Hepatic venous pressure gradient to assess fibrosis and its progression after liver transplantation for HCV cirrhosis

Abstract

Progression of fibrosis following recurrent hepatitis C virus (HCV) infection is frequent after liver transplantation (LT).Histology remains the gold standard to assess fibrosis, but the value of hepatic venous pressure gradient (HVPG) is being explored. We evaluated patients with recurrent HCV infection after LT to assess whether HVPG correlates with liver histology, particularly fibrosis. A total of 90 consecutive patients underwent 170 HVPG measurements concomitant with transjugular liver biopsy (TJB), with 31.5 (range, 6-156) months of follow up. Median biopsy length was 22 mm and total portal tract count was 12 (complete 6, partial 6). Median HVPG was 4 mmHg: 38% of patients Ն6 mmHg (portal hypertension, PHT), 13% Ն10 mmHg. HVPG correlated with Ishak stage (r ϭ 0.73, P Ͻ 0.001) for mild (0-3) and severe fibrosis (4-6), and grade score (r ϭ 0.47, P Ͻ 0.001), but neither correlated with interval from LT nor biopsy length. HVPG was Ն10 mmHg in 15 patients: 12 had stage 5 or 6, and 3 severe portal expansion. HVPG was repeated in 49, between 7 and 60 months with weak correlation to fibrosis score (r ϭ 0.30, P ϭ 0.045). A total of 12 patients with HVPG Ն6 mmHg had fibrosis score Յ3, while 8 patients had normal HVPG but fibrosis stage Ն4. These discrepancies were mostly associated with specific histological features such as perisinusoidal fibrosis rather than errors in measuring HVPG. In 29 with HVPG Ͻ6 mmHg at 1 yr, none decompensated compared to 4 of 13 (31%) with PHT. In conclusion, HVPG correlates with fibrosis and its progression, due to recurrent HCV infection, assessed in TJB. Liver Transpl 13:1305Transpl 13: -1311Transpl 13: , 2007 The severity of portal hypertension (PHT) correlates with the severity of liver disease and cirrhosis, both functionally and histologically 1 and also with the Model for End-Stage Liver Disease, 2 such that it has independent prognostic value separate from clinical and laboratory assessment. 2,3 Hepatic vein catheterisation 4 was modified by Groszmann et al. 5 using a balloon catheter. The measurement of hepatic venous pressure gradient (HVPG) (the difference between wedge hepatic venous pressure [WHVP] Ϫ free hepatic venous pressure) is reproducible 6 and is the preferred technique for evaluating PHT, correlating 1:1 with the direct measurement of portal vein pressure in patients with sinusoidal and postsinusoidal causes of cirrhosis, 7,8 particularly alcoholic and viral-related cirrhosis. Normally HVPG ranges from 1 to 5 mmHg; pressures Ն6 mmHg indicate PHT. 6 WHVP increases with progression of chronic hepatitis and PHT, before histologically detectable cirrhosis. 9 A gradient Ͼ5 mmHg was always associated with significant changes in liver biopsy in 1 study, although a normal gradient did not completely rule out cirrhosis, 10 suggesting that WHVP could provide supplementary information to liver biopsy, with a higher predictive value for assessing stage and activity of chronic liver disease, than routine biochemical tests. 10 Other studies have correlated HVPG both with severit...

Liver Stiffness 1 Year After Transplantation Predicts Clinical Outcomes in Patients With Recurrent Hepatitis C

“…2003, we showed that the presence of significant fibrosis and especially of portal hypertension 1 year after LT identifies patients with higher probabilities of developing clinical decompensations during follow-up (17), a finding that has been confirmed in other cohorts (20).…”

Liver fibrosis: consensus recommendations of the Asian Pacific Association for the Study of the Liver (APASL)

“…Samonakis et al [38] evaluated patients with recurrent HCV infection after liver transplantation to assess whether HVPG correlates with liver histology, particularly fibrosis. They concluded that HVPG correlates with fibrosis and its progression.…”

“…No reports of serious complications have been published in the medical literature [44]. Samonakis et al [38] reported one episode of supraventricular tachycardia, which disappeared with repositioning of the guide wire [38]. A number of observations over the past 5 years have led to a greater appreciation of how HVPG measurements could be used in the management of the patient with liver disease and the hepatology community may begin to use this technique in the same manner as they use liver biopsy.…”

“…Moreover, HVPG measurements are reproducible in experienced hands and the risks of the procedure are very low. HVPG has been shown to correlate well with the severity of advanced liver disease in HCV infection [38]. It has been even shown to be helpful in assessing reversal of fibrosis following antiviral therapy [48].…”

Hepatic venous pressure gradient in 2010: Optimal measurement is key

“…Our group and others have proposed HVPG measurement as an important marker in assessing prognosis and fibrosis in patients with chronic viral hepatitis. 15 This has been shown to be useful after liver transplantation for HCV-related cirrhosis 16,17 and for chronic hepatitis B-related cirrhosis after antiviral treatment. 18 Changes in HVPG after pharmacological intervention have been used to define an optimal hemodynamic response, which is a reduction of HVPG of 20% from the baseline or to <12 mm Hg.…”