Evaluation of three "beyond Baveno VI" criteria to safely spare endoscopies in compensated advanced chronic liver disease

Performance of Baveno VII criteria for the screening of varices needing treatment in patients with biliary atresia

OBJECTIVE

Biliary atresia (BA) is the leading cause of liver cirrhosis and chronic liver insufficiency in children in the world. Gastroesophageal varices bleeding is an ominous complication of cirrhosis in BA patients and is associated with high morbidity and mortality. In this study, we aimed to investigate the utility of noninvasive Baveno VI and Baveno VII criteria for the screening of varices need treatment (VNT) and the need for liver transplantation in BA patients.

METHODS

This study enrolled 48 BA patients (23 females and 25 males) who underwent an esophagogastroduodenoscopy (EGD) and transient elastography at a mean age of 11.18 ± 1.48 years; the clinical data were surveyed in a retrospective design.

RESULTS

The sensitivity and negative predictive value of Baveno VI and Baveno VII criteria for the prediction of VNT in BA patients are both 100% and 100%, respectively. The VNT missing rate of Baveno VI and Baveno VII criteria are both 0% in our cohort. The Baveno VI, expanded Baveno VI, and Baveno VII criteria are also predictive of the need for liver transplantation in our cohort (OR = 10.33, 4.24, and 21.33; p = 0.009, 0.03, and 0.007, respectively).

CONCLUSION

The Baveno VI and Baveno VII criteria are useful for the screening of VNT and minimize non-necessary invasive EGD in BA patients with low VNT missing rates. The Baveno VI, expanded Baveno VI, and Baveno VII criteria are associated with the need for liver transplantation.

Non-invasive diagnosis and follow-up of portal hypertension

Compensated advanced chronic liver disease (cACLD) describes the spectrum of advanced fibrosis/cirrhosis in asymptomatic patients at risk of developing clinically significant portal hypertension (CSPH, defined by a hepatic venous pressure gradient (HVPG) ≥10 mmHg). Patients with cACLD are at high risk of liver-related morbidity and mortality. In patients at risk of chronic liver disease, cACLD is strongly suggested by a liver stiffness (LSM) value >15 kPa or clinical/biological/radiological signs of portal hypertension, and ruled out by LSM <10 kPa, or Fibrotest® ≤0.58, or Fibrometer® ≤0.786. Patients with chronic liver disease (excluding vascular diseases) with a LSM <10 kPa are at low risk of developing portal hypertension complications. The presence of CSPH can be strongly suspected when LSM is ≥20 kPa. In a patient without clinical, endoscopic or radiological features of portal hypertension, measurement of the HVPG is recommended before major liver or intra-abdominal surgery, before extra-hepatic transplantation and in patients with unexplained ascites. Endoscopic screening for oesophageal varices can be avoided in patients with LSM <20 kPa and a platelet count >150 G/L (favourable Baveno VI criteria) at the time of diagnosis. There is no non-invasive method alternative for oeso-gastroduodenal endoscopy in patients with unfavourable Baveno criteria (liver stiffness ≥20 kPa or platelet count ≤50 G/l). Platelet count and liver stiffness measurements must be performed once a year in patients with cACLD with favourable Baveno VI criteria at the time of diagnosis. A screening oeso-gastroduodenal endoscopy is recommended if Baveno VI criteria become unfavourable.

Noninvasive assessment oesophageal varices: impact of the Baveno VI criteria

PURPOSE OF REVIEW

In 2015, as a consequence of the high development in noninvasive tests, Baveno VI consensus recommended for the first time the use of a prediction rule (liver stiffness <20kPa and platelet count > 150000) to identify patients at low risk of having varices and that could circumvent endoscopy. These became known as the Baveno VI criteria. We review here the data validating Baveno VI criteria and we discuss the attempts of expanding these criteria.

RECENT FINDINGS

We report 28 studies assessing the performance of Baveno VI criteria showing a pooled 99% negative predictive value for ruling out high-risk varices. Performance is not affected by the cause of cirrhosis. Different attempts at expanding these criteria show suboptimal performance. Nonelastography-based criteria require further validation.

