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Fibrosis-4plus score: a novel machine learning-based tool for screening high-risk varices in compensated cirrhosis (CHESS2004): an international multicenter study Bingtian Dong, Ruiling He, Shenghong Ju, Yuping Chen, Ivica Grgurevic, Jianzhong Ma, Ying Guo, Huizhen Fan, Qiang Yan, Chuan Liu, Huixiong Xu, Anita Madir, Kristian Podrug, Jia Wang, Linxue Qian, Zhengzi Geng, Shanghao Liu, Tao Ren, Guo Zhang, Kun Wang, M Clinical and Molecular Hepatology.2025; 31(3): 881. CrossRef
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Background/Aims The utility of Baveno-VII criteria of clinically significant portal hypertension (CSPH) to predict decompensation in compensated advanced chronic liver disease (cACLD) patient needs validation. We aim to validate the performance of CSPH criteria to predict the risk of decompensation in an international real-world cohort of cACLD patients.
Methods cACLD patients were stratified into three categories (CSPH excluded, grey zone, and CSPH). The risks of decompensation across different CSPH categories were estimated using competing risk regression for clustered data, with death and hepatocellular carcinoma as competing events. The performance of “treating definite CSPH” strategy to prevent decompensation using non-selective beta-blocker (NSBB) was compared against other strategies in decision curve analysis.
Results One thousand one hundred fifty-nine cACLD patients (36.8% had CSPH) were included; 7.2% experienced decompensation over a median follow-up of 40 months. Non-invasive assessment of CSPH predicts a 5-fold higher risk of liver decompensation in cACLD patients (subdistribution hazard ratio, 5.5; 95% confidence interval, 4.0–7.4). “Probable CSPH” is suboptimal to predict decompensation risk in cACLD patients. CSPH exclusion criteria reliably exclude cACLD patients at risk of decompensation, regardless of etiology. Among the grey zone, the decompensation risk was negligible among viral-related cACLD, but was substantially higher among the non-viral cACLD group. Decision curve analysis showed that “treating definite CSPH” strategy is superior to “treating all varices” or “treating probable CSPH” strategy to prevent decompensation using NSBB.
Conclusions Non-invasive assessment of CSPH may stratify decompensation risk and the need for NSBB in cACLD patients.
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Transjugular intrahepatic portosystemic shunt (TIPS) is an effective interventional procedure to relieve portal hypertension, which is a main mechanism for the development of complications of liver cirrhosis (LC), such as variceal hemorrhage, ascites, and hepatorenal syndrome. However, the high incidence of adverse events after TIPS implementation limits its application in clinical practice. Esophageal variceal hemorrhage is one of the major indications for TIPS. Recently, preemptively performed TIPS has been recommended, as several studies have shown that TIPS significantly reduced mortality as well as rebleeding or failure to control bleeding in patients who are at high risk of treatment failure for bleeding control with endoscopic variceal ligation and vasoactive drugs. Meanwhile, recurrent ascites is another indication for TIPS with a proven survival benefit. TIPS may also be considered as an effective treatment for other LC complications, usually as an alternative therapy. Although there are concerns about the development of hepatic encephalopathy and hepatic dysfunction after TIPS implementation, careful patient selection using prognostic scores can lead to excellent outcomes. Assessments of cardiac and renal function prior to TIPS may also be considered to improve patient prognosis.
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Clin Mol Hepatol 2021;27(1):197-206. Published online December 3, 2020
Background/Aims The hepatic venous pressure gradient (HVPG) reflects portal hypertension, but its measurement is invasive. Transient elastography (TE) is a noninvasive method for evaluating liver stiffness (LS). We investigated the correlation between the value of LS, LS to platelet ratio (LPR), LS-spleen diameter-to-platelet ratio score (LSPS) and HVPG according to the etiology of cirrhosis, especially focused on alcoholic cirrhosis.
Methods Between January 2008 and March 2017, 556 patients who underwent HVPG and TE were consecutively enrolled. We evaluated LS, LPR, and LSPS according to the etiology of cirrhosis and analyzed their correlations with HVPG.
Results The LS value was higher in patients with alcoholic cirrhosis than viral cirrhosis based on the HVPG (43.5 vs. 32.0 kPa, P<0.001). There were no significant differences in the LPR or LSPS between alcoholic and viral cirrhosis groups, and the areas under the curves for the LPR and LSPS in subgroups according to HVPG levels were not superior to that for LS. In alcoholic cirrhosis, the LS cutoff value for predicting an HVPG ≥10 mmHg was 32.2 kPa with positive predictive value (PPV) of 94.5% and 36.6 kPa for HVPG ≥12 mmHg with PPV of 91.0%.
