1
|
Rodrigues SG, Delgado MG, Stirnimann G, Berzigotti A, Bosch J. Hepatic Venous Pressure Gradient: Measurement and Pitfalls. Clin Liver Dis 2024; 28:383-400. [PMID: 38945633 DOI: 10.1016/j.cld.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Measurement of hepatic venous pressure gradient (HVPG) effectively mirrors the severity of portal hypertension (PH) and offers valuable insights into prognosis of liver disease, including the risk of decompensation and mortality. Additionally, HVPG offers crucial information about treatment response to nonselective beta-blockers and other medications, with its utility demonstrated in clinical trials in patients with PH. Despite the widespread dissemination and validation of noninvasive tests, HVPG still holds a significant role in hepatology. Physicians treating patients with liver diseases should comprehend the HVPG measurement procedure, its applications, and how to interpret the results and potential pitfalls.
Collapse
Affiliation(s)
- Susana G Rodrigues
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, MEM, Murtenstrasse 35 Office F807, Bern 3008, Switzerland
| | - Maria Gabriela Delgado
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, MEM, Murtenstrasse 35 Office F808, Bern 3008, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern 3010, Switzerland
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Freiburgstrasse 10, Bern 3010, Switzerland
| | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, MEM, Murtenstrasse 35 Office F805, Bern 3008, Switzerland; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Barcelona, Spain.
| |
Collapse
|
2
|
Yu JA, Yang SW, Wang Y, Li J, Su TH, Chang J, Chen G. The Balloon Catheter Method and the End-hole Catheter Method in the Measurement of Hepatic Venous Pressure Gradient: a Comparative Study. Cardiovasc Intervent Radiol 2024:10.1007/s00270-024-03814-w. [PMID: 39060793 DOI: 10.1007/s00270-024-03814-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/13/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE This study aims to evaluate the differences between The balloon catheter method and End-hole Catheter Method in measuring hepatic venous pressure gradient (HVPG) among cirrhosis patients. METHODS From October 2017 to January 2024, patients who underwent HVPG measurements using both methods were consecutively included. HVPGs obtained from both methods were compared with the portal vein pressure gradient (PPG) obtained via transjugular intrahepatic portosystemic shunt (TIPS) using paired comparisons. Additionally, the consistency and predictive ability for bleeding risk of the two methods, as well as the impact of intrahepatic veno-venous shunt (IHVS), were analyzed. RESULTS The study enrolled 145 patients, each of whom had HVPG measured by both methods. PPG was measured in 61 patients. There was a statistically significant difference between the PPGs and HVPGs measured by both the balloon catheter method and the end-hole catheter method (P < 0.001), with the HVPG mean values obtained by the end-hole catheter method being closer to the PPGs. In the non-IHVS group, no significant statistical difference was found between the two methods (P = 0.071). In contrast, the IHVS group showed a significant difference (P < 0.001), with a mean difference of 2.98 ± 4.03 mmHg. When IHVS was absent, the measurement results from the end-hole catheter method and the balloon catheter method were found to be highly correlated. The end-hole catheter method has a higher screening capability for patients at risk of bleeding compared to the balloon catheter method (75.90% vs. 72.86%). CONCLUSION HVPG measurements using either the balloon catheter method or end-hole catheter method showed significant difference with the PPG. The end-hole catheter method has a higher screening capability for patients at risk of bleeding, and IHVS could lead to lower HVPG measurements with The balloon catheter method.
Collapse
Affiliation(s)
- Jian-An Yu
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Si-Wei Yang
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Yu Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Jian Li
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Tian-Hao Su
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Jiang Chang
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Guang Chen
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
| |
Collapse
|
3
|
Pericàs JM, Anstee QM, Augustin S, Bataller R, Berzigotti A, Ciudin A, Francque S, Abraldes JG, Hernández-Gea V, Pons M, Reiberger T, Rowe IA, Rydqvist P, Schabel E, Tacke F, Tsochatzis EA, Genescà J. A roadmap for clinical trials in MASH-related compensated cirrhosis. Nat Rev Gastroenterol Hepatol 2024:10.1038/s41575-024-00955-8. [PMID: 39020089 DOI: 10.1038/s41575-024-00955-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/19/2024]
Abstract
Although metabolic dysfunction-associated steatohepatitis (MASH) is rapidly becoming a leading cause of cirrhosis worldwide, therapeutic options are limited and the number of clinical trials in MASH-related compensated cirrhosis is low as compared to those conducted in earlier disease stages. Moreover, designing clinical trials in MASH cirrhosis presents a series of challenges regarding the understanding and conceptualization of the natural history, regulatory considerations, inclusion criteria, recruitment, end points and trial duration, among others. The first international workshop on the state of the art and future direction of clinical trials in MASH-related compensated cirrhosis was held in April 2023 at Vall d'Hebron University Hospital in Barcelona (Spain) and was attended by a group of international experts on clinical trials from academia, regulatory agencies and industry, encompassing expertise in MASH, cirrhosis, portal hypertension, and regulatory affairs. The presented Roadmap summarizes important content of the workshop on current status, regulatory requirements and end points in MASH-related compensated cirrhosis clinical trials, exploring alternative study designs and highlighting the challenges that should be considered for upcoming studies on MASH cirrhosis.
Collapse
Affiliation(s)
- Juan M Pericàs
- Liver Unit, Division of Digestive Diseases, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Centros de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
| | - Quentin M Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle NIHR Biomedical Research Center, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | | | - Ramón Bataller
- Liver Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat Barcelona, Barcelona, Spain
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreea Ciudin
- Endocrinology and Nutrition Department, Morbid Obesity Unit Coordinator, Vall d'Hebron University Hospital, Barcelona, Spain
- Centros de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas asociadas (CIBERdem), Instituto de Salud Carlos III, Madrid, Spain
| | - Sven Francque
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, InflaMed Centre of Excellence, Laboratory for Experimental Medicine and Paediatrics, Translational Sciences in Inflammation and Immunology, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
| | - Virginia Hernández-Gea
- Centros de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat Barcelona, Barcelona, Spain
| | - Mònica Pons
- Liver Unit, Division of Digestive Diseases, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Peter Rydqvist
- Medical Department, Madrigal Pharmaceuticals, West Conshohocken, PA, USA
| | - Elmer Schabel
- Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Joan Genescà
- Liver Unit, Division of Digestive Diseases, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centros de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
4
|
Busch F, De Paepe KN, Gibbs P, Allison M, Hoare M, See TC. The clinical value of the hepatic venous pressure gradient in patients undergoing hepatic resection for hepatocellular carcinoma with or without liver cirrhosis. Open Med (Wars) 2024; 19:20230851. [PMID: 38584825 PMCID: PMC10996929 DOI: 10.1515/med-2023-0851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/03/2023] [Accepted: 10/27/2023] [Indexed: 04/09/2024] Open
Abstract
The role of hepatic venous pressure gradient (HVPG) measurement in risk stratification before liver resection is an ongoing area of debate. This study examines the impact of preoperative HVPG levels on overall survival (OS)/time to recurrence (TTR) and postoperative complications after hepatic resection of hepatocellular carcinoma (HCC). Thirty-eight HCC patients undergoing HVPG measurement before liver resection at Cambridge University Hospitals NHS Foundation Trust between January 2014 and April 2022 were retrospectively analysed. Statistical analysis comprised univariable/multivariable Cox/logistic regression to identify risk factors of reduced OS/TTR or 90-day post-resection complications and Kaplan-Meier estimator, log-rank, chi-squared, Fisher's exact, and Mann-Whitney U test, or Student's t-test for survival/subgroup analysis. The median HPVG was 6 (range: 0-14) mmHg. The HVPG was an independent risk factor for poorer TTR in the overall cohort (cut-off: ≥7.5 mmHg (17.18/43.81 months; P = 0.009)). In the subgroup analysis of cirrhotic patients (N = 29 (76%)), HVPG was additionally an independent risk factor for lower OS (cut-off: ≥8.5 mmHg [44.39/76.84 months; P = 0.012]). The HVPG had no impact on OS/TTR in non-cirrhotic patients (N = 9 (24%)), nor was it associated with postoperative complications in any cohort. In conclusion, preoperative HVPG levels are useful predictors for TTR and OS in cirrhotic HCC patients undergoing hepatic resection.
Collapse
Affiliation(s)
- Felix Busch
- Department of Radiology, Charité – Universitätsmedizin Berlin, Hindenburgdamm 30, Berlin, 12203, Germany
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
| | - Katja N. De Paepe
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
| | - Paul Gibbs
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
| | - Michael Allison
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
| | - Matthew Hoare
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
- Early Cancer Institute, University of Cambridge, Hutchison Research Institute, Cambridge, CB2 0XZ, United Kingdom
| | - Teik Choon See
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
| |
Collapse
|
5
|
Alsaeid M, Sung S, Bai W, Tam M, Wong YJ, Cortes J, Cobo E, Gonzalez JA, Abraldes JG. Heterogeneity of treatment response to beta-blockers in the treatment of portal hypertension: A systematic review. Hepatol Commun 2024; 8:e0321. [PMID: 38285880 PMCID: PMC10830085 DOI: 10.1097/hc9.0000000000000321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/28/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND It has been suggested that a relevant proportion of patients do not respond to nonselective beta-blockers (NSBB)s, which raises questions regarding the need for individualized therapy. The existence of potential heterogeneity in the treatment response can be assessed using the variability ratio (VR) of the outcome measurement (in this case, HVPG) between the treated and placebo groups. We conducted a systematic review and meta-analysis of randomized controlled trials to assess the potential heterogeneity in the portal pressure response to NSBBs. METHODS After a systematic search, we quantified the heterogeneity of treatment response with the VR between the treatment and control groups, with VR > 1 indicating potential heterogeneity. We used a similar approach to compare carvedilol with propranolol and statins with placebo. RESULTS We identified 18 studies that included 965 patients. A comparison between beta-blockers and placebo showed a pooled VR of 0.99 (95% CI:0.87-1.14), which suggests a homogeneous HVPG response to NSBB at the individual patient level (ie, no evidence to support that some patients responded to beta-blockers and others did not). For the comparison between carvedilol and propranolol, pooled VR was 0.97 (95% CI 0.82-1.14), suggesting that carvedilol achieves a greater average response (rather than an increase in the proportion of responders). There was no evidence of a heterogeneous response to statins. CONCLUSION Our analysis did not support the existence of a heterogeneous patient-by-patient response to NSBBs in cirrhosis. These findings challenge the concept of personalized therapy based on portal pressure response and indicate that routine portal pressure measurement may not be necessary to guide NSBB therapy.
Collapse
Affiliation(s)
- Mohammad Alsaeid
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Shuen Sung
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Wayne Bai
- Waikato District Health Board, University of Auckland, Auckland, New Zealand
| | - Matthew Tam
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Yu Jun Wong
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Jordi Cortes
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya, Barcelona-Tech (UPC), Barcelona-Tech, Spain
| | - Erik Cobo
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya, Barcelona-Tech (UPC), Barcelona-Tech, Spain
| | - Jose Antonio Gonzalez
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya, Barcelona-Tech (UPC), Barcelona-Tech, Spain
| | - Juan G. Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| |
Collapse
|
6
|
Liu Y, Wu S, Cai S, Xie B. The prognostic evaluation of ALBI score in endoscopic treatment of esophagogastric varices hemorrhage in liver cirrhosis. Sci Rep 2024; 14:780. [PMID: 38191888 PMCID: PMC10774391 DOI: 10.1038/s41598-023-50629-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/22/2023] [Indexed: 01/10/2024] Open
Abstract
To analyze the independent risk factors for recurrent bleeding and death within 1 year after endoscopic treatment of esophagogastric varices hemorrhage (EGVB) in patients with liver cirrhosis, and to validate the predictive value of ALBI score for recurrent bleeding and death within 1 year after endoscopic treatment of EGVB in patients with liver cirrhosis. A total of 338 patients with EGVB who received endoscopic treatment for the first time in the Department of Gastroenterology, First Affiliated Hospital of Nanchang University from January 1, 2016 to March 1, 2020 were selected. A database was established to analyze the patients' demographic data, surgical variables and postoperative outcomes. All patients were contacted and followed up to verify the predictive value of ALBI score for recurrent bleeding and mortality. 130 patients had rebleeding within 1 year after surgery (38.5%). 66 patients died within 1 year after surgery (19.5%). Patients with ALBI grade 3 had significantly higher rebleeding and mortality rates than those with grades 1 and 2. The AUC was used to compare the predictive value of the four scores for rebleeding and mortality within one year after endoscopic surgery. Both ALBI scores had the largest AUC. The ALBI score has certain predictive value for rebleeding and mortality within 1 year after endoscopic therapy in patients with cirrhotic EGVB.
Collapse
Affiliation(s)
- Yuhua Liu
- The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yongwai Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Shengnan Wu
- The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yongwai Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Shanshan Cai
- The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yongwai Street, Nanchang, 330006, Jiangxi, People's Republic of China.
- Department of Gastroenterology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yongwaizheng Street, Donghu District, Nanchang, 330006, Jiangxi, People's Republic of China.
| | - Bushan Xie
- The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yongwai Street, Nanchang, 330006, Jiangxi, People's Republic of China.