SUMMARY

Baveno VI criteria can be safely used to avoid endoscopy in a substantial proportion of patients with compensated cirrhosis. The progressive change in approach to the management of compensated cirrhosis, progressively focusing on treating portal hypertension with beta-blockers independently of the presence of varices, might render these criteria less relevant.

Prediction model of high risk esophageal and gastric varices in patients with compensated hepatitis B cirrhosis: A case-control study

BACKGROUND

Upper gastrointestinal endoscopy is the gold standard for judging esophageal and gastric varices in patients with liver cirrhosis. There is no effective noninvasive prediction model for high-risk esophageal and gastric fundus varices.

AIM

To construct and validate a prediction model of high-risk esophageal varices in patients with compensated cirrhosis.

METHODS

The clinical data of 276 patients with compensated hepatitis B cirrhosis treated from January 2018 to December 2020 at Tianjin Beichen Hospital and Armed Police Special Medical Center were analyzed retrospectively. A total of 81 patients with high-risk varices and 195 patients with non-high-risk varices were included. Logistic regression analysis was used to identify the independent risk factors for high-risk esophageal and gastric varices in patients with compensated hepatitis B cirrhosis, and a predictive model was constructed using these factors. Receiver operating characteristic (ROC) curve analysis was performed to verify the prediction efficiency of the constructed model.

RESULTS

Logistic regression showed that albumin (ALB) level (odds ratio [OR] = 0.825, 95% confidence interval [CI]: 0.779-0.873, P = 0.000), platelet (PLT) count (OR = 0.934, 95%CI: 0.895-0.975, P = 0.001), and portal vein width (OR = 1.481, 95%CI: 1.141-1.922, P = 0.002) were risk factors for high risk varicose veins in patients with compensated hepatitis B cirrhosis. The equation of the prediction model constructed based on these factors was: Y = -0.192 × ALB (g/L) -0.068 × PLT count (10⁹/L) + 0.393 × portal vein width (mm) + 6.87. The area under the ROC curve of the model for predicting high-risk esophagogastric varices was 0.976. The best diagnostic cut-off point was 0.767, and the sensitivity and specificity were 0.968 and 0.882, respectively.

CONCLUSION

The prediction model of high-risk esophagogastric varices based on PLT, ALB, and portal vein width has high diagnostic efficiency.

A Novel Score to Predict Esophageal Varices in Patients with Compensated Advanced Chronic Liver Disease

BACKGROUND AND AIMS

Several criteria have been described to noninvasively predict the presence of high-risk esophageal varices in patients with compensated advanced chronic liver disease (cACLD). However, a recent study showed that treatment with β blockers could increase decompensation-free survival in patients with clinically significant portal hypertension, thereby making it important to predict the presence of any esophageal varices. We aimed to develop a simple scoring system to predict any esophageal varices.

METHODS

We retrospectively reviewed patients who had vibration-controlled transient elastography (VCTE) at Cook County Hospital, Chicago, USA. Patients with cACLD and liver stiffness measurement (LSM) ≥ 10 kPa with esophagogastroduodenoscopy performed within one year of VCTE were analyzed. We generated a novel score to predict esophageal varices, using the beta coefficient of predictive variables. The score was validated in an external cohort at the University of Iowa Hospital, USA.

RESULTS

There were 372 patients in the development cohort and 200 patients in the validation cohort. LSM, platelet count, and albumin were identified as predictors of esophageal varices and were included for generating the Cook County score as "platelet count * - 0.0155872 + VCTE score * 0.0387052 + albumin * - 0.8549209." The area under receiver operating curve for our score was 0.86 for any varices and 0.85 for high risk varices and avoided more endoscopies than the expanded Baveno VI criteria while maintaining a very low miss rate (negative predictive value > 99%).

CONCLUSION

We propose a new, highly accurate, and easy-to-use scoring system to predict the presence of not only high-risk but any esophageal varices in patients with cACLD.