Conclusions The LS cutoff value should be determined separately for patients with alcoholic and viral cirrhosis. In alcoholic cirrhosis, the LS cutoff values were 32.2 and 36.6 kPa for predicting an HVPG ≥10 and ≥12 mmHg, respectively. However, there were no significant differences in the LPR or LSPS between alcoholic and viral cirrhosis groups.
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Managing liver cirrhosis in clinical practice is still a challenging problem as its progression is associated with serious complications, such as variceal bleeding that may increase mortality. Portal hypertension (PH) is the main key for the development of liver cirrhosis complications. Portal pressure above 10 mmHg, termed as clinically significant portal hypertension, is associated with formation of varices; meanwhile, portal pressure above 12 mmHg is associated with variceal bleeding. Hepatic vein pressure gradient measurement and esophagogastroduodenoscopy remain the gold standard for assessing portal pressure and detecting varices. Recently, non-invasive methods have been studied for evaluation of portal pressure and varices detection in liver cirrhotic patients. Various guidelines have been published for clinicians’ guidance in the management of esophagogastric varices which aims to prevent development of varices, acute variceal bleeding, and variceal rebleeding. This writing provides a comprehensive review on development of PH and varices in liver cirrhosis patients and its management based on current international guidelines and real experience in Indonesia.
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Background/Aims Transient elastography (TE) has been proposed as a promising noninvasive alternative to hepatic venous pressure gradient (HVPG) for detecting portal hypertension (PH). However, previous studies have yielded conflicting results. We gathered evidence from literature on the clinical usefulness of TE versus HVPG for assessing PH.
Methods We conducted a systematic review by searching databases for relevant literature evaluating the clinical usefulness of non-invasive TE for assessing PH in patients with cirrhosis. A literature search in Ovid Medline, EMBASE and the Cochrane Library was performed for all studies published prior to December 30, 2015.
Results Eight studies (1,356 patients) met our inclusion criteria. For the detection of PH (HVPG ≥6 mmHg), the summary sensitivity and specificity were 0.88 (95% confidence interval [CI] 0.86-0.90) and 0.74 (95% CI 0.67-0.81), respectively. Regarding clinically significant PH (HVPG ≥10 mmHg), the summary sensitivity and specificity were 0.85 (95% CI 0.63-0.97) and 0.71 (95% CI 0.50-0.93), respectively. The overall correlation estimate of TE and HVPG was large (0.75, 95% CI: 0.65; 0.82, P<0.0001).
Conclusions TE showed high accuracy and correlation for detecting the severity of PH. Therefore, TE shows promise as a reliable and non-invasive procedure for the evaluation of PH that should be integrated into clinical practice.
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Moon Young Kim, M.D., Soon Koo Baik, M.D., Ki Tae Suk, M.D., Change Jin Yea, M.D.,
Il Young Lee, M.D., Jae Woo Kim, M.D., Seung Hwan Cha, M.D.1,
Young Ju Kim, M.D.1, Soon Ho Um, M.D.2, Kwang-Hyub Han, M.D.3
Korean J Hepatol 2008;14(2):150-158. Published online June 20, 2008
Background/Aims The relationships between the hepatic venous pressure gradient (HVPG) and the status
of cirrhosis, complications of portal hypertension and the severity of cirrhosis are not clear. The aim of this
study was to determine the relationships between HVPG and the complications or status of cirrhosis.
Methods The HVPG, gastroesophageal varices, Child-Pugh score, Model for End-Stage Liver Disease
(MELD) score, presence of ascites, recent bleeding history and the status of cirrhosis were assessed in a
cohort of 172 patients (156 males, 16 females) with liver cirrhosis. Results: The HVPG was 15.6±5.1 (mean±
SD) mmHg (4-33 mmHg) and was significantly higher in patients in the decompensated stage than in those
in the compensated stage (16.6±4.3 vs. 10.8±6.1 mmHg, respectively; P<0.01). HVPG was higher in bleeders
than in nonbleeders (16.9±4.5 vs. 12.8±5.3 mmHg, respectively; P<0.01), and in patients with ascites than in
those without ascites (16.4±4.1 vs. 14.5±6.2 mmHg, respectively; P<0.05). HVPG was significantly lower in
the presence of gastric varices than in their absence (14.0±3.4 vs. 16.0±5.3 mmHg, respectively; P<0.05);
however, no significant correlation was detected between HVPG and the grade of esophageal varices (P>0.05).