- Department of Gastroenterology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yongwaizheng Street, Donghu District, Nanchang, 330006, Jiangxi, People's Republic of China.
| |
Collapse
|
7
|
Xia Y, Tie J, Wang G, Zhuge Y, Wu H, Xue H, Xu J, Zhang F, Zhao L, Huang G, Zhang M, Wei B, Li P, Wu W, Chen C, Tang C, Zhang C. Individualized portal pressure gradient threshold based on liver function categories in preventing rebleeding after TIPS. Hepatol Int 2023; 17:967-978. [PMID: 36807252 PMCID: PMC10386972 DOI: 10.1007/s12072-023-10489-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/16/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND The evidence in Portal pressure gradient (PPG) < 12 mmHg after transjugular intrahepatic portosystemic shunt (TIPS) for preventing rebleeding mostly comes from observations in uncovered stents era. Moreover, association between Child-Pugh classes and post-TIPS hepatic encephalopathy (HE) has indicated that tolerance of PPG reduction depends on liver function. This study aimed to investigate the optimal PPG for covered TIPS and explore the optimal threshold tailored to the Child-Pugh classes to find individualized PPG to balance rebleeding and overt HE. METHODS This multicenter retrospective study analyzed rebleeding, OHE, and mortality of patients associated with post-TIPS PPGs (8, 10, 12, and 14 mmHg) in the entire cohort and among different Child-Pugh classes. Propensity score matching (PSM) and competing risk analyses were performed for sensitivity analyses. RESULTS We included 2100 consecutively screened patients undergoing TIPS. In all patients, PPG < 12 mmHg reduced rebleeding after TIPS (p = 0.022). In Child-Pugh class A, none of the PPG thresholds were discriminative of clinical outcomes. In Child-Pugh class B, 12 mmHg (p = 0.022) and 14 mmHg (p = 0.037) discriminated rebleeding, but 12 mmHg showed a higher net benefit. In Child-Pugh class C, PPG < 14 mmHg had a lower rebleeding incidence (p = 0.017), and exhibited more net benefit than 12 mmHg. CONCLUSION Different PPG standards may be required for patients with different liver function categories. A PPG threshold < 12 mmHg might be suitable for patients in Child-Pugh class B, while < 14 mmHg might be optimal for patients in Child-Pugh class C.
Collapse
Affiliation(s)
- Yifu Xia
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Jun Tie
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Medical University, Xi'an, Shaanxi, China
| | - Guangchuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Department of Biostatistics, School of Public Health, Shandong University, Jinan, Shandong, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Hao Wu
- Department of Gastroenterology and Hepatology, West China Hospital, Chengdu, Sichuan, China
| | - Hui Xue
- Gastroenterology of the First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China
| | - Jiao Xu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Air Force Medical University, Xi'an, Shaanxi, China
| | - Feng Zhang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Lianhui Zhao
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Guangjun Huang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Mingyan Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Bo Wei
- Department of Gastroenterology and Hepatology, West China Hospital, Chengdu, Sichuan, China
| | - Peijie Li
- Gastroenterology of the First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi, China
| | - Wei Wu
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Chao Chen
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Chengwei Tang
- Department of Gastroenterology and Hepatology, West China Hospital, Chengdu, Sichuan, China.
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China.
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
| |
Collapse
|
8
|
Ferral H, Schepis F, Gaba RC, Garcia-Tsao G, Zanetto A, Perez-Campuzano V, Haskal ZJ, Garcia-Pagan JC. Endovascular Assessment of Liver Hemodynamics in Patients with Cirrhosis Complicated by Portal Hypertension. J Vasc Interv Radiol 2023; 34:327-336. [PMID: 36516940 DOI: 10.1016/j.jvir.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/02/2022] [Accepted: 12/04/2022] [Indexed: 12/14/2022] Open
Abstract
The hepatic venous pressure gradient (HVPG) is currently considered the gold standard to assess portal hypertension (PH) in patients with cirrhosis. A meticulous technique is important to achieve accurate and reproducible results, and values obtained during measurement are applied in risk stratification of patients with PH, allocating treatment options, monitoring follow-up, and deciding management options in surgical patients. The use of portosystemic pressure gradients in patients undergoing placement of transjugular intrahepatic portosystemic shunts has been studied extensively and has great influence on decisions on shunt diameter. The purpose of this study was to describe the recommended technique to measure HVPG and portosystemic pressure gradient and to review the existing literature describing the importance of these hemodynamic measurements in clinical practice.
Collapse
Affiliation(s)
- Hector Ferral
- Section of Interventional Radiology, Department of Radiology, Louisiana State University, New Orleans, Louisiana
| | - Filippo Schepis
- Hepatic Hemodynamic Laboratory, Division of Gastroenterology, AOU of Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Ron C Gaba
- Division of Interventional Radiology, Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Guadalupe Garcia-Tsao
- Digestive Disease Section, Internal Medicine, Yale School of Medicine, New Haven, Connecticut; VA-Connecticut Healthcare System, West Haven, Connecticut
| | - Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Italy
| | - Valeria Perez-Campuzano
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders, Hamburg, Germany
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders, Hamburg, Germany.
| |
Collapse
|
9
|
Gupta AN, Sze DY, Rigas DA. Smaller Diameter and Adjustable Diameter Transjugular Intrahepatic Portosystemic Shunts. Semin Intervent Radiol 2023; 40:21-26. [PMID: 37152799 PMCID: PMC10159728 DOI: 10.1055/s-0043-1764285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Complications of overshunting, including hepatic encephalopathy and hepatic insufficiency, remain prevalent following transjugular intrahepatic portosystemic shunt (TIPS) creation. Smaller diameter TIPS may reduce the risk of overshunting, but the use of smaller stents must be weighed against the risk of undershunting and persistent or recurrent hemorrhage, ascites, and other complications of portal hypertension. This article explores the question of optimal shunt diameter by examining outcomes for smaller diameter TIPS stent-grafts (<10 mm), underdilated stent-grafts, and variable diameter stent-grafts.
Collapse
Affiliation(s)
- Aakash N. Gupta
- Division of Interventional Radiology, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Daniel Y. Sze
- Division of Interventional Radiology, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Diamanto Amanda Rigas
- Division of Interventional Radiology, Department of Radiology, Stanford University School of Medicine, Stanford, California
- Division of Interventional Radiology, Department of Radiology, Veteran Administration Palo Alto Health Care System, Palo Alto, California
| |
Collapse
|
10
|
Lee S, Saffo S. Evolution of care in cirrhosis: Preventing hepatic decompensation through pharmacotherapy. World J Gastroenterol 2023; 29:61-74. [PMID: 36683719 PMCID: PMC9850948 DOI: 10.3748/wjg.v29.i1.61] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/22/2022] [Accepted: 12/14/2022] [Indexed: 01/04/2023] Open
Abstract
Cirrhosis is a leading cause of morbidity and mortality, impacting more than 120 million people worldwide. Although geographic differences exist, etiologic factors such as alcohol use disorder, chronic viral hepatitis infections, and non-alcoholic fatty liver disease are prevalent in nearly every region. Historically, significant effort has been devoted to modifying these risks to prevent disease progression. Nevertheless, more than 11% of patients with compensated cirrhosis experience hepatic decompensation each year. This transition signifies the most important prognostic factor in the natural history of the disease, corresponding to a decline in median survival to below 2 years. Over the past decade, the need for pharmacotherapies aimed at reducing the risk for hepatic decompensation has been emphasized, and non-selective beta-blockers have emerged as the most effective option to date. However, a critical therapeutic gap still exists, and additional therapies have been proposed, including statins, rifaximin, and sodium-glucose cotransporter-2 inhibitors. Based on the results of innovative retrospective analyses and small-scale prospective trials, these pharmacotherapies represent promising options, but further studies, including randomized controlled trials, are necessary before they can be incorporated into clinical use. This report highlights the potential impact of these agents and others in preventing hepatic decompensation and discusses how this paradigm shift may pave the way for guideline-directed medical therapy in cirrhosis.
Collapse
Affiliation(s)
- Seohyuk Lee
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520-8019, United States
| | - Saad Saffo
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520-8019, United States
| |
Collapse
|
11
|
Chooklin S, Chuklin S. Comprehensive treatment of patients with gastric variceal bleeding. EMERGENCY MEDICINE 2022; 18:14-21. [DOI: 10.22141/2224-0586.18.8.2022.1539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Bleeding from gastric varices is usually severe and is associated with higher mortality and a higher risk of rebleeding than from esophageal varices. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiological interventions. In terms of treatment, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires prompt intervention to stop it and achieve long-term hemostasis. This review describes the features of pharmacological, endoscopic and interventional radiological prophylactic and treatment options in gastric variceal bleeding. We searched the literature in the MedLine database on the PubMed platform.
Collapse
|
12
|
Romero-Cristóbal M, Clemente-Sánchez A, Ramón E, Téllez L, Canales E, Ortega-Lobete O, Velilla-Aparicio E, Catalina MV, Ibáñez-Samaniego L, Alonso S, Colón A, Matilla AM, Salcedo M, Albillos A, Bañares R, Rincón D. CT-derived liver and spleen volume accurately diagnose clinically significant portal hypertension in patients with hepatocellular carcinoma. JHEP Rep 2022; 5:100645. [PMID: 36691569 PMCID: PMC9860348 DOI: 10.1016/j.jhepr.2022.100645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/12/2022] [Indexed: 12/05/2022] Open
Abstract
Background & Aims Clinically significant portal hypertension (CSPH) is a landmark in the natural history of cirrhosis, influencing clinical decisions in patients with hepatocellular carcinoma (HCC). Previous small series suggested that splanchnic volume measurements may predict portal hypertension. We aimed to evaluate whether volumetry obtained by standard multidetector computerised tomography (MDCT) can predict CSPH in patients with HCC. Methods We included 175 patients with HCC, referred for hepatic venous pressure gradient (HVPG) evaluation, in whom contemporary MDCT was available. Liver volume, spleen volume (SV) and liver segmental volume ratio (LSVR: volume of the segments I-III/volume of the segments IV-VIII) were calculated semi-automatically from MDCT. Other non-invasive tests (NITs) were also employed. Results Volume parameters could be measured in almost 100% of cases with an excellent inter-observer agreement (intraclass correlation coefficient >0.950). SV and LSVR were independently associated with CSPH (HVPG ≥10 mmHg) and did not interact with aetiology. The volume Index (VI), calculated as the product of SV and LSVR, predicted CSPH (AUC 0.83; 95% CI 0.77-0.89). Similar results were observed in an external cohort (n = 23) (AUC 0.87; 95% CI 0.69-1.00). Setting a sensitivity and specificity of 98%, VI could have avoided 35.9% of HVPG measurements. The accuracy of VI was similar to that of other NITs. VI also accurately predicted HVPG greater than 12, 14, 16 and 18 mmHg (AUC 0.81 [95% CI 0.74-0.88], 0.84 [95% CI 0.77-0.91], 0.85 [95% CI 0.77-0.92] and 0.87 [95% CI 0.79-0.94], respectively). Conclusions Quantification of liver and spleen volumes by MDCT is a simple, accurate and reliable method of CSPH estimation in patients with compensated cirrhosis and HCC. Impact and implications An increase in portal pressure strongly impacts outcomes after surgery in patients with early hepatocellular carcinoma (HCC). Direct measurement through hepatic vein catheterization remains the reference standard for portal pressure assessment, but its invasiveness limits its application. Therefore, we evaluated the ability of CT scan-based liver and spleen volume measurements to predict portal hypertension in patients with HCC. Our results indicate that the newly described index, based on quantification of liver and spleen volume, accurately predicts portal hypertension. These results suggest that a single imaging test may be used to diagnose and stage HCC, while providing an accurate estimation of portal hypertension, thus helping to stratify surgical risks.
Collapse
Key Words
- CSPH, clinically significant portal hypertension
- DAAs, direct-acting antivirals agents
- HCC, hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- LSPS, liver stiffness-spleen size-to-platelet ratio score
- LSVR, liver segmental volume
- LV, liver volume
- LV/SV, liver/spleen volume ratio
- MAFLD, metabolic dysfunction-associated fatty liver disease
- MDCT, multidetector computerised tomography
- NITs, non-invasive tests
- PSR, platelet count to spleen diameter ratio
- SV, spleen volume
- TE, transient elastography
- VI, volume index
- cirrhosis
- cross-sectional imaging
- hepatocellular carcinoma
- non-invasive test
- organ size
- portal hypertension
- predictive model
Collapse
Affiliation(s)
| | - Ana Clemente-Sánchez
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Enrique Ramón
- Department of Radiology, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Luis Téllez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Elena Canales
- Department of Radiology, H. U. Ramón y Cajal, Madrid, Spain
| | - Olga Ortega-Lobete
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
| | | | - María-Vega Catalina
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Ibáñez-Samaniego
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Sonia Alonso
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Arturo Colón
- Liver Transplant and Hepatobiliary Surgery Unit, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Ana-María Matilla
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Magdalena Salcedo
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
| | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Rafael Bañares
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
- Corresponding author. Address: Liver Unit, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, Madrid, 28007, Spain..
| | - Diego Rincón
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
| |
Collapse
|
13
|
Kristensen H, Kimer N, Møller S. Indications and methods for measuring portal hypertension in cirrhosis. Scand J Gastroenterol 2022; 57:1149-1157. [PMID: 35514215 DOI: 10.1080/00365521.2022.2065889] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background and objectives: Over the last decade our understanding of the pathophysiology of portal hypertension has increased. Novel diagnostic technologies have facilitated and improved the diagnosis and treatment of hepatic fibrosis and cirrhosis. With this review we aim to provide an overview of contemporary diagnostic principles of portal hypertension and indications for measuring portal pressure in cirrhosis.Methods: By review of current literature, we assessed new and old principles of measuring portal hypertension and the diagnostic values of the methods.Results: Invasive measurement of the portal pressure is still the gold standard to quantitate portal hypertension and to assess response to vasoactive treatment. The size of the portal pressure is important to assess since it contains information on the course of the disease and risk of developing hepatic decompensation, hepatocellular carcinoma, and mortality. Reliable non-invasive Elastography techniques are emerging that adequately assess portal pressure, but the available methods are not yet sufficiently accurate.Conclusion: Although elastography techniques provide valuable information and are good monitoring tools, liver vein catheterization remains valuable in diagnosing and monitoring portal hypertension, especially in combination with a trans-jugular liver biopsy.