The role of liver and spleen elastography in advanced chronic liver disease

Portal hypertension is the main driver of complications in patients with advanced chronic liver disease (ACLD). In the last decade, many non-invasive tests, such us liver and spleen elastography, have been proposed and validated for the identification of patients with clinically significant portal hypertension (CSPH) and its complications, mainly hepatic decompensation and liver-related morbidity and mortality. Moreover, elastography accurately stratifies for the risk of HCC development, HCC recurrence and decompensation after liver surgery. Recent studies suggest a role of SSM in monitoring response to treatments and interventions in ACLD, such as viral eradication, non-selective beta-blockers and transjugular intrahepatic portosystemic shunt placement. However, one of the most indications to perform elastography in ACLD still remains the screening for esophageal varices. In fact, according to the Baveno VI consensus, liver stiffness measurement (LSM) <20 kPa and platelet count >150,000/mm³ can safely identify patients at low risk of varices requiring treatment (VNT) and could therefore avoid invasive upper invasive endoscopy; LSM>20-25 kPa can accurately rule-in CSPH in patients with viral etiology. Spleen stiffness measurement (SSM) is a direct surrogate of portal hypertension and has been demonstrated more accurate in predicting portal hypertension severity and VNT. A combined model including Baveno VI Criteria and SSM (≤46 kPa) can significantly increase the number of spared endoscopies (>40-50%), maintaining a low (<5%) of missed VNT.

Approaches to the Diagnosis of Portal Hypertension: Non-Invasive or Invasive Tests?

Portal hypertension is the main driver of complications in patients with advanced chronic liver disease (ACLD) and is defined by values of hepatic venous pressure gradient measurement (HVPG) >5 mmHg. Values of HVPG ≥10 mmHg determine the presence of clinically significant portal hypertension (CSPH), the main predictor of the risk of variceal bleeding, hepatic decompensation, and mortality. However, its measurement is invasive and requires high expertise, so its routine use outside third level centers or clinical trials is limited. In the last decades, several non-invasive tests (NITs) have been developed and validated for the diagnosis of portal hypertension. Among these, liver (LSM) and spleen stiffness measurement (SSM) are the most promising tools available, as they have been proven accurate to predict CSPH, high-risk esophageal varices, decompensation, and mortality in patients with ACLD. In the last Baveno VI Consensus proceedings, LSM evaluation was recommended for the first time for diagnosis of CSPH (LSM >20-25 kPa) and the screening of patients with a low probability of having high-risk varices (LSM <20 kPa and platelet count >150.000/mm³). In this review, we aimed to summarize the growing evidence supporting the use of non-invasive tests for the evaluation of portal hypertension in patients with chronic liver disease.

Screening varices in patients with HBV-related cirrhosis on antiviral therapy: Platelet alone or together with LSM

BACKGROUND & AIMS

Non-invasive assessment criteria to rule out high-risk varices (HRV) in compensated hepatitis B virus (HBV) cirrhosis on antiviral therapy remains unclear.

METHODS

HBV-related compensated cirrhotic patients who underwent screening endoscopy during antiviral therapy were enrolled and randomly divided into the derivation and validation sets. HRV were defined as medium to large varices or small varices with red signs. Univariate and multivariate logistic analysis were used to determine the parameters associated with HRV.

RESULTS

A total of 436 HBV-related compensated cirrhotic patients screened for varices were enrolled, the median duration of antiviral therapy was 4 years (IQR: 2.5-5.5 years). In the derivation set (N = 290, 17.2% with HRV), only platelet (PLT) count (OR = 0.972, 95% CI 0.961-0.984, P < .05) was independently associated with HRV, whereas liver stiffness measurement was not associated with the presence of HRV. With a PLT count cut-off value of 105 × 10⁹ /L, unnecessary endoscopies could be spared in 56.9% patients, with a 3.6%. risk of missing HRV. In the validation cohort (N = 146, 16.4% with HRV), the proportion of patients that could safely spare endoscopies (61.0%) identified by this PLT count cut-off value was higher than that obtained by using Baveno VI criteria (34.9%), with an acceptable risk of missing HRV (3.4%).

