Prediction of the varices needing treatment with non-invasive tests in patients with compensated advanced chronic liver disease

Non-invasive predictors of the first episode of bleeding from esophageal varices in patients with liver cirrhosis awaiting transplantation

Background. To date, various non-invasive techniques or tests have been proposed that can identify a high risk of bleeding from esophageal varices. Despite a significant number of studies revealing the presence of venous varices as a likely factor for the development of bleeding due to their rupture, data on predictors of the first episode of bleeding are few and often contradictory.

Objective. To determine non-invasive independent predictors of the first episode of bleeding in patients waiting for liver transplantation.

Material and methods. A comparative retrospective study was conducted in 729 patients with decompensated cirrhosis who were on the waiting list for liver transplantation. We analyzed demographic, clinical and laboratory parameters, MELD-Na, Child-Turcotte-Pugh scores, FIB-4 Index, APRI, AST/ALT ratio; we determined the liver stiffness, spleen diameter, studied the liver stiffness-spleen diameter to platelet ratio risk score (LSPS model), platelet count/spleen diameter ratio in the groups of patients with the first episode of bleeding (n=334) and without it (n=395). The accumulated risks in the compared groups were assessed using a model of proportional hazards (Cox regression) in univariate and multivariate analysis.

Results. During 48 months of follow-up from the time of patient placement on the liver transplant waiting list, primary bleeding events developed in 45.8%. The risk of developing the first episode of bleeding progressively increased with LSPS >3.5 and reached maximum values in patients awaiting liver transplantation within 48 months of inclusion in the waiting list, while with LSPS <3.5 the risk was minimal.

Conclusion. Independent non-invasive predictors of the first episode of bleeding are a high level of AST, a high fibrosis index (FIB-4), a decrease in the ratio of platelet count/spleen diameter and a high LSPS value. Their application in clinical practice will improve the results of dispensary and screening examinations of patients with portal hypertension.

Magnetic resonance elastography (MRE) outperforms acoustic force radiation impulse (ARFI) in predicting oesophageal varices in obese NAFLD cirrhosis

PURPOSE

Liver stiffness measurement (LSM) by transient elastography has been shown to underperform in high-risk varices (HRVs) prediction in obese non-alcoholic fatty liver disease (NAFLD) compensated cirrhosis (CC). LSM by magnetic resonance elastography (MRE) and acoustic force radiation impulse (ARFI) has been shown to be useful in prediction of oesophageal varices (EVs), but has limited evidence in obese NAFLD-CC.

METHODS

Obese patients with NAFLD-CC who underwent MRE and ARFI for LSM and endoscopy for screening of varices were enrolled. Performance of MRE and ARFI for predicting EVs or HRVs was evaluated using area under receiver operating characteristics (AUROC) curves and regression analyses were performed for predictor variables.

RESULTS

One hundred eight patients [mean age 54.7 ± 9.6 years, median BMI, 28.5 (26.4-30.0) kg/m2. 72.2% diabetics, 45.4% hypertensive] were enrolled. Fifty-two (48.1%) had no varices, while 29 (26.8%) and 27 (25%) had low-risk varices (LRVs) and HRVs, respectively. MRE-LSM was higher in patients with LRVs (p = 0.01) or HRVs (p = 0.001) against those without varices. ARFI-LSM did not differ significantly between those without and with LRVs or HRVs (p > 0.05 for all). There was a low correlation between ARFI-LSM and MRE-LSM in the overall cohort (r = 0.19). Only platelet count (PC) [0.98 (0.97-0.99)] and MRE-LSM [1.8 (1.26-2.79)] were predictors of HRVs. At a cut-off of 4.75, MRE showed a sensitivity of 96.3%. Model combining MRE-LSM with PC had a diagnostic AUROC of 0.77 and 0.76 for EVs and HRVs.

CONCLUSION

In obese NAFLD-CC, MRE-LSM is significantly higher in patients with varices. MRE combined with PC predicts EVs and HRVs with better accuracy than ARFI.

Prediction of Esophageal Varices in Viral Hepatitis C Cirrhosis: Performance of Combined Ultrasonography and Clinical Predictors

Objectives

This study is aimed at evaluating the diagnostic performance of clinical predictors and the Doppler ultrasonography in predicting esophageal varices (EV) in patients with hepatitis C-related cirrhosis and exploring the practical predictors of EV.