Collapse
Affiliation(s)
- Helle Kristensen
- Gastro Unit, Medical Division, University Hospital Hvidovre, Hvidovre, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, University Hospital Hvidovre, Hvidovre, Denmark
| | - Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Center of Functional Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark.,Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW This article discusses the most recent studies regarding the emerging field of endohepatology - the use of diagnostic and therapeutic endoscopic tools for the management of patients with liver disease and portal hypertension. RECENT FINDINGS New research has shown that liver biopsy specimens obtained by each Endoscopic ultrasound (EUS)-guidance, the percutaneous approach, and the transjugular approach contained sufficient portal triads to adequately analyzed by experienced pathologists - suggesting that any of these routes of liver biopsy is clinically acceptable; further, all had similar rates of adverse events. An initial prospective study showed that EUS guided portal pressure measurement was safe, effective, and accurate. A recent metanalysis showed that EUS-guided cyanoacrylate injection and coil embolization was statistically more efficacious and with less complications than EUS guided cyanoacrylate injection and EUS guided coil injection alone, suggesting that combination therapy appears to be the preferred approach for gastric varices (GV) bleeding. A prospective study evaluating focal liver lesions showed that the use of artificial intelligence had up to 100% sensitivity and 81% specificity for identifying malignant focal liver lesions. SUMMARY EUS guided liver biopsy is safe and enables accurate diagnosis of underlying liver disease. EUS guided portal pressure measurement is also safe and is accurate. Combination therapy of EUS guided cyanoacrylate injection and coil embolization is more efficacious and has less complications than injection or coil therapy alone when used for GV bleeding. Artificial intelligence is highly sensitive and specific when used in conjunction with EUS in the diagnosis of malignant focal liver lesions. Endohepatology is a rapidly expanding field with great potential.
Collapse
Affiliation(s)
- Jerome C Edelson
- Department of Gastroenterology and Hepatology
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Natalie E Mitchell
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
15
|
Téllez L, Albillos A. Non-selective beta-blockers in patients with ascites: The complex interplay among the liver, kidney and heart. Liver Int 2022; 42:749-761. [PMID: 35051310 DOI: 10.1111/liv.15166] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/31/2021] [Accepted: 01/09/2022] [Indexed: 12/12/2022]
Abstract
Non-selective beta-blockers (NSBBs) are the cornerstone of the primary and secondary prophylaxis of variceal bleeding in cirrhotic patients. They additionally prevent ascites development and death in compensated patients with clinically significant portal hypertension. After ascites onset, NSBBs remain beneficial for preventing further decompensations. However, as the cirrhosis progresses, the inflammation increases, systemic vasodilatation worsens, ascites turns refractory and cardiodynamic equilibrium becomes extremely fragile. In this scenario, NSBBs can critically impair the cardiac reserve and facilitate a haemodynamic breakdown, imperilling renal perfusion. Consequently, NSBB treatment should be carefully monitored or even avoided in such patients, and other options for portal hypertension management should be considered. In the present review, we explore the effects of NSBBs in patients with ascites and discuss the complex interplay among their hepatic, systemic and renal haemodynamic effects in this scenario.
Collapse
Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| |
Collapse
|
16
|
Choi AY, Chang KJ. Endoscopic Diagnosis of Portal Hypertension. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2022; 24:167-175. [DOI: 10.1016/j.tige.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
|
17
|
Bosch J, Chung C, Carrasco-Zevallos OM, Harrison SA, Abdelmalek MF, Shiffman ML, Rockey DC, Shanis Z, Juyal D, Pokkalla H, Le QH, Resnick M, Montalto M, Beck AH, Wapinski I, Han L, Jia C, Goodman Z, Afdhal N, Myers RP, Sanyal AJ. A Machine Learning Approach to Liver Histological Evaluation Predicts Clinically Significant Portal Hypertension in NASH Cirrhosis. Hepatology 2021; 74:3146-3160. [PMID: 34333790 DOI: 10.1002/hep.32087] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/23/2021] [Accepted: 06/28/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS The hepatic venous pressure gradient (HVPG) is the standard for estimating portal pressure but requires expertise for interpretation. We hypothesized that HVPG could be extrapolated from liver histology using a machine learning (ML) algorithm. APPROACH AND RESULTS Patients with NASH with compensated cirrhosis from a phase 2b trial were included. HVPG and biopsies from baseline and weeks 48 and 96 were reviewed centrally, and biopsies evaluated with a convolutional neural network (PathAI, Boston, MA). Using trichrome-stained biopsies in the training set (n = 130), an ML model was developed to recognize fibrosis patterns associated with HVPG, and the resultant ML HVPG score was validated in a held-out test set (n = 88). Associations between the ML HVPG score with measured HVPG and liver-related events, and performance of the ML HVPG score for clinically significant portal hypertension (CSPH) (HVPG ≥ 10 mm Hg), were determined. The ML-HVPG score was more strongly correlated with HVPG than hepatic collagen by morphometry (ρ = 0.47 vs. ρ = 0.28; P < 0.001). The ML HVPG score differentiated patients with normal (0-5 mm Hg) and elevated (5.5-9.5 mm Hg) HVPG and CSPH (median: 1.51 vs. 1.93 vs. 2.60; all P < 0.05). The areas under receiver operating characteristic curve (AUROCs) (95% CI) of the ML-HVPG score for CSPH were 0.85 (0.80, 0.90) and 0.76 (0.68, 0.85) in the training and test sets, respectively. Discrimination of the ML-HVPG score for CSPH improved with the addition of a ML parameter for nodularity, Enhanced Liver Fibrosis, platelets, aspartate aminotransferase (AST), and bilirubin (AUROC in test set: 0.85; 95% CI: 0.78, 0.92). Although baseline ML-HVPG score was not prognostic, changes were predictive of clinical events (HR: 2.13; 95% CI: 1.26, 3.59) and associated with hemodynamic response and fibrosis improvement. CONCLUSIONS An ML model based on trichrome-stained liver biopsy slides can predict CSPH in patients with NASH with cirrhosis.
Collapse
Affiliation(s)
- Jaime Bosch
- Department of Biomedical Research, University of Bern, Bern, Switzerland
- University of Barcelona-IDIBAPS and CIBERehd, Barcelona, Spain
| | | | | | | | | | | | - Don C Rockey
- Medical University of South Carolina, Charleston, SC
| | | | | | | | | | | | | | | | | | - Ling Han
- Gilead Sciences, Inc, Foster City, CA
| | | | | | - Nezam Afdhal
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | | | | |
Collapse
|
18
|
Frangakis C, Sohn JH, Bas A, Chapiro J, Schernthaner RE, Lin M, Hamilton JP, Pawlik TM, Hong K, Duran R. Longitudinal Analysis of the Effect of Repeated Transarterial Chemoembolization for Liver Cancer on Portal Venous Pressure. Front Oncol 2021; 11:639235. [PMID: 34804911 PMCID: PMC8602787 DOI: 10.3389/fonc.2021.639235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 10/22/2021] [Indexed: 12/05/2022] Open
Abstract
Objectives Investigate long-term effects of repeated transarterial chemoembolization (TACE) on portal venous pressure (PVP) using non-invasive surrogate markers of portal hypertension. Methods Retrospective, Institutional Review Board-approved study. 99 patients [hepatocellular carcinoma (HCC) group (n=57); liver metastasis group (n=42)] who underwent 279TACEs and had longitudinal pre-/post-therapy contrast-enhanced-MRI (n=388) and complete blood work were included. Outcomes of interest were platelet count (PC), spleen volume, ascites and portosystemic collaterals. Variables included TACE type/number, tumor type, microcatheter location, Child-Pugh, baseline tumor burden (tumor number/total/largest size), vessel invasion, alpha-fetoprotein, Eastern Cooperative Oncology Group (ECOG) performance status, and Model for End-Stage Liver Disease (MELD) score. Generalized Estimating Equations assessed the associations between TACE and outcomes. Power analysis determined the sample size was sufficient. Results No significant change in PC over time was observed in either groups, regardless of liver function (P>0.05). Baseline spleen volume was 226 cm3 for metastatic group, and was larger by 204 cm3 for HCC group (P<0.001). Spleen volume increased by 20 cm3 (95%CI: 8-32; P=0.001) for both groups after 1stTACE and by 16cm3/TACE (P=0.099) over the full follow-up (up to 9TACEs). Spleen volume also tended to increase by 23cm3 (95%CI: -1–48; P=0.064) with higher tumor burden. Odds of developing moderate/severe ascites for metastatic patients was decreased by 0.5 (95%CI: 0.3–0.9; P=0.014), regardless of the Child-Pugh, and increased by 1.5 (95%CI: 1.2–1.9; P<0.001) among HCC patients with unstable Child-Pugh, whereas no change was noted with stable Child-Pugh. HCC patients with unstable Child-Pugh demonstrated a significant increase in portosystemic collaterals number over time (P=0.008). PVP-related complications such as variceal bleeding post-TACE were low (0.4%). Conclusion Repeated TACEs did seem to have an impact on PVP. However, the increase in PVP had marginal effects with low portal hypertension-related complications.
Collapse
Affiliation(s)
- Constantine Frangakis
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Jae Ho Sohn
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Ahmet Bas
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States.,Department of Radiology, İstanbul University Cerrahpaşa Medical School, İstanbul, Turkey
| | - Julius Chapiro
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, United States
| | - Ruediger E Schernthaner
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States
| | - MingDe Lin
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, United States
| | - James P Hamilton
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, United States
| | - Kelvin Hong
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Rafael Duran
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD, United States.,Department of Radiology and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
19
|
Kim M, Kim T, Lee HY, Hong SY, Wang HJ, Kim BW. Risk Factors for Beyond Milan Recurrence After Hepatic Resection for Single Hepatocellular Carcinoma No Larger Than 5 Centimeters. Liver Transpl 2021; 27:1116-1129. [PMID: 33835642 DOI: 10.1002/lt.26070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 12/22/2022]
Abstract
Hepatic resection (HR) is considered a treatment of choice for a single hepatocellular carcinoma (HCC) ≤5 cm in patients with preserved liver function. However, it is possible for these patients to develop a severe form of recurrence (beyond Milan recurrence [BMR] criteria). This recurrence could have been avoided if liver transplantation (LT) was performed primarily, as LT is believed to yield a more favorable oncological outcome compared with HR. The aim of this study was to determine the risk factors for BMR after HR and to verify whether primary LT can provide a more favorable outcome in patients with BMR risk factors. Data from 493 patients who underwent HR for HCC ≤5 cm between 1995 and 2016 were analyzed. Among them, 74 patients (15%) experienced BMR. The 10-year survival rate of patients with BMR was significantly low compared with that of patients without BMR (22.6% versus 79.8%; P < 0.01). In multivariate analysis, calculated hepatic venous pressure gradient ≥7 mm Hg and microvascular invasion were identified as the risk factors for BMR (P < 0.05). During the same period, 63 eligible patients underwent LT as a primary treatment for HCC ≤5 cm. No significant difference in long-term survival rate was observed when no risk factor for BMR was present in the HR and LT groups (85.5% versus 100%; P = 0.39). However, 10-year survival was poorer in the HR group in the presence of risk factors for BMR (60.6% versus 91.8%; P < 0.001). Among the patients with HCCs ≤5 cm, which are resectable and transplantable, LT is indicated when calculated hepatic venous pressure gradient ≥7 mm Hg and/or microvascular invasion is present.