CONCLUSION

Compared with the 'Baveno VI criteria or beyond' criteria, PLT count higher than 105 × 10⁹ /L could safely spare more screening endoscopies without increasing the risk of missing HRV in patients with HBV-related compensated cirrhosis on antiviral therapy.

Spleen Stiffness Probability Index (SSPI): A simple and accurate method to detect esophageal varices in patients with compensated liver cirrhosis

INTRODUCTION AND OBJECTIVES

Recent findings pointed out that even low-risk esophageal varices (EVs) are markers of severe prognosis. Accordingly, we analyzed spleen stiffness (SS) as a non-invasive method to predict EVs of any grade in a cohort of patients with compensated liver cirrhosis.

METHOD

We measured SS and liver stiffness (LS) using point-Shear-Wave Elastography (pSWE) with Philips Affiniti 70 system in 210 cirrhotic patients who had undergone endoscopic screening for EVs. We compared SS and LS predictive capability for EVs of any grade.

RESULTS

SS was higher in cirrhotic patients with EVs if compared to patients without EVs (p<0.001). The cut-off analysis detected 31kPa (100% sensitivity and negative predictive value) as the value to rule-out EVs and 69kPa (100% specificity and positive predictive value) to rule-in EVs. Besides, we developed the Spleen Stiffness Probability Index (SSPI), that can provide a probability of presence/absence of EVs. SSPI was the best model according to all discriminative and calibration metrics (AIC=120, BIC=127, AUROC=0.95, Pseudo-R2=0.74). SS demonstrated higher correlation with spleen bipolar diameter and spleen surface (r=0.52/0.55) if compared to LS (r=0.30/0.25) - and with platelet count as well (r=0.67 vs r=0.4).

CONCLUSION

SS showed significantly higher performance than other parameters, proving to be the best non-invasive test in the screening of EVs: by directly applying SS cut-off of 31kPa, our department could have safely avoided endoscopy in 36% of patients. Despite cut-off analyses, it was possible to create a probability model that could further stratify low-risk from high-risk patients (for any grade of EVs).

Validation and comparison of non-invasive prediction models based on liver stiffness measurement to identify patients who could avoid gastroscopy

Several non‐invasive tests (NITs) based on liver stiffness measurement (LSM) have been developed to rule out varices needing treatment (VNT), including the Baveno VI criteria (B6C), the expanded Baveno VI criteria (EB6C), the LSM-spleen diameter to platelet ratio score (LSPS), and the VariScreen algorithm. We aimed to validate and compare those NITs in patients with compensated advanced chronic liver disease (cACLD). This retrospective study enrolled 354 patients with cACLD; LSM, platelet count (PLT), international normalized ratio (INR), gastroscopy and spleen diameter (SD) were collected. VNT prevalence was 28.5%. In comparison, patients with VNT included higher LSM, INR, and SD and lower PLT. Gastroscopies were spared for 27.7% of patients using the B6C with 1.0% VNT missed rate, 47.2% of patients using the EB6C with 5.9% VNT missed rate, 57.6% of patients using the LSPS with 9.9% VNT missed rate, and 45.5% of patients using the VariScreen algorithm with 3.0% VNT missed rate. Only the B6C and the VariScreen algorithm could safely avoid gastroscopies, and the VariScreen algorithm spared more gastroscopies than the B6C. The results were consistent with the previous when performed subgroup analysis. In conclusion, the VariScreen algorithm performed the best and can be used in clinical.

Development and Validation of an Easy-to-Use Risk Scoring System for Screening High-Risk Varices in Patients with HBV-Related Compensated Advanced Chronic Liver Disease

BACKGROUND

A large portion of patients with compensated advanced chronic liver disease (cACLD) do not have varices or only have low risk varices.

AIMS

To create and validate an easy-to-use risk scoring system to identify high-risk varices (HRV) and spare esophagogastroduodenoscopy (EGD) in patients with hepatitis B virus (HBV)-related cACLD.

