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

Abstract

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.

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

“…Compared to the PREDESCI study, and as discussed by the authors, the risk of first hepatic decompensation was considerably lower (24% in the placebo group of the PREDESCI study vs. 13.3% of CSPH ruled-in patients from this study) 23 . While this can be explained by differences in the underlying patient population (patients with CSPH vs. CSPH ruled-in by NIT; only active HCV infection in the PREDESCI trial vs. only cured HCV patients in the present study), this also influences the numberneeded-to-treat (NNT) for NSBB, which might be even lower than in the study by Wong and colleagues 9 (proposed NNT of 27-50). This calls for a 'non-invasive' PREDESCI trial to re-ensure our current clinical practice using contemporary patients.…”

“…In a recent issue of Clinical and Molecular Hepatology, Wong and colleagues 9 Singapore. Notably, this multi-ethnic cohort included predominantly cured HCV (56%) or suppressed HBV (21%) patients; median LSM was ~24kPa at study inclusion and patients were followed for 40 months.…”

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

“…There are several limitations of the study by Jun et al 8 . Among these, are the variability in patients' characteristics and clinical practices across the different institutions, the retrospective nature of the study introduces particularly information bias, not accounting for missing information in patients' records.…”

The rise of non-invasive tools in the diagnosis of portal hypertension: Validation of the Baveno VII consensus

“…Recently, a study was conducted to validate the recompensation criteria of the Baveno VII [ 8 ], but few studies thus far have validated the CSPH criteria based on a non-invasive assessment. At an opportune time, Wong et al [ 9 ] conducted a large-scale multinational study to validate the CSPH criteria based on TE and platelet count in cACLD patients (TE value ≥10 kPa). In this study, CSPH was classified into four groups.…”

“…Wong et al [ 9 ] showed that the definite CSPH (TE >25 kPa) criterion can effectively predict liver decompensation and liver-related events. In particular, the fact that any patient with the excluded CSPH condition did not experience decompensation augments the reliability of the exclusion criteria.…”