Influence of hepatic venous pressure gradient on the prediction of survival of patients with cirrhosis in the MELD Era

Abstract

Measurements of portal pressure, usually obtained via the hepatic venous pressure gradient (HVPG) may be a prognostic marker in cirrhosis. The aim of this study was to evaluate the impact of HVPG on survival in patients with cirrhosis in addition to the Model for EndStage Liver Disease (MELD) score. We also examined whether inclusion of HVPG in a model with MELD variables improves its prognostic ability. Retrospective analyses of all patients who had HVPG measurements between January 1998 and December 2002 were considered. Proportional hazards Cox models were developed. Prognostic calibrative and discriminative ability of the model was evaluated. In this period, 693 patients had a hepatic hemodynamic study, and 393 patients were included. Survival was significantly worse in those patients with greater HVPG value (univariate HR, 1.05; 95% CI, 1.02-1.08; P ‫؍‬ .001). HVPG remained as an independent variable in a model adjusted by MELD, ascites, encephalopathy, and age (multivariate HR, 1.03; 95% CI, 1.00-1.06; P ‫؍‬ .05) so that each 1-mmHg increase in HVPG had a 3% increase in death risk. In addition, HVPG as well as MELD score variables and age, significantly contributes to the calibrative predictive capacity of the prognostic model; however, discriminative ability improved only slightly (overall C statistic T he Model for End-Stage Liver Disease (MELD) score, initially developed for survival prediction of patients undergoing the transjugular intrahepatic portal systemic shunt (TIPS) procedure, 1 has been subsequently validated in an increasingly heterogeneous population of patients with cirrhosis as a very good tool to rank patients according to their short-term risk of death. [2][3][4][5] In the initial validation of the MELD score, individual complications of portal hypertension (ascites, spontaneous bacterial peritonitis, variceal bleeding, and encephalopathy) were added to the model, producing only minimal improvement in its discriminative ability. 2 However, each individual portal hypertensionrelated complication is only one aspect of the underlying pathophysiological mechanism, the portal hypertensive syndrome. Re-evaluation of the role of portal hypertension indexes in such predictive scores has been suggested, as portal hypertension has been described as the third parameter most frequently found to be a significant predictor of survival in cirrhosis. 6 Interestingly, after dividing patients in categories according to MELD score, 1-year mortality within each category was higher among patients with portal hypertension-related complications.

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

“…2) (expressed as difference between the last and first measurement) had a weak correlation with changes in fibrosis score (r ϭ 0.30, P ϭ 0.045). However, no significant correlation was found between change in grade and HVPG (P ϭ 0.042) and median HVPG did not change (5 mmHg; range, [1][2][3][4][5][6][7][8][9][10][11][12][13][14]. Regarding the whole paired group, the mean of the first evaluations for HVPG was 5.31 Ϯ 2.9 vs. 6.29 Ϯ 4.5 for the last (P ϭ 0.82); when evaluating those with PHT at first measurement, a better correlation was found, with mean first HVPG at 8.4 Ϯ 2.3 vs. 10 Ϯ 5 for the last HVPG (P ϭ 0.076).…”

“…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.…”

“…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.…”

“…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.…”

Models for prediction of mortality from cirrhosis with special reference to artificial neural network: a critical review

“…Limitations of this scoring system for deciding timings of liver transplantation include limited discriminative ability, variability in measurement of clinical and laboratory determinants [7] of this scoring system and, importantly, limited ability to predict short-term mortality. Several other scoring systems have been described that attempt to evaluate prognosis of patients with cirrhosis of liver (Table 1) [8][9][10][11][12][13][14][15][16][17][18][19]. However, none of these are applied widely in clinical practice because of their limited predictive ability and unacceptable complexity.…”