METHODS

In total, 334 patients with HBV-related cACLD who had undergone routine laboratory tests and ultrasound examination were enrolled. Multivariate logistic regression analysis was used to determine which variables were the independent risk factors for the presence of HRV, so as to establish the scoring system for screening HRV. The criteria were tested in a training cohort with 221 patients and validated in a validation cohort with 113 patients.

RESULTS

In the training cohort, the prevalence of HRV was 29.5%. Albumin (ALB) [OR 0.83; 95% confidence index (CI) 0.77-0.90; P < 0.0001], platelet count (PLT) (OR 0.96, 95% CI 0.96-0.99; P < 0.0001) and portal vein diameter (OR 1.40; 95% CI 1.15-1.71; P = 0.001) were independent risk factors for the presence of HRV. The negative predictive value was > 95%, when albumin-platelet-portal vein diameter varices scores (APP score) were < 0.24. One hundred twenty-five of 221 (56.6%) patients met an APP score < 0.24 with a 4.8% HRV miss rate. In the validation cohort, 59 of 113 (51.3%) patients met the APP score < 0.24 with a 1.7% HRV miss rate.

CONCLUSIONS

APP score is a potential model for safely screening HRV and sparing EGDs in patients with HBV-related cACLD.

Validation and Refinement of the Baveno VI Criteria for Ruling Out High-Risk Varices

In the past decade, numerous studies have evaluated the roles of noninvasive methods for diagnosing or excluding varices and high-risk varices in patients with liver cirrhosis. The Baveno VI criteria recommend the use of a simple algorithm based on a liver stiffness measurement < 20 kPa through transient elastography and a platelet count > 150 × 10⁹/L for ruling out high-risk varices in patients with compensated advanced chronic liver disease. A large number of studies have validated the clinical usefulness of Baveno VI criteria for excluding high-risk varices. Several strategies have been proposed to refine the Baveno VI criteria; however, currently there is no review to summarize the diagnostic accuracy and limitations of the Baveno VI criteria after extensive validation. In this review, we summarize the diagnostic accuracy and limitations of the Baveno VI criteria after extensive validation. We also discuss methods to refine these criteria.

Noninvasive scores for the prediction of esophageal varices and risk stratification in patients with cirrhosis

The primary purpose of variceal screening in patients with cirrhosis is to detect gastroesophageal varices at high risk of hemorrhage and implement preventative intervention(s). It was previously recommended that all patients with cirrhosis undergo initial and periodic longitudinal variceal screening via upper endoscopy. However, there has been growing interest and methods to identify patients with cirrhosis who may not have clinically significant portal hypertension and therefore be unlikely to have varices requiring intervention or benefit from upper endoscopy. Because the population of patients with compensated advanced chronic liver disease continues to grow, it is neither beneficial nor cost-effective to perform endoscopic variceal screening in all patients. Therefore, there is ongoing research into the development of methods to non-invasively risk stratify patients with cirrhosis for the presence of high-risk esophageal varices and effectively limit the population that undergoes endoscopic variceal screening. This is particularly important and timely in light of increasing healthcare reform and barriers to healthcare. In this review, we discuss and compare, with respect to test characteristics and clinical applicability, the available methods used to non-invasively predict the presence of esophageal varices.

Validation of the Combined Model Based on Platelet Count and Albumin to Rule out High-Risk Varices in Liver Cirrhosis

Background

The Baveno VI criteria based on platelet count and liver stiffness, measured by transient elastography (TE), have been proposed to rule out high-risk varices (HRV) defined as medium or large-sized varices or the presence of high-risk stigmata (cherry red spots and red wale marks). However, TE is not available in all hospitals. Recently, the Rete Sicilia Selezione Terapia hepatitis C virus (RESIST-HCV) criteria recommended that cirrhotic patients with a platelet count > 120000/μL and serum albumin > 36 g/L could avoid esophagogastroduodenoscopy (EGD) screening for HRV.

Aim

We aimed to validate the performance of the RESIST-HCV criteria in two cohorts predominantly characterized with hepatitis B infection.