Collapse
Affiliation(s)
- Mina Kim
- Department of Liver Transplantation and Hepatobiliary Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Taegyu Kim
- Department of Liver Transplantation and Hepatobiliary Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Hyun Young Lee
- Clinical Trial Center, Ajou University School of Medicine, Suwon, Korea
| | - Sung Yeon Hong
- Department of Liver Transplantation and Hepatobiliary Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Hee-Jung Wang
- Department of Liver Transplantation and Hepatobiliary Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Bong-Wan Kim
- Department of Liver Transplantation and Hepatobiliary Surgery, Ajou University School of Medicine, Suwon, Korea
| |
Collapse
|
20
|
Fujita K, Masaki T. Serum Biomarkers of Liver Fibrosis Staging in the Era of the Concept "Compensated Advanced Chronic Liver Disease". J Clin Med 2021; 10:3340. [PMID: 34362121 PMCID: PMC8347037 DOI: 10.3390/jcm10153340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/12/2021] [Accepted: 07/25/2021] [Indexed: 12/12/2022] Open
Abstract
Non-invasive indexes of liver fibrosis based on blood examinations have been developed for decades, partially replacing liver biopsy examinations. Recently, the concept of liver cirrhosis was revised and converted to "compensated advanced chronic liver diseases" since the Baveno VI consensus statement in 2015. The term "compensated advanced chronic liver diseases" was established based on the premise that serum biomarkers were not able to differentiate cirrhosis from severe fibrosis. The difficulty to histologically distinguish cirrhosis from severe fibrosis had been pointed out in 1977, when the definition and nomenclatures of cirrhosis had been determined by the World Health Organization. That was decades before serum biomarkers available at present were investigated. Though we are accustomed to differentiating the fibrosis stage as stage 1, 2, 3 (severe fibrosis), and 4 (cirrhosis), differentiation of cirrhosis from severe fibrosis is difficult even by histopathological examination. The current review will provide readers a framework to revise how to apply serum biomarkers on liver fibrosis staging in an era of the concept of "compensated advanced chronic liver disease".
Collapse
Affiliation(s)
- Koji Fujita
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki, Kita District, Kagawa 761-0793, Japan;
| | | |
Collapse
|
21
|
Bruha R, Vitek L, Smid V. Osteopontin - A potential biomarker of advanced liver disease. Ann Hepatol 2021; 19:344-352. [PMID: 32005637 DOI: 10.1016/j.aohep.2020.01.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 02/07/2023]
Abstract
Cirrhosis is a primary cause of liver-related mortality and morbidity. The basic process driving chronic liver disease to cirrhosis is accelerated fibrogenesis. Although the pathogenesis of liver cirrhosis is a multifactorial process, the essential step in the evolution of liver fibrosis is the activation of hepatic stellate cells, which are the main source of collagen produced in the extracellular matrix. This activation process is mediated by multiple growth factors, cytokines, and chemokines. One of the hepatic stellate cell-activating signaling molecules (and also one associated with cell injury and fibrosis) is osteopontin (OPN). OPN concentration in the plasma has been found to be predictive of liver fibrosis in various liver diseases. OPN concentrations correlate significantly with the stage of fibrosis, liver insufficiency, portal hypertension, and the presence of hepatocellular cancer. However, due to its versatile signaling functions, OPN not only contributes to the development of liver cirrhosis, but is also implicated in the pathogenesis of other chronic hepatic diseases such as viral hepatitis, both alcoholic and non-alcoholic steatohepatitis, drug-induced liver injury, and hepatocellular cancer. Thus, the targeting of OPN pathways seems to be a promising approach in the treatment of chronic liver diseases.
Collapse
Affiliation(s)
- Radan Bruha
- Charles University in Prague, 1st Faculty of Medicine and General University Hospital, 4th Department of Internal Medicine, U Nemocnice 2, Prague, Czech Republic.
| | - Libor Vitek
- Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Institute of Medical Biochemistry and Laboratory Diagnostics, U Nemocnice 2, Prague, Czech Republic
| | - Vaclav Smid
- Charles University in Prague, 1st Faculty of Medicine and General University Hospital, 4th Department of Internal Medicine, U Nemocnice 2, Prague, Czech Republic
| |
Collapse
|
22
|
Lu Q, Leong S, Lee KA, Patel A, Chua JME, Venkatanarasimha N, Lo RH, Irani FG, Zhuang KD, Gogna A, Chang PEJ, Tan HK, Too CW. Hepatic venous-portal gradient (HVPG) measurement: pearls and pitfalls. Br J Radiol 2021; 94:20210061. [PMID: 34106779 DOI: 10.1259/bjr.20210061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Hepatic venous pressure gradient (HVPG) is the gold-standard for measurement of portal hypertension, a common cause for life-threatening conditions such as variceal bleeding and hepatic encephalopathy. HVPG also plays a crucial role in risk stratification, treatment selection and assessment of treatment response. Thus recognition of common pitfalls and unusual hepatic venous conditions is crucial. This article aims to provide a radiographical and clinical guide to HVPG with representative clinical cases.
Collapse
Affiliation(s)
- Qiqi Lu
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Sum Leong
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Kristen Alexa Lee
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Ankur Patel
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Jasmine Ming Er Chua
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Nanda Venkatanarasimha
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Richard Hg Lo
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Farah Gillan Irani
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Kun Da Zhuang
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Apoorva Gogna
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Pik Eu Jason Chang
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Hiang Keat Tan
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Chow Wei Too
- Department of Vascular and Interventional Radiology, Division of Radiological Sciences, Singapore General Hospital, Radiological Sciences Academic Clinical Program, Singhealth-Duke-NUS Academic Medical Centre, Singapore, Singapore
| |
Collapse
|
23
|
Mandorfer M, Simbrunner B. Prevention of First Decompensation in Advanced Chronic Liver Disease. Clin Liver Dis 2021; 25:291-310. [PMID: 33838851 DOI: 10.1016/j.cld.2021.01.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 10/20/2020] [Indexed: 01/31/2023]
Abstract
The first occurrence of decompensation constitutes a watershed moment in the natural history of chronic liver disease; it denotes a point of no return in a relevant proportion of patients. Preventive strategies may profoundly decrease cirrhosis-related morbidity and mortality. Removing the primary etiologic factor and cofactors, is key; however, a considerable proportion of patients require additional etiology-independent treatment strategies that target important pathomechanisms promoting decompensation (ie, portal hypertension and systemic inflammation). This article explains the importance of preventing first decompensation and summarizes the evidence for etiologic and etiology-independent (most important, nonselective beta-blockers and statins) therapies.
Collapse
Affiliation(s)
- Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
24
|
Veldhuijzen van Zanten D, Buganza E, Abraldes JG. The Role of Hepatic Venous Pressure Gradient in the Management of Cirrhosis. Clin Liver Dis 2021; 25:327-343. [PMID: 33838853 DOI: 10.1016/j.cld.2021.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Quantifying the degree of portal hypertension provides useful information to estimate prognosis and to evaluate new therapies for portal hypertension. This quantification is done in clinical practice with the measurement of the hepatic venous pressure gradient. This article addresses the applications of measuring portal pressure in cirrhosis, including the differential diagnosis of portal hypertension; estimation of prognosis in cirrhosis, including preoperative evaluation before hepatic and extrahepatic surgery; assessment of the response to drug therapy (mainly in the context of drug development); and assessing the regression of portal hypertension syndrome.
Collapse
Affiliation(s)
- Daniel Veldhuijzen van Zanten
- Department of Medicine, University of Alberta, 13-103 Clinical Sciences Building, 11350-83 Avenue, Edmonton, Alberta T6G 2G3, Canada
| | - Elizabeth Buganza
- Division of Gastroenterology, Zeidler Ledcor Centre, University of Alberta, 8540 112 St NW, Edmonton, Alberta T6G 2X8, Canada
| | - Juan G Abraldes
- Division of Gastroenterology, University of Alberta, 8540 112 St NW, 1-38 Zeidler Ledcor Centre, Edmonton, Alberta T6G 2X8, Canada.
| |
Collapse
|
25
|
Jachs M, Reiberger T. Prevention of Variceal Bleeding and Rebleeding by Nonselective Beta-Blockers: A Tailored Approach. Clin Liver Dis 2021; 25:311-326. [PMID: 33838852 DOI: 10.1016/j.cld.2021.01.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Indexed: 01/31/2023]
Abstract
Nonselective beta-blockers represent the mainstay of medical therapy in the prophylaxis of variceal bleeding and rebleeding in patients with portal hypertension. Their efficacy has been demonstrated by numerous trials; however, there exist safety concerns in advanced disease, such as in patients with refractory ascites. Importantly, nonselective beta-blockers also exert nonhemodynamic beneficial effects that may contribute to a prolonged decompensation-free survival, as recently shown in the PREDESCI trial. This review summarizes the current evidence on nonselective beta-blocker therapy and proposes a tailored, patient-centered approach for the use of nonselective beta-blockers in patients with portal hypertension.
Collapse
Affiliation(s)
- Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna A-1090, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Christian Doppler Lab for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna A-1090, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Christian Doppler Lab for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
26
|
Roccarina D, Best LM, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, Benmassaoud A, Plaz Torres MC, Iogna Prat L, Csenar M, Arunan S, Begum T, Milne EJ, Tapp M, Pavlov CS, Davidson BR, Tsochatzis E, Williams NR, Gurusamy KS. Primary prevention of variceal bleeding in people with oesophageal varices due to liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013121. [PMID: 33822357 PMCID: PMC8092414 DOI: 10.1002/14651858.cd013121.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years. There are several different treatments to prevent bleeding, including: beta-blockers, endoscopic sclerotherapy, and variceal band ligation. However, there is uncertainty surrounding their individual and relative benefits and harms. OBJECTIVES To compare the benefits and harms of different treatments for prevention of first variceal bleeding from oesophageal varices in adults with liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for prevention of first variceal bleeding from oesophageal varices according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers to December 2019 to identify randomised clinical trials in people with cirrhosis and oesophageal varices with no history of bleeding. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and oesophageal varices with no history of bleeding. We excluded randomised clinical trials in which participants had previous bleeding from oesophageal varices and those who had previously undergone liver transplantation or previously received prophylactic treatment for oesophageal varices. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR), and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute for Health and Care Excellence Decision Support Unit guidance. We performed the direct comparisons from randomised clinical trials using the same codes and the same technical details. MAIN RESULTS We included 66 randomised clinical trials (6653 participants) in the review. Sixty trials (6212 participants) provided data for one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those at high risk of bleeding from oesophageal varices. The follow-up in the trials that reported outcomes ranged from 6 months to 60 months. All but one of the trials were at high risk of bias. The interventions compared included beta-blockers, no active intervention, variceal band ligation, sclerotherapy, beta-blockers plus variceal band ligation, beta-blockers plus nitrates, nitrates, beta-blockers plus sclerotherapy, and portocaval shunt. Overall, 21.2% of participants who received non-selective beta-blockers ('beta-blockers') - the reference treatment (chosen because this was the most common treatment compared in the trials) - died during 8-month to 60-month follow-up. Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates all had lower mortality versus no active intervention (beta-blockers: HR 0.49, 95% CrI 0.36 to 0.67; direct comparison HR: 0.59, 95% CrI 0.42 to 0.83; 10 trials, 1200 participants; variceal band ligation: HR 0.51, 95% CrI 0.35 to 0.74; direct comparison HR 0.49, 95% CrI 0.12 to 2.14; 3 trials, 355 participants; sclerotherapy: HR 0.66, 95% CrI 0.51 to 0.85; direct comparison HR 0.61, 95% CrI 0.41 to 0.90; 18 trials, 1666 participants; beta-blockers plus nitrates: HR 0.41, 95% CrI 0.20 to 0.85; no direct comparison). No trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation had a higher number of serious adverse events (number of events) than beta-blockers (rate ratio 10.49, 95% CrI 2.83 to 60.64; 1 trial, 168 participants). Based on low-certainty evidence, beta-blockers plus nitrates had a higher number of 'any adverse events (number of participants)' than beta-blockers alone (OR 3.41, 95% CrI 1.11 to 11.28; 1 trial, 57 participants). Based on low-certainty evidence, adverse events (number of events) were higher in sclerotherapy than in beta-blockers (rate ratio 2.49, 95% CrI 1.53 to 4.22; direct comparison rate ratio 2.47, 95% CrI 1.27 to 5.06; 2 trials, 90 participants), and in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison rate ratio 1.72, 95% CrI 1.08 to 2.76; 1 trial, 140 participants). Based on low-certainty evidence, any variceal bleed was lower in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison HR 0.21, 95% CrI 0.04 to 0.71; 1 trial, 173 participants). Based on low-certainty evidence, any variceal bleed was higher in nitrates than beta-blockers (direct comparison HR 6.40, 95% CrI 1.58 to 47.42; 1 trial, 52 participants). The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. AUTHORS' CONCLUSIONS Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates may decrease mortality compared to no intervention in people with high-risk oesophageal varices in people with cirrhosis and no previous history of bleeding. Based on low-certainty evidence, variceal band ligation may result in a higher number of serious adverse events than beta-blockers. The evidence indicates considerable uncertainty about the effect of beta-blockers versus variceal band ligation on variceal bleeding. The evidence also indicates considerable uncertainty about the effect of the interventions in most of the remaining comparisons.
