A Combined Baveno VII and Spleen Stiffness Algorithm to Improve the Noninvasive Diagnosis of Clinically Significant Portal Hypertension in Patients With Compensated Advanced Chronic Liver Disease

Abstract

INTRODUCTION: A noninvasive diagnosis of clinically significant portal hypertension (CSPH) has important prognostic and therapeutic implications for patients with compensated advanced chronic liver disease. We aimed to validate and improve the available algorithms for the CSPH diagnosis by evaluating spleen stiffness measurement (SSM) in patients with compensated advanced chronic liver disease.

Baveno-VII criteria to predict decompensation and initiate non-selective beta-blocker in compensated advanced chronic liver disease patients

“…In our cohort, the etiology of liver cirrhosis, serum INR, albumin and bilirubin correlates with the risk of liver decompensation in patients within CSPH grey zone ( Supplementary Table 6 ). A recent study by Dajti and colleagues [ 16 ] demonstrated that spleen stiffness can reduce the proportion of patients within the CSPH grey zone. Further studies are required to validate the performance of spleen stiffness to stratify decompensation risk in patients with the CSPH grey zone.…”

Non-invasive tests-based risk stratification: Baveno VII and beyond

“…Here, recent approaches have introduced spleen stiffness measurement (SSM) 10 or the ratio of von Willebrand factor (VWF) and PLT (VITRO score) 11 to close this diagnostic gap (Figure 1; 1 st scenario) 12,13 . Specifically, combining BAVENO VII criteria (as outlined above) with SSM ≤40kPa/ >40kPa 12 , or sequentially applying BAVENO VII criteria and a VITRO-score ≤1.5 or ≥2.5 reallocated up to 75% of previously unclassified patients into the ruled-out/in category while maintaining a high diagnostic accuracy, thereby reducing the grey-zone for CSPH to only 10-15 % of all cACLD patients 12,13 . Most importantly, both SSM-and VITRO-based approached were also able to discriminate between patients at risk vs. not at risk for first hepatic decompensation 12,13 .…”

“…Specifically, combining Baveno VII criteria (as outlined above) with SSM ≤40 kPa/>40 kPa [ 12 ], or sequentially applying Baveno VII criteria and a VITRO-score ≤1.5 or ≥2.5 reallocated up to 75% of previously unclassified patients into the ruled-out/in category while maintaining a high diagnostic accuracy, thereby reducing the grey-zone for CSPH to only 10–15% of all cACLD patients [ 12 , 13 ]. Most importantly, both SSM- and VITRO-based approached were also able to discriminate between patients at risk vs. those not at risk for first hepatic decompensation [ 12 , 13 ]. The sequential application might especially be important to identify ‘at-risk’ patients with CSPH who are otherwise missed by LSM alone.…”

“…All things considered, the study by Wong et al [ 9 ] is an important proof-of-concept, indicating that non-invasive risk stratification for CSPH is valid across different aetiologies, ethnicities, and countries, as it identifies patients at risk for first hepatic decompensation who may benefit from NSBB treatment (CSPH ruled-in), and those at negligible risk of hepatic decompensation (CSPH excluded). More granular information is required to optimize risk stratification/treatment allocation in the broad diagnostic grey-zone of the Baveno VII recommendations; however, specifically designed NIT-based approaches (SSM [ 12 ] and VITRO [ 13 ]) have already been added to our armamentarium. Finally, a randomized controlled trial would be desirable to provide a definite proof for the Baveno VII approach to use NSBB treatment to prevent first hepatic decompensation in patients in whom CSPH has been ruledin non-invasively.…”

Baveno VII criteria to predict decompensation in compensated advanced chronic liver disease: Still some shades of grey

“…In fact, pilot data from a recent retrospective study, using an algorithm combining spleen stiffness measurement (cut-off >/<40 kPa) with the latest rule in and rule out CSPH criteria (LSM ≤15 kPa + PLT ≥150 g/L to rule out CSPH and LSM >25 kPa to rule in CSPH), reduced the grey zone from 40–60% to 7–15%. All first decompensation events occurred in the “rule-in” zone of the model including spleen stiffness measurement [ 12 ]. Besides combining with other tools to refine the patients at risk, these criteria require validation in patients with nonviral causes for cACLD, particularly in obese NASH patients, where LSM is not as accurate [ 10 ].…”