) imaging, contrast-enhanced ultrasound (CEUS), and subharmonic-aided pressure estimation (SHAPE). Sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curve (AUC) for summary receiver operating characteristic were calculated using both frequentist random effects and Bayesian network meta-analytic approaches.

RESULTS

We analyzed 45 studies of 5678 patients. A broad overlapping confidence interval (CI) of DOR was observed among different imaging modalities: ARFI (30.5; 95% CI 12.7-73.3), CEUS and SHAPE (21.1; 95% CI 6.4-69.8), TE of liver stiffness (21.1; 95% CI 13.3-33.5), CT and MRI (13.7; 95% CI 7.40-25.4), SWE of liver stiffness (10.5; 95% CI 5.2-21.1), and ultrasound (9.5; 95% CI 4.9-18.4). The AUC of all imaging methods exceeded 0.8, indicating very good performance. At a cutoff of 80% specificity, TE, CEUS, and SHAPE exceeded 80% sensitivity.

CONCLUSION

Overall, noninvasive imaging modalities perform well for identifying CSPH. Clinicians should consider these noninvasive and cost-efficient tests when diagnosing CSPH.