Collapse
Affiliation(s)
- Davide Roccarina
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Amine Benmassaoud
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | | | - Laura Iogna Prat
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | | | | | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| |
Collapse
|
27
|
Sharma S, Agarwal S, Gunjan D, Kaushal K, Anand A, Gopi S, Mohta S, Saraya A. Outcomes of Portal Pressure-Guided Therapy in Decompensated Cirrhosis With Index Variceal Bleed in Asian Cohort. J Clin Exp Hepatol 2021; 11:443-452. [PMID: 34276151 PMCID: PMC8267357 DOI: 10.1016/j.jceh.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Hemodynamic response to pharmacotherapy improves survival in patients with cirrhosis post variceal bleeding, but long-term outcomes remain unexplored especially in this part of the world. We aimed to study the long-term impact of portal pressure reduction on liver-related outcomes after index variceal bleed. METHODS Patients with hepatic venous pressure gradient (HVPG) more than 12 mm Hg after index variceal bleed were given non-selective beta-blockers in combination with variceal band ligation. HVPG response was assessed after 4 weeks. Patients were followed up for rebleed events, survival, additional decompensation events and safety outcomes. Rebleed and other decompensations were compared using competing risks analysis, taking death as competing event, and survival was compared using Kaplan-Meier analysis. RESULTS Forty-eight patients (29 responders and 19 non-responders) were followed up for a median duration of 45 (24-56) months. Rebleeding rates at 1, 3 and 5 years were 10.3%, 20.7% and 20.7% in responders and 15.8%, 44.7% and 51.1% in non-responders, respectively (Gray's test, P = 0.044). Survival rates at 1, 3 and 5 years were 89.7%, 72.1% and 51.9% in responders and 89.5%, 44% and 37.7% in non-responders, respectively (log-rank test, P = 0.1). Both severity of liver disease (MELD score, multivariate sub-distributional hazards ratio: 1.166 [1.014-1.341], P = 0.030) and HVPG non-response (multivariate sub-distributional hazards ratio: 2.476 [1.87-7.030], P = 0.045) predicted rebleeding risk while survival was dependent only on severity of liver disease (MELD > 12, multivariate hazards ratio: 2.36 [1.04-5.38], P = 0.041). CONCLUSION Baseline severity of liver disease predicted survival and rebleed in these patients. Hemodynamic response, although associated with lower rebleeding rate, had limited impact on survival.
Collapse
Key Words
- ACLF, acute on chronic liver failure
- AFP, alpha-fetoprotein
- AVB, acute variceal bleed
- CT, computed tomography
- CTP, Child–Turcotte–Pugh
- EASL-CLIF, European Association of Study of Liver Disease – Chronic Liver Failure Consortium
- EBL, endoscopic band ligation
- EGD, esophagogastroduodenoscopy
- HE, hepatic encephalopathy
- HRS, hepatorenal syndrome
- HVPG, hepatic venous pressure gradient
- MELD, model for end-stage liver disease
- NSBB, non-selective beta-blockers
- SBP, spontaneous bacterial peritonitis
- acute variceal bleed
- hemodynamic response and carvedilol
- hepatic venous pressure gradient
- non-selective beta-blockers
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Anoop Saraya
- Address for correspondence: Anoop Saraya, Professor and Head of Department, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India.
| |
Collapse
|
28
|
Gunarathne LS, Rajapaksha H, Shackel N, Angus PW, Herath CB. Cirrhotic portal hypertension: From pathophysiology to novel therapeutics. World J Gastroenterol 2020; 26:6111-6140. [PMID: 33177789 PMCID: PMC7596642 DOI: 10.3748/wjg.v26.i40.6111] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/28/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
Portal hypertension and bleeding from gastroesophageal varices is the major cause of morbidity and mortality in patients with cirrhosis. Portal hypertension is initiated by increased intrahepatic vascular resistance and a hyperdynamic circulatory state. The latter is characterized by a high cardiac output, increased total blood volume and splanchnic vasodilatation, resulting in increased mesenteric blood flow. Pharmacological manipulation of cirrhotic portal hypertension targets both the splanchnic and hepatic vascular beds. Drugs such as angiotensin converting enzyme inhibitors and angiotensin II type receptor 1 blockers, which target the components of the classical renin angiotensin system (RAS), are expected to reduce intrahepatic vascular tone by reducing extracellular matrix deposition and vasoactivity of contractile cells and thereby improve portal hypertension. However, these drugs have been shown to produce significant off-target effects such as systemic hypotension and renal failure. Therefore, the current pharmacological mainstay in clinical practice to prevent variceal bleeding and improving patient survival by reducing portal pressure is non-selective -blockers (NSBBs). These NSBBs work by reducing cardiac output and splanchnic vasodilatation but most patients do not achieve an optimal therapeutic response and a significant proportion of patients are unable to tolerate these drugs. Although statins, used alone or in combination with NSBBs, have been shown to improve portal pressure and overall mortality in cirrhotic patients, further randomized clinical trials are warranted involving larger patient populations with clear clinical end points. On the other hand, recent findings from studies that have investigated the potential use of the blockers of the components of the alternate RAS provided compelling evidence that could lead to the development of drugs targeting the splanchnic vascular bed to inhibit splanchnic vasodilatation in portal hypertension. This review outlines the mechanisms related to the pathogenesis of portal hypertension and attempts to provide an update on currently available therapeutic approaches in the management of portal hypertension with special emphasis on how the alternate RAS could be manipulated in our search for development of safe, specific and effective novel therapies to treat portal hypertension in cirrhosis.
Collapse
Affiliation(s)
- Lakmie S Gunarathne
- Department of Medicine, Melbourne Medical School, The University of Melbourne, Heidelberg, VIC 3084, Australia
| | - Harinda Rajapaksha
- School of Molecular Science, College of Science, Health and Engineering, La Trobe University, Bundoora, VIC 3086, Australia
| | | | - Peter W Angus
- Department of Gastroenterology, Austin Health, Heidelberg, VIC 3084, Australia
| | - Chandana B Herath
- Department of Medicine, Melbourne Medical School, The University of Melbourne, Heidelberg, VIC 3084, Australia
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170, Australia
| |
Collapse
|
29
|
La Mura V, Garcia-Guix M, Berzigotti A, Abraldes JG, García-Pagán JC, Villanueva C, Bosch J. A Prognostic Strategy Based on Stage of Cirrhosis and HVPG to Improve Risk Stratification After Variceal Bleeding. Hepatology 2020; 72:1353-1365. [PMID: 31960441 DOI: 10.1002/hep.31125] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 12/22/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS A hepatic venous pressure gradient (HVPG) decrease of 20% or more (or ≤12 mm Hg) indicates a good prognosis during propranolol/nadolol treatment but requires two HVPG measurements. We aimed to simplify the risk stratification after variceal bleeding using clinical data and HVPG. METHODS A total of 193 patients with cirrhosis (62% with ascites and/or hepatic encephalopathy [HE]) who were within 7 days of bleeding had their HVPG measured before and at 1-3 months of treatment with propranolol/nadolol plus endoscopic band ligation. The endpoints were rebleeding and rebleeding/transplantation-free survival for 4 years. Another cohort (n = 231) served as the validation set. RESULTS During follow-up, 45 patients had variceal bleeding and 61 died. The HVPG responders (n = 71) had lower rebleeding risk (10% vs. 34%, P = 0.001) and better survival than the 122 nonresponders (61% vs. 39%, P = 0.001). Patients with HE (n = 120) had lower survival than patients without HE (40% vs. 63%, P = 0.005). Among the patients with ascites/HE, those with baseline HVPG ≤ 16 mm Hg (n = 16) had a low rebleeding risk (13%). In contrast, among patients with ascites/HE and baseline HVPG > 16 mm Hg, only the HVPG responders (n = 32) had a good prognosis, with lower rebleeding risk and better survival than the nonresponders (n = 72) (respective proportions: 7% vs. 39%, P = 0.018; 56% vs. 30% P = 0.010). These findings allowed us to develop a strategy for risk stratification in which HVPG response was measured only in patients with ascites and/or HE and baseline HVPG > 16 mm Hg. This method reduced the "gray zone" (i.e., high-risk patients who had not died on follow-up) from 46% to 35% and decreased the HVPG measurements required by 42%. The validation cohort confirmed these results. CONCLUSIONS Restricting HVPG measurements to patients with ascites/HE and measuring HVPG response only if the patient's baseline HVPG is over 16 mm Hg improves detection of high-risk patients while markedly reducing the number of HVPG measurements required.
Collapse
Affiliation(s)
- Vincenzo La Mura
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain.,Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Medicina Generale-Emostasi e Trombosi, Milano, Italy.,CRC "A.M. e A. Migliavacca" per lo Studio e la Cura delle Malattie del Fegato, Milano, Italy.,Dipartimento di Scienze Biomediche per la Salute, Università Degli Studi di Milano, Milano, Italy
| | - Marta Garcia-Guix
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain.,Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Autonomous University, Barcelona, Spain
| | - Annalisa Berzigotti
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain.,Swiss Liver, Hepatology, University Clinic for Visceral Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Juan G Abraldes
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain.,Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Juan Carlos García-Pagán
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Candid Villanueva
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain.,Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Autonomous University, Barcelona, Spain
| | - Jaime Bosch
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain.,Swiss Liver, Hepatology, University Clinic for Visceral Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| |
Collapse
|
30
|
Han MAT, Vipani A, Noureddin N, Ramirez K, Gornbein J, Saouaf R, Baniesh N, Cummings-John O, Okubote T, Setiawan VW, Rotman Y, Loomba R, Alkhouri N, Noureddin M. MR elastography-based liver fibrosis correlates with liver events in nonalcoholic fatty liver patients: A multicenter study. Liver Int 2020; 40:2242-2251. [PMID: 32652744 DOI: 10.1111/liv.14593] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/23/2020] [Accepted: 07/01/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Liver fibrosis assessed by liver biopsy is predictive of clinical liver events in patients with nonalcoholic fatty liver disease (NAFLD). Magnetic resonance elastography (MRE) correlates with liver biopsy in assessing liver fibrosis. However, data assessing the relationship between MRE and clinical liver events are lacking. We investigated the association between MRE and clinical liver events/death and identified the cut-off to predict clinical liver events in NAFLD patients. METHODS We conducted a multicenter retrospective study of NAFLD patients who underwent MRE between 2016 and 2019. Clinical liver events were defined as decompensation events and death. We categorized patients into noncirrhosis, compensated cirrhosis and decompensated cirrhosis. Fisher's exact test was used to test association strength. Receiver operative curve methods were used to determine the optimal cut-off of MRE liver stiffness and to maximize the accuracy for classifying noncirrhosis, compensated cirrhosis and decompensated cirrhosis. Logistic regression modelling was used to predict decompensation. RESULTS The study included 320 NAFLD patients who underwent MRE. The best threshold for distinguishing cirrhosis from noncirrhosis was 4.39 kPa (AUROC 0.92) and from decompensated cirrhosis was 6.48 kPa (AUROC 0.71). Odds of decompensation increased as liver stiffness increased (OR 3.28) (P < .001). Increased liver stiffness was associated with ascites, hepatic encephalopathy, oesophageal variceal bleeding and mortality (median 7.10, 10.15 and 10.15 kPa respectively). CONCLUSION In NAFLD patients, liver stiffness measured by MRE with a cut-off of ≥6.48 kPa is associated with decompensation and mortality, and specific MRE cut-offs are predictive of individual clinical liver events.
Collapse
Affiliation(s)
- Ma Ai Thanda Han
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Aarshi Vipani
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nabil Noureddin
- Department of Internal Medicine, University of Nevada, Las Vegas, NV, USA
| | - Kim Ramirez
- Fatty Liver Program, Division of Digestive and Liver Diseases, Comprehensive Transplant Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jeffrey Gornbein
- Department of Biostatistics, University of California at Los Angeles, Los Angeles, CA, USA
| | - Rola Saouaf
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nader Baniesh
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | | | - Yaron Rotman
- Liver & Energy Metabolism Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health, Bethesda, MD, USA
| | - Rohit Loomba
- Division of Gastroenterology, NAFLD Translational Research Unit, Division of Epidemiology, Department of Family and Preventive Medicine, University of California at San Diego, La Jolla, CA, USA
| | - Naim Alkhouri
- Division of Liver, Texas Liver Institute, San Antonio, TX, USA
| | - Mazen Noureddin
- Fatty Liver Program, Division of Digestive and Liver Diseases, Comprehensive Transplant Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
31
|
Magaz M, Baiges A, Hernández-Gea V. Precision medicine in variceal bleeding: Are we there yet? J Hepatol 2020; 72:774-784. [PMID: 31981725 DOI: 10.1016/j.jhep.2020.01.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 12/14/2022]
Abstract
Variceal bleeding is one of the most feared complications of portal hypertension in patients with cirrhosis because of its deleterious impact on prognosis. Adequate management of patients at risk of developing variceal bleeding includes the prevention of the first episode of variceal bleeding and rebleeding, and is crucial in modifying prognosis. The presence of clinically significant portal hypertension is the main factor determining the risk of development of varices and other liver-related decompensations; therefore, it should be carefully screened for and monitored. Treating patients with clinically significant portal hypertension based on their individual risk of portal hypertension-related bleeding undoubtedly improves prognosis. The evaluation of liver haemodynamics and liver function can stratify patients according to their risk of bleeding and are no question useful tools to guide therapy in an individualised manner. That said, recent data support the idea that tailoring therapy to patient characteristics may effectively impact on prognosis and increase survival in all clinical scenarios. This review will focus on evaluating the available evidence supporting the use of individual risk characteristics for clinical decision-making and their impact on clinical outcome and survival. In primary prophylaxis, identification and treatment of patients with clinically significant portal hypertension improves decompensation-free survival. In the setting of acute variceal bleeding, the risk of failure and rebleeding can be easily predicted, allowing for early escalation of treatment (i.e. pre-emptive transjugular intrahepatic portosystemic shunt) which can improve survival in appropriate candidates. Stratifying the risk of recurrent variceal bleeding based on liver function and haemodynamic response to non-selective beta-blockers allows for tailored treatment, thereby increasing survival and avoiding adverse events.