Methods

We conducted a prospective study from July 2020 to January 2021, enrolling 65 patients with mild hepatitis C-related cirrhosis. We obtained clinical data and performed grayscale and the Doppler ultrasound to explore the predictors of EV. Esophagogastroduodenoscopy (EGD) was performed as the reference test by the gastroenterologist within a week.

Results

The prevalence of EV in the study was 41.5%. Multivariable regression analysis revealed that gender (female, OR = 4.04, p = 0.02), platelet count (<150000 per ml, OR = 3.13, p = 0.09), splenic length (>11 cm, OR = 3.64, p = 0.02), and absent right hepatic vein (RHV) triphasicity (OR = 3.15, p = 0.03) were significant predictors of EV. However, the diagnostic accuracy indices for isolated predictors were not good (AUROC = 0.63-0.66). A combination of these four predictors increases the diagnostic accuracy in predicting the presence of EV (AUROC = 0.80, 95% CI 0.69-0.91). Furthermore, the Doppler assessment of the right hepatic vein waveform showed good reproducibility (κ = 0.76).

Conclusion

Combining clinical and Doppler ultrasound features can be used as a screening test for predicting the presence of EV in patients with hepatitis C-related cirrhosis. The practical predictors identified in this study could serve as an alternative to invasive EGD in EV diagnosis. Further studies are needed to explore the diagnostic accuracy of additional noninvasive predictors, such as elastography, to improve EV screening.

Personalized prediction for multiple chronic diseases by developing the multi-task Cox learning model

Personalized prediction of chronic diseases is crucial for reducing the disease burden. However, previous studies on chronic diseases have not adequately considered the relationship between chronic diseases. To explore the patient-wise risk of multiple chronic diseases, we developed a multitask learning Cox (MTL-Cox) model for personalized prediction of nine typical chronic diseases on the UK Biobank dataset. MTL-Cox employs a multitask learning framework to train semiparametric multivariable Cox models. To comprehensively estimate the performance of the MTL-Cox model, we measured it via five commonly used survival analysis metrics: concordance index, area under the curve (AUC), specificity, sensitivity, and Youden index. In addition, we verified the validity of the MTL-Cox model framework in the Weihai physical examination dataset, from Shandong province, China. The MTL-Cox model achieved a statistically significant (p<0.05) improvement in results compared with competing methods in the evaluation metrics of the concordance index, AUC, sensitivity, and Youden index using the paired-sample Wilcoxon signed-rank test. In particular, the MTL-Cox model improved prediction accuracy by up to 12% compared to other models. We also applied the MTL-Cox model to rank the absolute risk of nine chronic diseases in patients on the UK Biobank dataset. This was the first known study to use the multitask learning-based Cox model to predict the personalized risk of the nine chronic diseases. The study can contribute to early screening, personalized risk ranking, and diagnosing of chronic diseases.

Age, Sex, and Body Mass Index Should Be Considered When Assessing Spleen Length in Patients with Compensated Advanced Chronic Liver Disease

BACKGROUND/AIMS

We investigated the factors related to spleen length and the diagnostic accuracy of a model using spleen length corrected by related factors, for the prediction of varices needing treatment (VNT).

METHODS

Various prediction models for VNT including spleen length were analyzed in the cohort of compensated advanced chronic liver disease (cACLD), defined as liver stiffness (LS) ≥10 kPa in a recent study. The associated factors for spleen length were identified in healthy subjects to improve the prediction of VNT.

RESULTS

Among 1,218 cACLD patients, VNT was noted in 249 patients (20.4%). On multivariate analysis, longer spleen length, lower platelet count, and higher LS value were independent predictors for VNT (all p<0.001). In multivariate analysis of 1,041 healthy subjects, age (β=-0.027), sex (β=0.762), and body mass index (β=0.097) were found to be significant factors for spleen length (all p<0.001). Using the β values, the estimated spleen length was calculated. To improve the prediction of VNT, the ratio of measured and estimated spleen length was calculated. Based on binary regression analysis results, the LS value-spleen ratio to platelet score (LSRPS) was calculated as follows: 0.027×LS value (kPa)+2.690×measured/estimated spleen ratio-0.011×platelet count (cells×109/L)-4.215. The area under the receiver operating characteristic of the LSRPS for VNT was 0.820, which was significantly higher than 0.797 of LS value-spleen diameter to platelet ratio score (LSPS) (p=0.006).

