Baveno Criteria Safely Identify Patients With Compensated Advanced Chronic Liver Disease Who Can Avoid Variceal Screening Endoscopy: A Diagnostic Test Accuracy Meta-Analysis

Abstract

Background: The Baveno VI Consensus Workshop defined criteria (liver stiffness measured by transient elastography <20 kPa and platelet count >150 × 10 9 cells/L) to identify those patients with compensated advanced chronic liver diseases (cACLD) who are unlikely to have varices needing treatment (VNTs) and can safely avoid variceal screening endoscopy. This meta-analysis aimed to quantify the safety and efficacy of these criteria in suspected cACLD with liver stiffness >10 kPa and in compensated chronic liver diseases (cCLD) irrespective of liver stiffness. Methods: A systematic search was conducted in nine databases for studies discussed cACLD or cCLD and tested Baveno criteria against variceal screening endoscopy. The main safety and efficacy endpoints were missed VNT rate and spared endoscopy rate (SER), respectively; calculated with the random effect model. Pooled sensitivity, specificity, and area under the curve (AUC) were calculated with the hierarchical summary receiver operating characteristic model. For all outcome measures, 95% confidence intervals were computed. Heterogeneity was tested with I 2 -statistics. Results: The search yielded 13 studies including 4,464 patients which reported on suspected cACLD. Pooled missed VNT rate was 0.3% (0.1–0.6%; I 2 = 45.5%), pooled SER was 32.8% (24.8–41.4%; I 2 = 97.0%). Sensitivity, specificity, and AUC of Baveno criteria were 97% (95–98%), 41% (27–57%), and 96% (94–97%), respectively. In the subgroups of cACLD from hepatitis C and B viruses, non-alcoholic fatty liver disease/steatohepatitis, or alcohol, missed VNT rates were 0.0% (0.0–0.3%), 1.2% (0.4–2.2%), 0.0% (0.0–1.3%), or 0.0% (0.0–0.4%), while SERs were 24.2% (20.5–28.1%), 24.9% (21.7–28.4%), 38.6% (10.9–70.8%), or 27.0% (16.9–38.4%), respectively. If we expanded the study population to cCLD, 27 studies included 7,534 patients. Missed VNT rate was 0.2% (0.1–0.5%; I 2 = 39.8%) with a SER of 30.5% (25.2–36.2%; I 2 = 96.1%) while Se, Sp, and AUC were 97% (93–99%), 35% (27–44%), and 80% (77–84%), respectively. Conclusions: The application of Baveno criteria significantly reduces the number of unnecessary variceal screening endoscopies while being safe: cACLD patients with liver stiffness <20 kPa and platelet count > 150 × 10 9 cells/L carry a very low chance (i.e., 0.3%) of having VNTs. The criteria preserve low missed VNT rate with lower diagnostic performance among cCLD patients.

Screening varices in patients with HBV‐related cirrhosis on antiviral therapy: Platelet alone or together with LSM

“…Thereafter, some studies tried to optimize the thresholds to increase the number of EGDs that could be avoided. The Expanded Baveno VI criteria (PLT count >110 × 10 −9 /L and LSM < 25 kPa) seemed to spare more EGDs at a proportion of about 30.5%‐51.7% 8‐11 . The other two most widely validated criteria are “PLT > 125/LSM < 25” and ‘stepwise PLT‐MELD’ strategy (platelet >150 × 10 −9 /L or platelet ≤150 × 10 −9 /L but MELD = 6), showing 14%‐28% increase in the proportion of spared endoscopies compared to Baveno VI criteria 6,9 …”

Validation and Refinement of the Baveno VI Criteria for Ruling Out High-Risk Varices

“…Another meta-analysis, including 13 studies and 4464 patients with cACLD, yielded similar results; the pooled rate of missing HRV was 0.3% and 32.8% of the gastroscopies could be avoided. The sensitivity, specificity, and area under the receiver operating curve of the Baveno VI criteria were 97%, 41%, and 96%, respectively [ 29 ]. These studies demonstrated that the Baveno VI criteria is a reliable method for stratifying the risk of EV and sparing gastroscopies in patients with cACLD or compensated cirrhosis.…”

“…The Baveno VI criteria spared 39% and 30% of gastroscopies in patients with PBC and PSC, respectively, without missing HRV [ 33 ]. In a recent meta-analysis involving patients with cACLD due to HCV, HBV infection, NAFLD, and alcohol liver disease, the Baveno VI criteria missed HRVs at a rate of 0.0%, 1.2%, 0.0%, and 0.0%, respectively [ 29 ]. In addition, gastroscopies were spared in 24.2%, 24.9%, 38.6%, and 27.0% of patients, respectively.…”

“…Several factors that may influence the rate of spared gastroscopies have been investigated. A meta-analysis found a negative correlation of the proportion of viral liver disease, as well as the levels of alanine amino transferases (ALT) and aspartate amino transferases, with the rate of spared endoscopy [ 29 ]. In patients with HBV infection, the diagnostic thresholds of LSM for cACLD and liver cirrhosis are lower than those in patients with other etiologies.…”

“…Therefore, the risk of having HRVs in HBV patients with LSM < 20 kPa and a PLT count > 150 × 10 9 /L is higher than that in patients with other etiologies [ 39 ]. A positive correlation between the proportion of NAFLD and rate of spared endoscopy was reported [ 29 ]. In a previous study, we found that, among patients with HBV-related compensated liver cirrhosis who did not meet the Baveno VI criteria, the prevalence of HRV was significantly lower in those with ALT or total bilirubin (TBil) ≥ 2 upper limit of normal (ULN) (14.3%) than in those with both ALT and TBil < 2 ULN (34.1%) [ 40 ].…”