Collapse
Affiliation(s)
- Marta Magaz
- Unidad de Hemodinámica Hepática, Servicio de Hepatología, Hospital Clínic, Universidad de Barcelona, Instituto de Investigaciones Biomédicas Augusto Pi Suñer (IDIBAPS), Barcelona, Spain
| | - Anna Baiges
- Unidad de Hemodinámica Hepática, Servicio de Hepatología, Hospital Clínic, Universidad de Barcelona, Instituto de Investigaciones Biomédicas Augusto Pi Suñer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Virginia Hernández-Gea
- Unidad de Hemodinámica Hepática, Servicio de Hepatología, Hospital Clínic, Universidad de Barcelona, Instituto de Investigaciones Biomédicas Augusto Pi Suñer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain.
| |
Collapse
|
32
|
Turco L, Villanueva C, La Mura V, García-Pagán JC, Reiberger T, Genescà J, Groszmann RJ, Sharma BC, Merkel C, Bureau C, Alvarado E, Abraldes JG, Albillos A, Bañares R, Peck-Radosavljevic M, Augustin S, Sarin SK, Bosch J, García-Tsao G. Lowering Portal Pressure Improves Outcomes of Patients With Cirrhosis, With or Without Ascites: A Meta-Analysis. Clin Gastroenterol Hepatol 2020; 18:313-327.e6. [PMID: 31176013 DOI: 10.1016/j.cgh.2019.05.050] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 05/24/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In unselected patients with cirrhosis, those with reductions in hepatic venous pressure gradient (HVPG) to below a defined threshold (responders) have a reduced risk of variceal hemorrhage (VH) and death. We performed a meta-analysis to compare this effect in patients with vs without ascites. METHODS We collected data from 15 studies of primary or secondary prophylaxis of VH that reported data on VH and death in responders vs nonresponders. We included studies in which data on ascites at baseline and on other relevant outcomes during follow-up evaluation were available. We performed separate meta-analyses for patients with vs without ascites. RESULTS Of the 1113 patients included in the studies, 968 patients (87%) had been treated with nonselective β-blockers. In 993 patients (89%), HVPG response was defined as a decrease of more than 20% from baseline (>10% in 11% of patients) or to less than 12 mm Hg. In the 661 patients without ascites, responders (n = 329; 50%) had significantly lower odds of events (ascites, VH, or encephalopathy) than nonresponders (odds ratio [OR], 0.35; 95% CI, 0.22-0.56). Odds of death or liver transplantation were also significantly lower among responders than nonresponders (OR, 0.50, 95% CI, 0.32-0.78). In the 452 patients with ascites, responders (n = 188; 42%) had significantly lower odds of events (VH, refractory ascites, spontaneous bacterial peritonitis, or hepatorenal syndrome) than nonresponders (OR, 0.27; 95% CI, 0.16-0.43). Overall, odds of death or liver transplantation were lower among responders (OR, 0.47; 95% CI, 0.29-0.75). No heterogeneity was observed among studies. CONCLUSIONS In a meta-analysis of clinical trials, we found that patients with cirrhosis with and without ascites who respond to treatment with nonselective β-blockers (based on reductions in HVPG) have a reduced risk of events, death, or liver transplantation.
Collapse
Affiliation(s)
- Laura Turco
- Division of Gastroenterology, Azienda Ospedaliero, Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy; PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Candid Villanueva
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Vincenzo La Mura
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda, Ospedale Maggiore Policlinico, Medicina Generale - Emostasi e Trombosi, Milano, Italy; Centro Ricerca e Cura "Angela Maria ed Antonio Migliavacca" per lo Studio e la Cura delle Malattie del Fegato and Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy
| | - Juan Carlos García-Pagán
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Joan Genescà
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain; Liver Unit, Department of Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Roberto J Groszmann
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut; Section of Digestive Diseases, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Barjesh C Sharma
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research, New Delhi, India
| | - Carlo Merkel
- Department of Medicine Dipartimento di Medicina and Centro Interdipartimentale di Ricerca sulla Modellistica delle Alterazioni Neuropsichiche in Medicina Clinica, University of Padua, Padua, Italy
| | - Christophe Bureau
- Service d'Hépato-Gastroentérologie, Hôpital Purpan Centre Hospitalier Universitaire Toulouse, Université Paul Sabatier, Toulouse, France
| | - Edilmar Alvarado
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Gonzalez Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), University of Alberta, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, Edmonton, Canada
| | - Agustin Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain; Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain; Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Markus Peck-Radosavljevic
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria; Klinikum Klagenfurth am Wörthersee, Klagenfurth, Austria
| | - Salvador Augustin
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain; Liver Unit, Department of Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Shiv K Sarin
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research, New Delhi, India
| | - Jaime Bosch
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain; Swiss Liver Center, Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Guadalupe García-Tsao
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut; Section of Digestive Diseases, VA Connecticut Healthcare System, West Haven, Connecticut.
| |
Collapse
|
33
|
Liu C, Liu Y, Shao R, Wang S, Wang G, Wang L, Zhang M, Hou J, Zhang C, Qi X. The predictive value of baseline hepatic venous pressure gradient for variceal rebleeding in cirrhotic patients receiving secondary prevention. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:91. [PMID: 32175384 PMCID: PMC7049047 DOI: 10.21037/atm.2019.12.143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/06/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Baseline hepatic venous pressure gradient (HVPG) has been applied for prediction of variceal rebleeding in patients after acute variceal bleeding. However, for patients receiving secondary prevention, there still lacks evidence about the predictive performance of baseline-HVPG for rebleeding. This study aims to investigate the predictive value of baseline-HVPG for variceal rebleeding in cirrhotic patients receiving secondary prevention. METHODS This retrospective study included 122 patients with cirrhosis accepting secondary prevention of variceal rebleeding in a university hospital. All the included patients had HVPG measurements before rebleeding and had at least 1-year follow-up after HVPG measurement unless the rebleeding occurred. The rebleeding rate in patients with different HVPG levels and time-dependent predictive performance of baseline-HVPG were analysed. A Cox regression model and P for trend were used to assess the rebleeding risk. RESULTS Variceal rebleeding occurred in 22 (18.0%) patients during 1-year follow-up. No significant difference was observed in rebleeding rate between patients with HVPG <16 mmHg and HVPG ≥16 mmHg (17.91% vs. 26.41%, P=0.200). A decreasing trend was observed in area under the curve of HVPG for predicting rebleeding by time. The multivariate Cox model showed an overall decreasing trend in hazard ratio of rebleeding (vs. patients with HVPG <12 mmHg) for patients with 12≤ HVPG <16 mmHg, 16≤ HVPG <20 mmHg and HVPG ≥20 mmHg; besides, an increasing P for trend was observed. CONCLUSIONS A single baseline-HVPG measurement was insufficient for predicting rebleeding in patients with cirrhosis who received secondary prevention.
Collapse
Affiliation(s)
- Chuan Liu
- Department of Hepatology Unit and Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yanna Liu
- Department of Hepatology Unit and Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Ruoyang Shao
- Department of Hepatology Unit and Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Sining Wang
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan 250012, China
| | - Guangchuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan 250012, China
| | - Lifen Wang
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan 250012, China
| | - Mingyan Zhang
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan 250012, China
| | - Jinlin Hou
- Department of Hepatology Unit and Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan 250012, China
| | - Xiaolong Qi
- Department of Hepatology Unit and Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| |
Collapse
|
34
|
Abstract
PURPOSE OF REVIEW There are no well-established guidelines for the management of gastric variceal bleeding. Endoscopic management of acute gastric variceal bleeding has been premised on the injection of sclerosants and synthetic glue. However, these therapies are associated with various complications including systemic embolization and recurrent bleeding. Recently, endoscopic ultrasound (EUS)-guided interventions including coil injection have emerged as promising modalities with high technical and clinical success rates and low rates of recurrence. RECENT FINDINGS In this review we discuss the classification, natural history, prognosis, and treatment options of gastric variceal. Discussion of treatment is further subdivided into primary and secondary prophylaxis and the management of acute gastric variceal bleeding with a focus on emerging endoscopic interventions. SUMMARY Cyanoacrylate injection may have a role in the primary and secondary prophylaxis of gastric variceal. Endoscopic band ligation should be considered for GOV1. EUS-guided injection of synthetic glues like cyanoacrylate is superior to direct injection. However, EUS-guided coil injections with or without cyanoacrylate should be considered first-line endoscopic treatment in all bleeding gastric variceal except for GOV1. Balloon retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunts (TIPS) remain important interventional radiologic therapeutic options as primary therapy in centers without EUS expertise or as salvage therapy.
Collapse
Affiliation(s)
- Ahmad Najdat Bazarbashi
- Department of Medicine, Brigham and Women's Hospital, Division of Gastroenterology, Hepatology and Endoscopy, Boston, Massachusetts, USA
| | | |
Collapse
|
35
|
Abstract
Gastrointestinal varices are associated with cirrhosis and portal hypertension. Variceal hemorrhage is a substantial cause of morbidity and mortality, with esophageal and gastric varices the most common source and rectal varices a much less common cause of severe gastrointestinal bleeding. The goals of managing variceal hemorrhage are control of active bleeding and prevention of rebleeding. This article focuses on reviewing the current management strategies, including optimal medical, endoscopic, and angiographic interventions and their clinical outcomes to achieve these goals. Evidence based discussion is used with current references as much as possible.
Collapse
Affiliation(s)
- Thomas O G Kovacs
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Ronald Reagan - UCLA Medical Center, Olive View-UCLA Medical Center, Sylmar, CA, USA.
| | - Dennis M Jensen
- Medicine-GI, VA Greater Los Angeles Healthcare System, Ronald Reagan - UCLA Medical Center, David Geffen School of Medicine at UCLA, CURE:DDRC, Room 318, Building 115, 11301 Wilshire Boulevard, Los Angeles, CA 90073-1003, USA; Human Studies Core and GI Hemostasis Research Unit, VA/CURE Digestive Disease Research Center, Los Angeles, CA, USA
| |
Collapse
|
36
|
Kim BH, Chung JW, Lee CS, Jang ES, Jeong SH, Kim N, Kim JW. Liver volume index predicts the risk of esophageal variceal hemorrhage in cirrhotic patients on propranolol prophylaxis. Korean J Intern Med 2019; 34:1233-1243. [PMID: 30759966 PMCID: PMC6823564 DOI: 10.3904/kjim.2018.120] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 05/21/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS Non-selective β-blockers (NSBBs) are used for primary prevention of esophageal variceal hemorrhage (VH) in patients with portal hypertension, but a significant number of patients develop VH while on NSBB therapy. In this study, we sought to determine whether liver volume can predict the risk of primary prophylaxis failure in cirrhotic patients on NSBB therapy. METHODS A retrospective cohort of 309 patients on prophylactic propranolol was analyzed. Liver volume was measured in portal venous phase images of multidetector computed tomography. Predictors of VH were assessed using a Cox proportional hazards model with competing-risks analysis. A nomogram was developed for estimation of the risk of primary prophylaxis failure. RESULTS During a median follow-up of 36 months, 37 patients on propranolol developed VH. Liver volume index, the ratio of measured-to-expected liver volume, was an independent predictor of VH (adjusted hazard ratio [HR], 2.70; 95% confidence interval [CI], 1.37 to 5.33; p = 0.004) as were the presence of large varices and the absence of ascites. A nomogram-based volume score of > 0.6 was predictive of prophylaxis failure (HR, 7.54; 95% CI, 2.88 to 19.73; p < 0.001). Time-dependent receiver operating characteristic curve analysis revealed that a nomogram-based risk score had significantly better discriminatory power than the North Italian Endoscopy Club index in predicting prophylaxis failure at 6 and 8 years. CONCLUSION Liver volume index is an independent predictor of first VH and a nomogram-based volume score stratifies the VH risk in cirrhotic patients on propranolol prophylaxis.
Collapse
Affiliation(s)
- Beom Hee Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Wha Chung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chung Seop Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Sun Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Wook Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Correspondence to Jin-Wook Kim, M.D. Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7013 Fax: +82-31-787-4051 E-mail:
| |
Collapse
|
37
|
Xu G, Li F, Mao Y. Portal pressure monitoring-state-of-the-art and future perspective. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:583. [PMID: 31807564 DOI: 10.21037/atm.2019.09.22] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Portal hypertension is a serious symptom of chronic liver diseases, which can lead to many critical complications, such as the formation of varices related to upper digestive bleeding, ascites, infection, hepatic encephalopathy, renal failure, and even death. As a result, portal pressure monitoring has important prognostic and clinical implications. The hepatic venous pressure gradient measurement, a gold-standard method applied to monitor portal pressure, is invasive and only available in experienced centers. Over the past decade, noninvasive methods aimed at monitoring the portal pressure have been increasingly investigated, including serum markers, radiological features, ultrasound elastography, doppler and contrast-enhanced ultrasonography. In this study, we focused on both invasive and noninvasive methods for portal pressure monitoring and explored their roles in clinical setting. The advantages and limitations of various techniques for future research are also discussed.