CONCLUSIONS

Spleen length is influenced by age, sex, and body mass index in the Asian population. The LSRPS using the measured/estimated spleen ratio had higher diagnostic accuracy than LSPS in predicting VNT in patients with cACLD.

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.

Unlocking the benefits of the Baveno VI guidance when screening for varices: an audit of clinical practice across London

BACKGROUND

The Baveno VI consensus identifies patients with compensated advanced chronic liver disease (cACLD) who can safely avoid screening endoscopy. However, concordance in clinical practice with this guidance is unknown. We audited clinical practice and the provision of transient elastography (TE) aiming to identify potential cost savings and benefits.

METHODS

Retrospective data collection from 12 sites across London over 6 months by reviewing oesophagogastroduodenoscopy (OGD) reports, platelet count and TE results as well as information on site-specific provision of TE.

RESULTS

Three-hundred and fifty-one screening procedures were identified; 177 (50.43%) had a TE test performed within the preceding 12 months; 142 (80.23%) patients with a recent TE test did not meet criteria for screening OGD. TE provision varied widely between sites.

CONCLUSION

Improving concordance with the Baveno criteria through improved provision of TE would have benefits for patients, healthcare systems and the environment and would help to address the challenges of moving on from the COVID-19 pandemic.

Liver stiffness by two-dimensional shear wave elastography for screening high-risk varices in patients with compensated advanced chronic liver disease

OBJECTIVES

To investigate the usefulness of the criteria with liver stiffness (LS) measured by two-dimensional shear wave elastography (2D-SWE) and platelet count (PLT) for ruling out high-risk varices in patients with compensated advanced chronic liver disease (cACLD).

METHODS

A total of 661 patients with cACLD had successfully undergone 2D-SWE and endoscopy screening. We analyzed risk factors for the presence of high-risk varices and compared proportions of patients who were spared endoscopy when used the predicting criteria with LS (ranged from 16 to 25 kPa) and PLT (ranged from 80 × 109/L to 150 × 109/L).

RESULTS

PLT, albumin, LS were found to be independent predictors of high-risk varices. The LS values for ruling out and ruling in high-risk varices were 14.0 kPa and 24.8 kPa, respectively. When the Baveno VI criteria LS < 20 kPa and PLT > 150 × 109/L were used, the high-risk varices miss rate was 2.1%, while the saved endoscopy rate only was 19.2%. The new criteria that LS < 16 kPa and PLT > 100 × 109/L saved 30.4-34.6% endoscopy with 0-3.2% high-risk varices miss rate in the subgroup analysis stratified according to the types of underlying liver disease.

CONCLUSIONS

The Baveno VI criteria can be applied to LS measurement by 2D-SWE. The new criteria that LS < 16 kPa and PLT > 100 × 109/L could be a potential model to spare more endoscopy screening with < 5% high-risk varices miss rate.

KEY POINTS

• LS measured by 2D-SWE is reliable predictive factor for predicting all-size varices and high-risk varices in patients with compensated advanced chronic liver disease. • LS measured by 2D-SWE < 16 kPa and PLT > 100 × 109 /L, which can spare more endoscopy than Baveno VI criteria with < 5% high-risk varices miss rate. • The Baveno VI criteria can be applied to LS measurement by 2D-SWE.

Validation of PH and Varices Risk Scores for Prediction of High-Risk Esophageal Varix and Bleeding in Patients with B-Viral Cirrhosis

Esophageal varices (EVs) can be accurately predicted using PH and varices risk scores. We aimed to validate their prognostic performances. Methods: We enrolled patients with B-viral cirrhosis as the training cohort (n = 503). Areas under receiver operating characteristic curves (AUROCs) for HEV were calculated for PH (=-5.953 + 0.188 × liver stiffness (LS) + 1.583 × sex (1:male/0:female) + 26.705 × spleen diameter/platelet count ratio) and varices (=-4.364 + 0.538 × spleen diameter -0.049 × platelet count -0.044 × LS + 0.001 × LS × platelet count) risk scores, and compared to LSPS (=LS × spleen diameter/platelet count). An independent cohort was recruited for further validation (n = 222). In the training cohort, the varices risk score showed the highest AUROC (0.926), followed by the PH risk score (0.924) and LSPS (0.924), but without any statistically significant differences. For varices risk scores ≤-1.70 and ≥1.48, a 95.0% negative predictive value (NPV) and 91.2% positive predictive value (PPV) were observed, respectively. At PH risk scores ≤2.25 and ≥7.71, 95.0% NPV and 90.0% PPV were observed, respectively. At LSPS ≤1.73 and ≥13.9, 95.3% NPV and 95.0% PPV were observed, respectively. The EV bleeding (EVB) risk during follow-up increased stepwise and significantly when stratified by PH, varices risk scores, and LSPS (all p < 0.001). In the validation cohort, NPVs were generally similar when stratified by PH (88.2%), varices risk scores (93.2%), and LSPS (88.9%); however, corresponding PPVs were suboptimal. PH and variceal risk scores are reliable for predicting HEV and future EVB. Patients with PH and varices risk scores ≤2.25 and ≤-1.70, respectively, may avoid endoscopy safely. For convenience, LSPS might be a good alternative, with comparable prognostic performance to these two models.