Methods

Patients with compensated cirrhosis who had blood tests within three months of performing EGD and TE were enrolled retrospectively from two centers. RESIST-HCV criteria were applied to identify patients who did not require EGD screening.

Results

This study included 188 patients from the Xingtai cohort (28 (14.9%) with HRV) and 104 patients from the Beijing cohort (19 (18.3%) with HRV). Of the patients who met the RESIST-HCV criteria (83 in the Xingtai cohort and 26 in the Beijing cohort), 0 and 1 had HRV, respectively, accounting for 44.1% (Xingtai cohort) and 25% (Beijing cohort) of endoscopies that were unnecessary. In the combined cohort, 109 (37.3%) patients met the RESIST-HCV criteria, only 1 (0.9%) HRV was missed, and the negative predictive value was 99.1%. Baveno VI and Expanded Baveno VI criteria spared 15.6% and 23.3% of EGDs, respectively, while missing 0% and 4.8% of HRV, respectively.

Conclusions

In our population, the combined criteria based on platelet count and serum albumin performed well, saving 30-40% of EGDs and correctly identifying 99.1% of patients who could safely avoid screening endoscopies for high-risk varices in compensated cirrhotic patients.

Baveno Criteria Safely Identify Patients With Compensated Advanced Chronic Liver Disease Who Can Avoid Variceal Screening Endoscopy: A Diagnostic Test Accuracy Meta-Analysis

Background: The Baveno VI Consensus Workshop defined criteria (liver stiffness measured by transient elastography <20 kPa and platelet count >150 × 10⁹ cells/L) to identify those patients with compensated advanced chronic liver diseases (cACLD) who are unlikely to have varices needing treatment (VNTs) and can safely avoid variceal screening endoscopy. This meta-analysis aimed to quantify the safety and efficacy of these criteria in suspected cACLD with liver stiffness >10 kPa and in compensated chronic liver diseases (cCLD) irrespective of liver stiffness. Methods: A systematic search was conducted in nine databases for studies discussed cACLD or cCLD and tested Baveno criteria against variceal screening endoscopy. The main safety and efficacy endpoints were missed VNT rate and spared endoscopy rate (SER), respectively; calculated with the random effect model. Pooled sensitivity, specificity, and area under the curve (AUC) were calculated with the hierarchical summary receiver operating characteristic model. For all outcome measures, 95% confidence intervals were computed. Heterogeneity was tested with I ²-statistics. Results: The search yielded 13 studies including 4,464 patients which reported on suspected cACLD. Pooled missed VNT rate was 0.3% (0.1-0.6%; I ² = 45.5%), pooled SER was 32.8% (24.8-41.4%; I ² = 97.0%). Sensitivity, specificity, and AUC of Baveno criteria were 97% (95-98%), 41% (27-57%), and 96% (94-97%), respectively. In the subgroups of cACLD from hepatitis C and B viruses, non-alcoholic fatty liver disease/steatohepatitis, or alcohol, missed VNT rates were 0.0% (0.0-0.3%), 1.2% (0.4-2.2%), 0.0% (0.0-1.3%), or 0.0% (0.0-0.4%), while SERs were 24.2% (20.5-28.1%), 24.9% (21.7-28.4%), 38.6% (10.9-70.8%), or 27.0% (16.9-38.4%), respectively. If we expanded the study population to cCLD, 27 studies included 7,534 patients. Missed VNT rate was 0.2% (0.1-0.5%; I ² = 39.8%) with a SER of 30.5% (25.2-36.2%; I ² = 96.1%) while Se, Sp, and AUC were 97% (93-99%), 35% (27-44%), and 80% (77-84%), respectively. Conclusions: The application of Baveno criteria significantly reduces the number of unnecessary variceal screening endoscopies while being safe: cACLD patients with liver stiffness <20 kPa and platelet count > 150 × 10⁹ cells/L carry a very low chance (i.e., 0.3%) of having VNTs. The criteria preserve low missed VNT rate with lower diagnostic performance among cCLD patients.