Collapse
Affiliation(s)
- Gang Xu
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, PUMC and Chinese Academy of Medical Sciences, Beijing 100730, China.,Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Fei Li
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.,Shenzhen Key Laboratory of Ultrasound Imaging and Therapy, Shenzhen 518055, China
| | - Yilei Mao
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, PUMC and Chinese Academy of Medical Sciences, Beijing 100730, China
| |
Collapse
|
38
|
Duah A, Nkrumah KN, Tachi K. Non-invasive markers as predictors of oesophageal varices in cirrhotic patient in a teaching hospital in Ghana. Ghana Med J 2019; 53:142-149. [PMID: 31481810 PMCID: PMC6697776 DOI: 10.4314/gmj.v53i2.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Introduction Oesophageal variceal (OV) bleeding is a potentially fatal consequence of portal hypertension in patients with liver cirrhosis. Upper GI endoscopy is recommended for screening for varices in cirrhotics for early detection and treatment, however, this is invasive. The purpose of this study was to assess the predictive values of the noninvasive tests in detecting the presence of OV. Methods A cross-sectional hospital-based study involving 149 patients with liver cirrhosis was carried out at the Korle-Bu Teaching Hospital from 1st November 2015 to 25th November 2016. Relevant clinical parameters assessed included Child-Pugh class, ascites and splenomegaly. Full blood count and liver function tests, abdominal ultrasound and gastroscopy were done for all the participants. Receiver operating characteristic curve was generated to determine the cut-off values for the best sensitivity, specificity, negative and positive predictive values of the variables (serum albumin, platelet count (PC), aspartate aminotransferase (AST)/alanine aminotransferase (ALT), PC/Spleen diameter( SD)) with regard to the presence of OV. Results On gastroscopy, 135 (90.60%) had OV and 14 patients (9.40%) had no OV. One hundred and eleven of the varices (82.22%) were large varices and the rest (17.78%) small varices. The overall mean of serum albumin, PC and PC/SD were not significant predictors of the presence of OV. However, the overall mean of AST/ALT significantly predicted the presence of OV. A PC/SD cut off value of ≤833.3 had 72.62% diagnostic accuracy for diagnosing all OV. Conclusion PC/SD cut-off could be used to screen cirrhotics for OV and treatment initiated in geographical areas lacking endoscopy facilities Funding None declared
Collapse
Affiliation(s)
- Amoako Duah
- Department of Medicine, St. Dominic Hospital, Akwatia, Ghana
| | - Kofi N Nkrumah
- Department of Medicine and Therapeutics, School of Medicine and Dentistry, College of Health Science, University of Ghana
| | - Kenneth Tachi
- Department of Medicine and Therapeutics, School of Medicine and Dentistry, College of Health Science, University of Ghana
| |
Collapse
|
39
|
Non-invasive assessment of portal hypertension by multi-parametric magnetic resonance imaging of the spleen: A proof of concept study. PLoS One 2019; 14:e0221066. [PMID: 31430314 PMCID: PMC6701782 DOI: 10.1371/journal.pone.0221066] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND AIMS Non-invasive assessment of portal hypertension is an area of unmet need. This proof of concept study aimed to evaluate the diagnostic accuracy of a multi-parametric magnetic resonance technique in the assessment of portal hypertension. Comparison to other non-invasive technologies was a secondary aim. METHODS T1 and T2* maps through the liver and spleen were acquired prior to trans-jugular liver biopsy and hepatic vein pressure gradient (HVPG) measurement. T1 measurements reflect changes in tissue water content, but this relationship is confounded by the presence of iron, which in turn can be quantified accurately from T2* maps. Data were analysed using LiverMultiScan (Perspectum Diagnostics, Oxford, UK) which applies an algorithm to remove the confounding effect of iron, yielding the "iron corrected T1" (cT1). Sensitivity, specificity, diagnostic values and area under the curve were derived for spleen cT1, liver cT1, transient elastography, and serum fibrosis scores. HVPG was the reference standard. RESULTS Nineteen patients (15 men) with median age 57 years were included. Liver disease aetiologies included non-alcoholic fatty liver disease (n = 9; 47%) and viral hepatitis (n = 4; 21%). There was strong correlation between spleen cT1 and HVPG (r = 0.69; p = 0.001). Other non-invasive biomarkers did not correlate with HVPG. Spleen cT1 had excellent diagnostic accuracy for portal hypertension (HVPG >5 mmHg) and clinically significant portal hypertension (HVPG ≥10 mmHg) with an area under the receiver operating characteristic curve of 0.92 for both. CONCLUSION Spleen cT1 is a promising biomarker of portal pressure that outperforms other non-invasive scores and should be explored further.
Collapse
|
40
|
Mandorfer M, Hernández-Gea V, Reiberger T, García-Pagán JC. Hepatic Venous Pressure Gradient Response in Non-Selective Beta-Blocker Treatment—Is It Worth Measuring? ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s11901-019-00469-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
41
|
Slowik V, Monroe EJ, Friedman SD, Hsu EK, Horslen S. Pressure gradients, laboratory changes, and outcomes with transjugular intrahepatic portosystemic shunts in pediatric portal hypertension. Pediatr Transplant 2019; 23:e13387. [PMID: 30932316 DOI: 10.1111/petr.13387] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Indications for TIPS are well described in adults and involve complications of PHTN. Complications from PHTN are associated with PSG of > 12 mm Hg in adults. It is unclear if these parameters apply to children with PHTN. OBJECTIVE To assess whether adult criteria for TIPS placement can be utilized in children, describe laboratory changes over time, and report outcomes. METHODS We performed a retrospective review of 34 pediatric patients who underwent TIPS, examining indications, radiology, PSG reductions, laboratory changes, and outcomes. RESULTS Most patients had PHTN due to parenchymal liver disease including congenital hepatic fibrosis (n = 5), biliary atresia (n = 5), cystic fibrosis-related liver disease (n = 3) and cavernous transformation of the portal vein (n = 6). Indications for TIPS included variceal bleeding, recurrent ascites, and maintenance of portal vein flow following thrombolysis. Variceal bleeding was observed in six children with PSG < 12 mm Hg. Minor complications occurred in eight subjects. Continued bleeding occurred in one patient. Six patients were successfully bridged to transplantation, and three patients died secondary to end-stage disease. Standard laboratory tests stabilized after TIPS placement and hematocrit increased. CONCLUSION TIPS placement in pediatric patients was performed for complications of PHTN. Unlike adult series, a substantial proportion of our cases treated extrahepatic PHTN from cavernous transformation of the portal vein. Children presented with sequelae of PHTN with PSG below 12 mm Hg, below the adult standard. We found TIPS in pediatrics to be safe and effective with laboratory stabilization and improvement in hematocrit.
Collapse
Affiliation(s)
- Voytek Slowik
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, Washington
| | - Eric J Monroe
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Seth D Friedman
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Evelyn K Hsu
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, Washington
| | - Simon Horslen
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, Washington
| |
Collapse
|
42
|
Karagiannakis DS, Voulgaris T, Siakavellas SI, Papatheodoridis GV, Vlachogiannakos J. Evaluation of portal hypertension in the cirrhotic patient: hepatic vein pressure gradient and beyond. Scand J Gastroenterol 2019; 53:1153-1164. [PMID: 30345856 DOI: 10.1080/00365521.2018.1506046] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Portal hypertension (PH) is a major complication of liver cirrhosis, as it predisposes to the development of serious clinical manifestations such as ascites, hepatic encephalopathy and variceal bleeding. Till now, the measurement of hepatic vein pressure gradient (HVPG) is the gold standard method to ascertain the presence and significance of PH, as many studies have shown its correlation with the appearance of varices and the possibility of variceal bleeding. However, the invasiveness of this procedure makes it difficult to be used in daily clinical practice. Several noninvasive methods with adequate capability of evaluating liver fibrosis, including elastographic techniques, are currently used as alternatives to HVPG in order to assess the presence and the severity of PH. The aim of this paper is to express an overview of the literature about the actual role of HVPG and all available noninvasive tests on the prediction of development of PH complications, to highlight their advantages and their potential limitations, and to provide the latest trends on clinical practice.
Collapse
Affiliation(s)
- D S Karagiannakis
- a Academic Department of Gastroenterology , Laiko General Hospital Medical School University of Athens , Athens , Greece
| | - T Voulgaris
- a Academic Department of Gastroenterology , Laiko General Hospital Medical School University of Athens , Athens , Greece
| | - S I Siakavellas
- a Academic Department of Gastroenterology , Laiko General Hospital Medical School University of Athens , Athens , Greece
| | - G V Papatheodoridis
- a Academic Department of Gastroenterology , Laiko General Hospital Medical School University of Athens , Athens , Greece
| | - J Vlachogiannakos
- a Academic Department of Gastroenterology , Laiko General Hospital Medical School University of Athens , Athens , Greece
| |
Collapse
|
43
|
Samarasena JB, Chang KJ. Endoscopic Ultrasound-Guided Interventions for the Measurement and Treatment of Portal Hypertension. Gastrointest Endosc Clin N Am 2019; 29:311-320. [PMID: 30846155 DOI: 10.1016/j.giec.2018.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The number of endoscopic ultrasound (EUS)-guided interventions is rapidly growing within advanced endoscopy. EUS offers high-resolution imaging of mediastinal and intra-abdominal vasculature, which can be targeted for various interventions, hence a growing number of studies have explored EUS-guided vascular catheterization. Potential clinical applications of EUS-guided portal venous access include angiography, measurement of the portosystemic pressure gradient, and EUS-guided transhepatic intrahepatic portosystemic shunt creation. This article reviews different devices and techniques used in these applications.
Collapse
Affiliation(s)
- Jason B Samarasena
- Division of Gastroenterology and Hepatology, University of California - Irvine, 333 The Boulevard West, Suite 400, Orange, CA 92868, USA
| | - Kenneth J Chang
- Division of Gastroenterology and Hepatology, University of California - Irvine, 333 The Boulevard West, Suite 400, Orange, CA 92868, USA.
| |
Collapse
|
44
|
Non-invasive response prediction in prophylactic carvedilol therapy for cirrhotic patients with esophageal varices. J Hepatol 2019; 70:412-422. [PMID: 30389550 DOI: 10.1016/j.jhep.2018.10.018] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/15/2018] [Accepted: 10/21/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Non-selective beta-blockers (NSBBs) are the mainstay of primary prophylaxis of esophageal variceal bleeding in patients with liver cirrhosis. We investigated whether non-invasive markers of portal hypertension correlate with hemodynamic responses to NSBBs in cirrhotic patients with esophageal varices. METHODS In this prospective cohort study, 106 cirrhotic patients with high-risk esophageal varices in the derivation cohort received carvedilol prophylaxis, and completed paired measurements of hepatic venous pressure gradient, liver stiffness (LS), and spleen stiffness (SS) at the beginning and end of dose titration. LS and SS were measured using acoustic radiation force impulse imaging. A prediction model for hemodynamic response was derived, and subject to an external validation in the validation cohort (63 patients). RESULTS Hemodynamic response occurred in 59 patients (55.7%) in the derivation cohort, and in 33 patients (52.4%) in the validation cohort, respectively. Multivariate logistic regression analysis identified that ΔSS was the only significant predictor of hemodynamic response (odds ratio 0.039; 95% confidence interval 0.008-0.135; p <0.0001). The response prediction model (ModelΔSS = 0.0490-2.8345 × ΔSS; score = (exp[ModelΔSS])/(1 + exp[ModelΔSS]) showed good predictive performance (area under the receiver-operating characteristic curve [AUC] = 0.803) using 0.530 as the threshold value. The predictive performance of the ModelΔSS in the validation set improved using the same threshold value (AUC = 0.848). CONCLUSION A new model based on dynamic changes in SS exhibited good performance in predicting hemodynamic response to NSBB prophylaxis in patients with high-risk esophageal varices. LAY SUMMARY Non-selective beta-blockers are the mainstay of primary prophylaxis to prevent variceal bleeding in patients with cirrhosis and high-risk esophageal varices. This prospective study showed that a prediction model based on changes in spleen stiffness before vs. after dose titration might be a non-invasive marker for response to prophylactic non-selective beta-blocker (carvedilol) therapy in patients with cirrhosis and high-risk esophageal varices. ClinicalTrials.gov Identifier: NCT01943318.