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.

Two-dimensional shear wave elastography for sparing endoscopy screening in patients with HBV-related compensated advanced chronic liver disease

OBJECTIVES

To investigate the diagnostic performance of liver stiffness (LS) measured by 2D-SWE for predicting esophageal varices (EV) and high-risk varices (HRV) in patients with hepatitis B virus (HBV)-related compensated advanced chronic liver disease (cACLD).

METHODS

In total, 268 patients with HBV-related cACLD who underwent 2D-SWE and esophagogastroduodenoscopy (EGD) were retrospectively evaluated. The new criteria for ruling out HRV were tested in the training cohort with 175 patients and validated in the validation cohort with 93 patients.

RESULTS

The AUROCs of LS for predicting EV and HRV were 0.90(0.86-0.95) and 0.93(0.89-0.96) respectively. LS (OR, 1.64 (95% CI: 1.31-2.07); P < 0.0001), PLT (OR, 0.94 (95% CI: 0.91-0.97); P < 0.0001) and albumin (OR, 0.75 (95% CI: 0.62-0.90); P = 0.02) were independent factors for the presence of HRV. The Baveno VI criteria of LS < 20 kPa and PLT > 150 × 109 /L saved 15.1%-17.1% EGD screening with 0-4.3% HRV miss rate. LS < 16 kPa and PLT > 60 × 109 /L spared 51.4%-52.7% EGD screening with 3.8%-4.3% HRV miss rate.

CONCLUSION

Baveno VI criteria is suitable for 2D-SWE to rule out HRV. LS < 16 kPa and PLT > 60 × 109 /L could be a reliable model for ruling out HRV in patients with HBV-related cACLD.

Novel albumin, bilirubin and platelet criteria for the exclusion of high-risk varices in compensated advanced chronic liver disease: A validation study

BACKGROUND AND AIMS

Availability of transient elastography (TE) limits the application of Baveno-VI criteria. In a derivation study, the ABP criteria (Albumin >40 g/l, Bilirubin <22 μmol/l and Platelet >114,000/μl) had been shown to perform well in identifying compensated advanced chronic liver disease (cACLD) patients without high-risk varices (HRV). We aim to externally validate this novel ABP criteria for the exclusion of HRVs among cACLD patients.

METHODS

Data was retrospectively collected from consecutive cACLD patients with paired TE and esophagogastroduodenoscopy (EGD) performed between 2011 and 2017 in Changi General Hospital, Singapore. We estimate the discriminative ability of ABP criteria in validation cohort using AUROC and calibration-in-the-large. We subsequently compare the performance between ABP and Baveno-VI criteria in the validation cohort.

RESULTS

Among 314 patients included in our validation cohort, 32 (10.2%) had HRV on screening EGD. Application of ABP criteria within this validation cohort has increased discriminative ability than the derivation cohort. The AUROC of validation and derivation cohort were 0.68 (0.60-0.76) and 0.66 (0.60-0.76), respectively. The mean and standard error for calibration-in-the-large and calibration slope were -0.08 (0.22) and 0.93 (0.26) respectively. The ABP criteria had excellent performance in excluding HRV and will spare more screening EGDs than the Baveno-VI criteria (39.2% vs 27.4%, p < 0.001), without missing more HRVs.

CONCLUSION

We validated the performance of ABP criteria for the exclusion of HRVs in cACLD patients. ABP criteria is superior to Baveno-VI criteria by sparing more screening EGD without the need of TE.

