Clinically significant portal hypertension (CSPH), which is defined as a hepatic venous pressure gradient (HVPG) ≥10 mmHg, is the main determinant of decompensation in patients with compensated advanced chronic liver disease (cACLD) [
1]. Patients with cACLD and CSPH have an increased risk of developing varices [
2], clinical decompensation [
1], and significantly shorter survival [
3]. The gold standard for diagnosing CSPH is the measurement of the HVPG. However, since HVPG measurement is an invasive procedure, the Baveno VI and Baveno VII consensus guidelines have proposed noninvasive methods for predicting CSPH via liver stiffness measurement (LSM) [
4,
5]. The Baveno VI consensus stated that patients with a platelet count greater than 150,000/μL and an LSM below 20 kPa are at low risk of having varices needing treatment [
4]. The Baveno VII consensus proposed that CSPH can be ruled in when the LSM exceeds 25 kPa and ruled out when the LSM is below 15 kPa and the platelet count is greater than 150,000/μL [
5].
LSM is widely used as an accurate noninvasive method for predicting CSPH; however, its accuracy may be affected by confounding factors, such as hepatic necroinflammation, hepatic congestion, and extrahepatic cholestasis [
6]. Recent studies suggest that the spleen stiffness measurement (SSM) can increase the accuracy of the LSM in predicting CSPH and liver-related complications [
7,
8]. SSM is influenced not only by splenic congestion secondary to portal hypertension but also by structural changes, including alterations in the splenic vasculature and fibrosis [
9]. As a result, the SSM reflects both chronic architectural modifications and dynamic hemodynamic changes associated with portal hypertension. The Baveno VII consensus conferences have recognized the potential role of SSM as an adjunct to LSM, emphasizing its utility in refining risk stratification and clinical decision-making in patients with cACLD [
4,
5].
Recent prospective research conducted by Wang et al. [
10] evaluated the predictive accuracy of LSM and SSM for decompensation events in patients with hepatitis B virus (HBV)-related cirrhosis. Compared with the Baveno VI model, the Baveno VI-SSM model identified a greater proportion of patients as not being at risk for high-risk varices (HRV), thereby reducing the need for endoscopic screening. Among the three models compared—Baveno VII, Baveno VII-SSM (single cutoff), and Baveno VII-SSM (dual cutoff)—the Baveno VII-SSM (single cutoff) model exhibited the highest accuracy in identifying patients at low risk of decompensation. However, when Baveno VII-SSM (single cutoff) was compared with Baveno VI-SSM, the latter identified a greater proportion of patients at low risk of decompensation. Patients classified as low risk by both the Baveno VI model and the Baveno VI-SSM had a lower risk of esophageal varices progression than those classified as high risk. During the observation period, the worsening of the Baveno VI-SSM status was driven primarily by changes in SSM. Patients who experienced worsening of the Baveno VI-SSM classification had significantly higher rates of esophageal varices progression and decompensation than those who remained in the low-risk group.
Wang et al’s. [
10] study prospectively demonstrated that the combined assessment of the LSM and SSM provides greater accuracy than the LSM alone does, thereby validating the Baveno VII consensus. SSM reflects splenic angiogenesis and fibrosis, driven by elevated vascular endothelial growth factor in cirrhosis-related hyperdynamic circulation [
11]. Furthermore, unlike LSM, SSM is strongly associated with hemodynamic changes induced by nonselective beta-blockers (NSBBs) [
12,
13]. By capturing changes in portal hypertension that LSM alone may not detect, SSM improves the prediction of decompensation and HRV. Notably, Wang et al. [
10] demonstrated that the deterioration of Baveno VI-SSM was attributed primarily to a decrease in SSM, which was associated with an increased risk of decompensation. This finding suggests that changes in the SSM may serve as an earlier indicator of PHT progression than changes in the LSM.
Another strength of Wang et al’s. [
10] study is its validation and comparison of two LSM+SSM combination models. In a study by Zhang et al. [
14], no significant difference was observed in the rate of missed HRV or the endoscopy-sparing rate when comparing Baveno VI+SSM (SSM <46 kPa) and Baveno VII+SSM (SSM <40 kPa), both of which used the same LSM cutoff of <20 kPa. However, Wang et al. [
10] demonstrated that when a consistent SSM threshold of <40 kPa was applied, the LSM cutoff for ruling out HRV in Baveno VI (LSM <20 kPa) led to a higher endoscopy-sparing rate and better prediction of decompensation than the LSM cutoff for ruling out CSPH in Baveno VII (LSM <15 kPa). Moreover, this study demonstrated that using a single SSM cutoff is superior to a dual cutoff, as it reduces the gray zone and allows more patients to avoid unnecessary endoscopy. These findings provide valuable insights for future updates to the Baveno consensus, supporting the establishment of optimal LSM and SSM cutoffs to reduce unnecessary endoscopies.
However, the results of this study should be interpreted with caution due to several limitations. First, it was conducted exclusively in HBV-related cirrhosis patients with virologic suppression. In the ANTICIPATE study by Pons et al., the positive predictive value of the LSM cutoff for ruling out CSPH (LSM >25 kPa) was significantly lower in obese patients with nonalcoholic steatohepatitis than in those with other etiologies [
15]. Given the increasing prevalence of liver diseases caused by excessive alcohol consumption and metabolic dysfunction-associated steatotic liver disease in clinical practice, further research is needed to determine whether these cutoff criteria can be reliably applied beyond viral hepatitis. Second, although 57 patients in this study were reported to have used NSBBs, their impact was not analyzed. The PREDESCI study demonstrated that long-term NSBB use reduces the risk of decompensation in patients with cACLD and CSPH [
16]. Furthermore, the Baveno VII consensus recommends the use of NSBBs in patients with CSPH. Third, recent studies have suggested that using a spleen-dedicated probe (100 Hz) offers more accurate prognostic predictions than does the conventional 50 Hz probe used for LSM measurements [
14]. Therefore, further research is warranted to explore the clinical utility and prognostic value of spleen-specific probes in risk stratification and disease monitoring.
In conclusion, this study demonstrated that the combined use of SSMs and LSMs is more effective than the use of LSMs alone for the noninvasive prediction of CSPH. Additionally, since changes in SSM more accurately reflect variations in portal hypertension, monitoring SSM is clinically valuable in practice. Future research should focus on developing a noninvasive assessment model that considers liver disease etiology, medication use, and measurement techniques to enable personalized patient care.
FOOTNOTES
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Conflicts of Interest
The author declares no conflicts of interest.
Abbreviations
compensated advanced chronic liver disease
clinically significant portal hypertension
hepatic venous pressure gradient
liver stiffness measurement
nonselective beta-blockers
spleen stiffness measurement
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Citations
Citations to this article as recorded by
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