Spleen stiffness: a predictive factor of dismal prognosis in liver cirrhosis

Standard technique in Japan for measuring hepatic venous pressure gradient

BACKGROUND

Direct measurement of portal venous pressure (PVP) is invasive, so the hepatic venous pressure gradient (HVPG) is commonly measured to evaluate portal hypertension (PH). HVPG is the gold standard for estimating PVP but few reports have covered standardized measurement techniques.

METHODS

This study validated standardized techniques for PVP measurement.

RESULTS

In Western countries, electronic transducers are commonly used to measure PVP, whereas the water column method is still frequently applied in Japan. Setting a reference point for accurate PVP measurement is important but complicated. According to Japanese guidelines, the reference point for PVP measurement is 10 cm above the dorsal surface or in the midaxillary line. For simpler determination, the anterior axillary point, defined as the point of convergence between the proximal pectoralis major muscle and arm when both arms are positioned against the trunk in a supine position, can be used as the reference point. New methods, such as endoscopic ultrasound-guided portal pressure gradient, offer less invasive alternatives. Non-invasive methods like elastography measure liver and spleen stiffness, which correlate with HVPG. The Baveno VII criteria incorporate measurements of liver and splenic stiffness for risk stratification. Biomarkers such as type IV collagen, M2BPGi, and FIB-4 score also predict HVPG. The Baveno VII consensus emphasizes the status of HVPG as the gold standard while advocating for non-invasive alternative methods to improve patient care and monitor treatment efficacy.

CONCLUSIONS

Continued development of non-invasive tests is crucial for safer, more convenient PH management.

Evaluation of spleen stiffness by 2D shear wave elastography for ruling out high risk varices in patients with chronic advanced liver disease. A systematic review and meta-analysis

OBJECTIVES

To systematically review the accuracy of spleen stiffness measurement (SSM) by 2D- Shear Wave Elastography (2D-SWE) in predicting high risk for bleeding varices (HRV) in cirrhotic patients.

METHODS

PubMed, Embase, Web of Science, Medline, Cochrane, and Google Scholar databases were searched up to 31/05/2023 for all human studies using 2D-SWE to estimate SSM and endoscopy to detect HRV. Meta-analysis was performed using a generalized linear mixed model. Publication bias was evaluated using the funnel plot asymmetry test. The Area Under the Summarized Receiver Operating Characteristic curve (AUSROC) was estimated using the "mada" package.

RESULTS

A total of 13 studies and 1970 patients were included. Of them, 27.8 % had HRV. The pooled sensitivity and polled specificity of SSM in detecting HRV were 90 % (95 %CI:87-92 %) and 68 % (95 %CI:58-77 %), respectively, with an AUSROC at 0.86 (95 %CI:0.82-0.90). The median cutoff value of SSM in detecting HRV was 34.2 kPa. In studies including exclusively HBV cirrhotic patients, SSM's polled sensitivity and specificity in predicting HRV was 88 % (95 %CI:82-92 %) and 73 % (95 %CI:68-78 %), respectively. The AUSROC was 0.84 (95 %CI:0.81-0.87). The number of repeated measurements per patient (<5 or ≥ 5) did not affect the method's capability. Using Aixplorer to evaluate SSM had a higher sensitivity in ruling out HRV than other 2D-SWE devices.

CONCLUSIONS

Our meta-analysis supports that SSM by 2D-SWE has a good diagnostic performance for ruling out HRV in cirrhosis.

Role of Spleen Stiffness Measurement in the Evaluation of Metabolic Dysfunction-Associated Steatotic Liver Disease

BACKGROUND

Spleen stiffness measurement (SSM) correlates with the severity of portal hypertension.

AIMS

We investigated the utility of SSM in individuals with metabolic dysfunction-associated steatotic liver disease (MASLD) for detecting cirrhosis, esophageal varices (EV), and high-risk EV.

METHODS

154 study participants with MASLD underwent simultaneous liver stiffness measurement (LSM) and SSM. 96 (62%) participants had an upper endoscopy (73 participants, i.e., 47% undergoing within a year). The diagnostic performance of SSM, as well as the BAVENO VII proposed SSM cutoffs (≥ 21 kPa, > 40 kPa, and > 50 kPa), was examined.

RESULTS

The failure rate for SSM was 19% compared to 5% for LSM. An invalid SSM was statistically significantly associated with a higher body mass index, a larger waist circumference, and a lower fibrosis stage. The area under the receiver operating characteristics for SSM to diagnose cirrhosis, EV, and high-risk EV was 0.78 (95% CI 0.70-0.85), 0.74 (95% CI 0.61-0.84), and 0.82 (95% CI 0.75-0.98), respectively. SSM ≥ 21 kPa cutoff had a sensitivity > 96% for all three outcomes, with a positive predictive value (PPV) of 88% for cirrhosis. In contrast, SSM > 40 kPa and SSM > 50 kPa cutoffs had better diagnostic abilities for identifying EV, particularly high-risk EV (sensitivity of 100% and 93% with NPV of 100% and 96%, respectively).

CONCLUSION

SSM has a higher failure rate in individuals who are non-cirrhotic or have a higher BMI, or larger waist circumference. Although useful for diagnosing NASH cirrhosis, SSM is most reliable in excluding EV and high-risk EV.

B-Blockers in Liver Cirrhosis: A Wonder Drug for Every Stage of Portal Hypertension? A Narrative Review

In cirrhotic patients, non-selective b-blockers (NSBBs) constitute the reference treatment of choice as monotherapy or combined with band ligation for the prevention of first variceal bleeding and rebleeding, respectively. Furthermore, the last Baveno VII guidelines recommended carvedilol, a b-blocker with additional anti-a1 receptor activity, in all compensated cirrhotics with clinically significant portal hypertension, to prevent liver decompensation. Interestingly enough, NSBBs have been reported to have a potentially positive impact on the short-term mortality of patients with acute-on-chronic liver failure. However, concerns remain about the use of b-blockers in the presence of severe complications, such as refractory ascites, hepatorenal syndrome, spontaneous bacterial peritonitis, or established cirrhotic cardiomyopathy. In addition, it has not been verified yet whether carvedilol supersedes all the other NSBBs in every stage of liver disease, even when severe complications have developed. Therefore, this review aims to illustrate recent data regarding the potential role of b-blockers across all stages of liver disease, beyond the primary and secondary prophylaxis of variceal bleeding, and address the authors' proposals on the use of NSBBs concerning the severity of liver disease and the patient's performance status.