Identification of potential metabolic biomarkers in predicting esophageal varices needing treatment in patients with liver cirrhosis

The goal of this study was to determine the diagnostic performance of in vivo quantitative proton magnetic resonance spectroscopy (¹H-MRS) to identify the presence of esophageal varices needing treatment (VNT), as well as investigate its correlation with clinical characteristics in patients with liver cirrhosis. Forty cirrhotic patients without VNT showing the negative red color sign, and 40 cirrhotic patients with VNT showing positive red color sign underwent laboratory tests, esophago-gastro-duodenoscopy, and ¹H-MRS with single-voxel localization in the cirrhotic liver parenchyma. The levels of lactate + triglyceride (TG) and choline in cirrhotic patients with VNT were significantly higher than those in cirrhotic patients without VNT. In multivariate analysis, spleen diameter, platelet count, and platelet count/spleen diameter ratio, as well as lactate + TG, and choline were associated with the presence of VNT. Moreover, lactate + TG and choline levels were positively correlated with spleen diameter and negatively correlated with platelet count in the combined group of cirrhotic patients with and without VNT. Our study demonstrated that higher hepatic lactate + TG and choline levels in cirrhotic patients in conjunction with longer spleen diameter, lower platelet counts, and lower ratios of platelet count to spleen diameter were associated with the presence of esophageal VNT and the risk of developing variceal bleeding. Therefore, in vivo ¹H-MRS might be an effective tool for diagnosing and predicting esophageal VNT in patients with liver cirrhosis.

Noninvasive Detection of Clinically Significant Portal Hypertension in Compensated Advanced Chronic Liver Disease

Patients with compensated advanced chronic liver disease have different prognoses depending on the presence of portal hypertension. Current non-invasive diagnostic methods allow identification of clinically significant portal hypertension. Portosystemic collaterals on imaging or liver stiffness of more than 20 to 25 kPa by using transient elastography identifies patients with clinically significant portal hypertension. Patients with liver stiffness of less than 20 kPa and platelet count of greater than 150 g/L can avoid endoscopy. This rule could be expanded using spleen stiffness. Methods to risk stratify for portal hypertension in compensated advanced chronic liver disease and successfully treated chronic hepatitis C and B are subject of research.

Validation of the Expanded Baveno-VI Criteria for Screening Gastroscopy in Asian Patients with Compensated Advanced Chronic Liver Disease

BACKGROUND

The expanded Baveno-VI criteria may further reduce the need for screening gastroscopy compared to Baveno-VI criteria.

AIM

We sought to validate the performance of these criteria in a cohort of compensated advanced chronic liver disease (cACLD) patients with predominantly hepatitis B infection.

METHODS

Consecutive cACLD patients from 2006 to 2012 with paired liver stiffness measurements and screening gastroscopy within 1 year were included. The expanded Baveno-VI criteria were applied to evaluate the sensitivity (SS), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) for the presence of high-risk varices (HRV).

RESULTS

Among 165 cACLD patients included, 17 (10.3%) had HRV. The commonest etiology of cACLD was chronic hepatitis B (36.4%) followed by NAFLD (20.0%). Application of expanded Baveno-VI criteria avoided more screening gastroscopy (43.6%) as compared to the original Baveno-VI criteria (18.8%) without missing more HRV (1 with both criteria). The overall SS, SP, PPV and NPV of the expanded Baveno-VI criteria in predicting HRV were 94.1%, 48.0%, 17.2% and 98.6%, respectively.

CONCLUSION

Application of the expanded Baveno-VI criteria can safely avoid screening gastroscopy in 43.6% of cACLD patients with an excellent ability to exclude HRV.

Association of the Modified ALBI Grade With Endoscopic Findings of Gastroesophageal Varices

BACKGROUND/AIM

This study aimed to assess the association of the modified albumin-bilirubin (mALBI) grade with the endoscopic findings of gastroesophageal varices (GEVs).

PATIENTS AND METHODS

A total of 141 patients with histologically proven cirrhosis who underwent a liver biopsy and esophagogastroduodenoscopy were enrolled. The relationships between the mALBI grade and endoscopic findings were evaluated.

RESULTS

The incidence of GEVs and high-risk GEVs differed among mALBI grades. Patients with mALBI grades of 2b-3 had higher rates of GEVs and high-risk GEVs in comparison to those with mALBI grades of 1-2a (p<0.0001). In addition, patients with mALBI grade 2b or grade 3, but not those with mALBI grade 2a, had significantly higher rates of complicated GEVs and high-risk GEVs in comparison to those with mALBI grade 1.