Collapse
|
45
|
Kockerling D, Nathwani R, Forlano R, Manousou P, Mullish BH, Dhar A. Current and future pharmacological therapies for managing cirrhosis and its complications. World J Gastroenterol 2019; 25:888-908. [PMID: 30833797 PMCID: PMC6397723 DOI: 10.3748/wjg.v25.i8.888] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/17/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
Due to the restrictions of liver transplantation, complication-guided pharmacological therapy has become the mainstay of long-term management of cirrhosis. This article aims to provide a complete overview of pharmacotherapy options that may be commenced in the outpatient setting which are available for managing cirrhosis and its complications, together with discussion of current controversies and potential future directions. PubMed/Medline/Cochrane Library were electronically searched up to December 2018 to identify studies evaluating safety, efficacy and therapeutic mechanisms of pharmacological agents in cirrhotic adults and animal models of cirrhosis. Non-selective beta-blockers effectively reduce variceal re-bleeding risk in cirrhotic patients with moderate/large varices, but appear ineffective for primary prevention of variceal development and may compromise renal function and haemodynamic stability in advanced decompensation. Recent observational studies suggest protective, haemodynamically-independent effects of beta-blockers relating to reduced bacterial translocation. The gut-selective antibiotic rifaximin is effective for secondary prophylaxis of hepatic encephalopathy; recent small trials also indicate its potential superiority to norfloxacin for secondary prevention of spontaneous bacterial peritonitis. Diuretics remain the mainstay of uncomplicated ascites treatment, and early trials suggest alpha-adrenergic receptor agonists may improve diuretic response in refractory ascites. Vaptans have not demonstrated clinical effectiveness in treating refractory ascites and may cause detrimental complications. Despite initial hepatotoxicity concerns, safety of statin administration has been demonstrated in compensated cirrhosis. Furthermore, statins are suggested to have protective effects upon fibrosis progression, decompensation and mortality. Evidence as to whether proton pump inhibitors cause gut-liver-brain axis dysfunction is conflicting. Emerging evidence indicates that anticoagulation therapy reduces incidence and increases recanalisation rates of non-malignant portal vein thrombosis, and may impede hepatic fibrogenesis and decompensation. Pharmacotherapy for cirrhosis should be implemented in accordance with up-to-date guidelines and in conjunction with aetiology management, nutritional optimisation and patient education.
Collapse
Affiliation(s)
- David Kockerling
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Rooshi Nathwani
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Roberta Forlano
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Pinelopi Manousou
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Benjamin H Mullish
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Ameet Dhar
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| |
Collapse
|
46
|
Boregowda U, Umapathy C, Halim N, Desai M, Nanjappa A, Arekapudi S, Theethira T, Wong H, Roytman M, Saligram S. Update on the management of gastrointestinal varices. World J Gastrointest Pharmacol Ther 2019; 10:1-21. [PMID: 30697445 PMCID: PMC6347650 DOI: 10.4292/wjgpt.v10.i1.1] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/24/2018] [Accepted: 12/11/2018] [Indexed: 02/06/2023] Open
Abstract
Cirrhosis of liver is a major problem in the western world. Portal hypertension is a complication of cirrhosis and can lead to a myriad of pathology of which include the development of porto-systemic collaterals. Gastrointestinal varices are dilated submucosal veins, which often develop at sites near the formation of gastroesophageal collateral circulation. The incidence of varices is on the rise due to alcohol and obesity. The most significant complication of portal hypertension is life-threatening bleeding from gastrointestinal varices, which is associated with substantial morbidity and mortality. In addition, this can cause a significant burden on the health care facility. Gastrointestinal varices can happen in esophagus, stomach or ectopic varices. There has been considerable progress made in the understanding of the natural history, pathophysiology and etiology of portal hypertension. Despite the development of endoscopic and medical treatments, early mortality due to variceal bleeding remains high due to significant illness of the patient. Recurrent variceal bleed is common and in some cases, there is refractory variceal bleed. This article aims to provide a comprehensive review of the management of gastrointestinal varices with an emphasis on endoscopic interventions, strategies to handle refractory variceal bleed and newer endoscopic treatment modalities. Early treatment and improved endoscopic techniques can help in improving morbidity and mortality.
Collapse
Affiliation(s)
- Umesha Boregowda
- Department of Gastroenterology and Hepatology, University of California San Francisco, Fresno, CA 93721, United States
| | - Chandraprakash Umapathy
- Department of Gastroenterology and Hepatology, University of California San Francisco, Fresno, CA 93721, United States
| | - Nasir Halim
- Department of Gastroenterology and Hepatology, University of California San Francisco, Fresno, CA 93721, United States
| | - Madhav Desai
- Department of Gastroenterology and Hepatology, Kansas University Medical Center, Kansas City, KS 66160, United States
| | - Arpitha Nanjappa
- Department of Gastroenterology and Hepatology, University of California San Francisco, Fresno, CA 93721, United States
| | | | - Thimmaiah Theethira
- Department of Gastroenterology and Hepatology, University of California San Francisco, Fresno, CA 93721, United States
| | - Helen Wong
- Department of Gastroenterology and Hepatology, VA Central California Healthcare System, Fresno, CA 93703, United States
| | - Marina Roytman
- Department of Gastroenterology and Hepatology, University of California San Francisco, Fresno, CA 93721, United States
| | - Shreyas Saligram
- Department of Gastroenterology and Hepatology, University of California San Francisco, Fresno, CA 93721, United States
- Department of Gastroenterology and Hepatology, VA Central California Healthcare System, Fresno, CA 93703, United States
| |
Collapse
|
47
|
Duah A, Nkrumah KN, Tachi K. Oesophageal varices in patients with liver cirrhosis attending a major tertiary hospital in Ghana. Pan Afr Med J 2018; 31:230. [PMID: 31447987 PMCID: PMC6691363 DOI: 10.11604/pamj.2018.31.230.16657] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/22/2018] [Indexed: 12/21/2022] Open
Abstract
Introduction Oesophageal variceal bleeding is a potentially fatal consequence of portal hypertension in cirrhotic patients. In Ghana, bleeding oesophageal varices (OV) are a significant cause of acute upper gastrointestinal bleeding with comparatively high mortality. This study was to determine the prevalence of OV and its clinical correlate in cirrhotic patients. Methods This was a cross sectional hospital based study of 149 subjects with liver cirrhosis from 5thNovember, 2015 to 4th November, 2016. Demographic and other clinical data were collected using standardized questionnaire. Liver function, full blood count, HBsAg and anti-HCV Ab tests were done for all patients. All patients underwent an abdominal ultrasound to assess liver and document ascites. Upper GI endoscopy (UGIE) was done to screen for and grade varices. Results A total of 149 patients with a mean age of 45 ± 12.28 years were evaluated. There were 77.85% and 22.15% men and women respectively, with a male to female ratio of 3.5:1. By Child-Pugh Classification, 12 (8.16%) patients were in class A, 64 (43.54%) in class B and 71 (48.3%) in class C at presentation. On UGIE, 135 (90.60%) had varices and 14 patients (9.40%) had no varices. One hundred and eleven of the varices (82.22%) were large varices and the rest (17.78%) small varices. Conclusion Majority of cirrhotic patients present late with advance disease to this referral centre. Most have large varices on their first screening endoscopy. Prophylactic treatment should be considered for all cirrhotics especially patients with decompensated liver cirrhosis when UGIE cannot be done immediately.
Collapse
Affiliation(s)
| | - Kofi Nyaako Nkrumah
- Department of Medicine and Therapeutics School of Medicine and Dentistry, College of Health Science, University of Ghana, Korle-Bu, Accra, Ghana
| | - Kenneth Tachi
- Department of Medicine and Therapeutics School of Medicine and Dentistry, College of Health Science, University of Ghana, Korle-Bu, Accra, Ghana
| |
Collapse
|
48
|
Hsieh YC, Lee KC, Wang YW, Yang YY, Hou MC, Huo TI, Lin HC. Correlation and prognostic accuracy between noninvasive liver fibrosismarkers and portal pressure in cirrhosis: Role of ALBI score. PLoS One 2018; 13:e0208903. [PMID: 30540824 PMCID: PMC6291250 DOI: 10.1371/journal.pone.0208903] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 11/27/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The role of noninvasive liver fibrosis markers which were developed to evaluate the severity of chronic liver disease remains unclear in cirrhosis. AIMS To evaluate the correlation between noninvasive markers and hemodynamic parameters and their prognostic performance in cirrhotic patients. METHODS A total of 242 cirrhotic patients undergoing hemodynamic study were analyzed. The correlations between noninvasive models, including FIB-4, aspartate aminotransferase to platelet ratio index, cirrhosis discriminant score, Lok index, Goteborg University Cirrhosis Index, and albumin-bilirubin (ALBI) score and hemodynamic parameters were investigated, along with their predictive accuracy for short- and long-term survival. RESULTS There was a significant correlation between all noninvasive markers and hepatic venous pressure gradient (HVPG), and ALBI score had the best correlation (r = 0.307, p<0.001). For the prediction of 3-month and 6-month mortality, serum sodium (sNa) levels had the highest area under curve (AUC; 0.799 and 0.818, respectively) among all parameters, and ALBI score showed the best performance (AUC = 0.691 and 0.740, respectively) compared with other 5 noninvasive models. Of 159 patients with low MELD scores (<14), high ALBI score (>-1.4) and low sNa (<135 mmol/L) predicted early mortality. In the Cox multivariate model, ALBI, MELD, HVPG and sNa were independent predictors of long-term survival. CONCLUSIONS Among noninvasive markers, ALBI score is best correlated with HVPG and associated with short-term outcome in cirrhotic patients. A high ALBI score and low sNa identify high-risk patients with low MELD scores. High MELD, HVPG, ALBI and low sNa levels are independent predictors of survival. Independent studies are required to confirm our findings.
Collapse
Affiliation(s)
- Yun-Cheng Hsieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ying-Wen Wang
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ying-Ying Yang
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Teh-Ia Huo
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Institute of Pharmacology, National Yang-Ming University School of Medicine, Taipei, Taiwan
- * E-mail: (TH); (MCL)
| | - Han-Chieh Lin
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- * E-mail: (TH); (MCL)
| |
Collapse
|
49
|
Piyachaturawat P, Siramolpiwat S, Sonsiri K, Tangkijvanich P, Treeprasertsuk S. Changes in transient elastography in early cirrhotic patients after receiving nonselective B-blocker for primary variceal bleeding prophylaxis: Three-month follow up. JGH OPEN 2018; 2:172-177. [PMID: 30483585 PMCID: PMC6206988 DOI: 10.1002/jgh3.12063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 04/29/2018] [Accepted: 05/07/2018] [Indexed: 12/11/2022]
Abstract
Background and Aim A nonselective B‐blocker (NSBB) is recommended for primary prophylaxis of variceal bleeding. The impact of treatment with NSBB on modulating transient elastography (TE) has not been reported. The aim of the study is to investigate the effect of NSBB treatment on TE in early cirrhotic patients. Methods In this prospective study, we enrolled all early cirrhotic patients who underwent esophagogastroduodenoscopy (EGD) and showed small esophageal varices (EV) at our institute for a period of 1 year. The TE and heart rate (HR) of all participants were measured before and 3 months after receiving NSBB. Results Thirty‐nine patients receiving propanolol for 3 months were analyzed. There were 16 patients in the HR responder group (41%) and 23 patients in the HR nonresponder group (59%). The reduction of TE was preferably found in the HR responder group compared with the HR nonresponder group, in which mean changes in TE were −5.6 and −0.7 kPa, respectively (P = 0.23). In addition, we categorized the patients using their TE responses. Twenty‐five patients (64.1%) showed reduced TE during the follow‐up period, in which the mean TE value change was −2.94 kPa. Using correlation analysis, TE and HR responses were insignificantly correlated (r = 0.23, P = 0.15). Conclusion The NSBB administered for 3 months mainly improved TE value in early cirrhotic patients even though the changes of HR and TE did not correlate. Further study is needed to confirm whether the monitoring of TE change may be a better predictor for pharmacological response than the HR response.
Collapse
Affiliation(s)
- Panida Piyachaturawat
- Department of Medicine, Faculty of Medicine Chulalongkorn University Bangkok Thailand.,Gastroenterology Unit, Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | - Sith Siramolpiwat
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine Thammasat University Pathumthani Thailand
| | - Kanokwan Sonsiri
- Gastroenterology Unit, Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | - Pisit Tangkijvanich
- Liver Research Unit, Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | - Sombat Treeprasertsuk
- Department of Medicine, Faculty of Medicine Chulalongkorn University Bangkok Thailand.,Gastroenterology Unit, Faculty of Medicine Chulalongkorn University Bangkok Thailand
| |
Collapse
|
50
|
Reiberger T, Bucsics T, Paternostro R, Pfisterer N, Riedl F, Mandorfer M. Small Esophageal Varices in Patients with Cirrhosis-Should We Treat Them? CURRENT HEPATOLOGY REPORTS 2018; 17:301-315. [PMID: 30546995 PMCID: PMC6267385 DOI: 10.1007/s11901-018-0420-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW The natural history and classification systems of small varices (≤ 5 mm in diameter) in cirrhotic patients with portal hypertension are summarized. Studies that assessed the course of and therapeutic intervention for small varices are discussed. RECENT FINDINGS Current non-invasive methods show suboptimal sensitivity to detect small varices in patients with cirrhosis. Next to etiological therapy, hepatic venous pressure gradient (HVPG)-guided non-selective betablocker or carvedilol treatment has shown to impact on natural history of small varices. SUMMARY The main therapeutic focus in cirrhotic patients with small varices is the cure of the underlying etiology. The optimal management of small varices should include measurement of HVPG. A pharmacological decrease in HVPG by non-selective betablocker therapy of ≥ 10% reduces the risk of progression to large varices, first variceal bleeding, and hepatic decompensation. If HVPG is not available, we would recommend carvedilol 12.5 mg q.d. for treatment of small varices in compensated patients without severe ascites. Only if small esophageal varices (EV) are not treated or in hemodynamic non-responders, follow-up endoscopies should be performed in 1-2 years of intervals considering the activity of liver disease or if hepatic decompensation occurs.
Collapse
Affiliation(s)
- Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Theresa Bucsics
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Nikolaus Pfisterer
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - Florian Riedl
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology, Medicine II, Universitätsklinikum St. Pölten, St. Pölten, Austria
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|