HVPG was significantly higher in Child’s B cirrhosis (n=87, 15.6±4.7 mmHg) and Child’s C cirrhosis (n=36,
18.4±4.7 mmHg) than in Child’s A cirrhosis (n=49, 13.7±5.1 mmHg; P<0.01). HVPG also was strongly
correlated with the MELD score (P<0.01). The time required to measure the HVPG was 11.2±6.4 min, and
only three cases of minor complication occurred during the procedure. Conclusions: HVPG was correlated
with the severity of liver cirrhosis, presence of ascites, and risk of variceal bleeding in patients with liver
cirrhosis. (Korean J Hepatol 2008;14:150-158)
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The relation between hepatic venous pressure gradient and complications of liver cirrhosis Yong-Han Paik The Korean Journal of Hepatology.2008; 14(2): 136. CrossRef
Myeong Gwan Jee , Soon Koo Baik , Dong Hun Park , Moon Young Kim , Dae Wook Rhim , Ki Won Jo , Jin Hon Hong , Jae Wook Kim , Hyun Soo Kim , Sang Ok Kwon
Backgrounds/Aims Doppler ultrasongraphy is used to evaluate hemodynamic alternations in patients with liver cirrhosis. Purpose of this study was to determine the interequipment variability of Doppler indices in portal and splenic vein in cirrhosis. Methods: Blood velocity, diameter, flow and congestive index in portal and splenic vein were measured by Doppler ultrasonography in 30 patients with cirrhosis using two different machines. Results: Portal venous velocities measured by HDI-5000 and SSD-5000 were 8.72±3.69 cm/sec, 12.21±2.84 cm/sec, respectively which showed significant difference (P<0.001). Measured portal blood flows and congestive indices also had significant difference between HDI-5000 and SSD-5000 (P<0.01). Splenic venous velocity by HDI-5000 was 8.55±2.71 cm/sec, which was lower than that of 12.32±3.11 cm/sec by SSD- 5000 (P<0.001). Splenic blood flows measured by HDI-5000 and SSD-5000 were 390.73±260.98 mL/min, 595.01±346.53 mL/min, respectively, showing significant difference (P=0.015). However, no differences were in the diameters of portal and splenic vein between HDI-5000 and SSD-5000. Conclusion: Doppler indices in portal and splenic vein showed significant interequipment variability. Therefore, in liver cirrhosis, hemodynamic investigations using different Doppler ultrasonographic machines is inappropriate. (Korean J Hepatol 2006;12:539-545)
Backgrounds/Aims Surgical resection is considered as a curative treatment modality for patient with hepatocellular carcinoma (HCC). Since HCC often occurs in chronic liver disease, selecting optimal candidates based on the hepatic function reserve and the risk of hepatic decompensation after resection is important. In recent studies, clinically relevant portal hypertension including hepatic venous pressure gradient (HVPG) is considered as the best predictor of postoperative hepatic decompensation. However, since measuring HVPG requires an invasive procedure it is not widely used in practice. We aimed to evaluate whether the portal hypertension diagnosed indirectly could be a useful parameter for predicting postoperative prognosis. Methods: A total of 142 patients with HCC who had endoscopic examination, computed tomography and surgical resection from January 2001 to June 2004 were included in the study. We diagnosed portal hypertension indirectly by the presence of varices or splenomegaly with thrmobocytopenia. Postoperative complications and survival rate according to the presence of portal hypertension was studied. Results: The postoperative morbidity rate was 42.2%. The incidence of ascites and prolonged hyperbilirubinemia were significantly higher in portal hypertension group (ascites 43.8 vs. 10.3%, hyperbilirubinemia 20.3 vs. 1.3%, respectively, P<0.01). The cumulative 3-year recurrence-free survival rate showed no statistical difference between the two groups. However, the cumulative 3-year survival rate was significantly higher in the non-portal hypertension group (82.8% vs. 53%, respectively, P=0.014). Conclusion: Indirectly diagnosed portal hypertension is correlated with the development of complications and poor prognosis after the surgical resection of HCC. (Korean J Hepatol 2006;12:553-561)
Most patients with liver cirrhosis have hyperdynamic circulatory alterations with increased cardiac output,
and decreased systemic vascular resistance and arterial pressure. But, in spite of the increased resting cardiac
output, ventricular contractile response to stressful stimuli is attenuated in cirrhotic patients which is termed
as cirrhotic cardiomyopathy. The prevalence of cirrhotic cardiomyopathy remains unknown at present. Clinical
features include structural, histological, electrophysiological, systolic and diastolic dysfunction. Multiple factors
are considered as responsible, including impaired β-adrenergic receptor signal transduction, abnormal
membrane biophysical characteristics, and increased activity of cardiodepressant systems mediated by cGMP.
Generally, cirrhotic cardiomyopathy with overt severe heart failure is rare. However, major stresses on the
cardiovascular system such as liver transplantation, infections and insertion of transjugular intrahepatic
portosystemic shunts (TIPS) can unmask the presence of cirrhotic cardiomyopathy and thereby convert latent
to overt heart failure. Cirrhotic cardiomyopathy may also contribute to the pathogenesis of hepatorenal
syndrome and circulatory failure in liver cirrhosis. Because of the marked paucity of treatment studies, current
recommendations for management are empirical, nonspecific measures. Further studies for pathogenesis and
new therapeutic strategies in this area are required. (Korean J Hepatol 2007;13:20-26)
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