CONCLUSION

The mALBI grade may be useful in predicting the presence of GEVs and for stratifying their bleeding risk.

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.

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.

Managing liver cirrhotic complications: Overview of esophageal and gastric varices

Managing liver cirrhosis in clinical practice is still a challenging problem as its progression is associated with serious complications, such as variceal bleeding that may increase mortality. Portal hypertension (PH) is the main key for the development of liver cirrhosis complications. Portal pressure above 10 mmHg, termed as clinically significant portal hypertension, is associated with formation of varices; meanwhile, portal pressure above 12 mmHg is associated with variceal bleeding. Hepatic vein pressure gradient measurement and esophagogastroduodenoscopy remain the gold standard for assessing portal pressure and detecting varices. Recently, non-invasive methods have been studied for evaluation of portal pressure and varices detection in liver cirrhotic patients. Various guidelines have been published for clinicians' guidance in the management of esophagogastric varices which aims to prevent development of varices, acute variceal bleeding, and variceal rebleeding. This writing provides a comprehensive review on development of PH and varices in liver cirrhosis patients and its management based on current international guidelines and real experience in Indonesia.

Deciding Among Noninvasive Tools for Predicting Varices Needing Treatment in Chronic Liver Disease: An Analysis of Asian Cohort

INTRODUCTION

Both transient elastography (TE)-based and non-TE-based criteria exist for detection of varices needing treatment (VNT) in patients with asymptomatic advanced chronic liver disease (CLD). However, their performance in clinical settings at different risk thresholds of detection of VNT and in regions where elastography is not widely available is unknown. We aimed to validate existing noninvasive criteria in our patients with CLD and identify best TE- and non-TE-based criteria for VNT screening at usual risk thresholds.

METHODS

Patients with compensated advanced CLD (cACLD) who underwent esophagogastroduodenoscopy and TE within 3 months were included. Diagnostic performance of Baveno VI, expanded Baveno VI, platelet-model for end-stage liver disease, and platelet-albumin (Rete Sicilia Selezione Terapia-hepatitis C virus) criteria were estimated. Decision curve analysis was conducted for different predictors across range of threshold probabilities. A repeat analysis including all patients with compensated CLD (cACLD and non-cACLD) was performed to simulate absence of TE.

RESULTS

A total of 1,657 patients (cACLD, 895; non-cACLD, 762) related to hepatitis B virus (38.2%), hepatitis C virus (33.4%), nonalcoholic steatohepatitis (14.7%), and alcohol (11.8%) were included. Baveno VI identified maximum VNT (97.3%) and had best negative predictive value (96.9%), followed by platelet-albumin criteria. Expanded Baveno VI and platelet-model for end-stage liver disease had intermediate performance. At threshold probability of 5%, Baveno VI criteria showed maximum net benefit, and platelet-albumin criteria was next best, with need for 95 additional elastographies to detect 1 additional VNT. Similar results were obtained on including all patients with compensated CLD irrespective of TE.

DISCUSSION

Baveno VI criteria maximizes VNT yield at 5% threshold probability. An acceptable alternative is the platelet-albumin criteria in resource-limited settings.

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.

Portal Hypertension: Pathogenesis and Diagnosis

Portal hypertension (PH) is an increase in the pressure gradient between portal vein and inferior vena cava. Increased resistance occurs at different levels within the portal venous system, followed by increased portal venous inflow. PH is the main driver of cirrhosis decompensation. Varices on endoscopy or portosystemic collaterals on imaging indicate PH. Although its cause is determined mostly via noninvasive tests, the gold standard to measure portal pressure in cirrhosis and determine its severity is hepatic vein catheterization with determination of the hepatic venous pressure gradient. Measuring portal pressure is essential in proof-of-concept studies of portal pressure-lowering drugs.

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.

Performance of Baveno VI and Expanded Baveno VI Criteria for Excluding High-Risk Varices in Patients With Chronic Liver Diseases: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

We aimed to assess the accuracy of Baveno VI criteria for identification of high-risk varices (HRVs) and varices of any size in patients with compensated advanced chronic liver disease (cACLD).

METHODS

We performed a systematic search of publications through December 2018 for studies that assessed the accuracy of Baveno VI criteria for screening for varices in patients with cACLD. We used hierarchical models to synthesize evidence. We also conducted a post hoc analysis to assess the accuracy of Εxpanded Baveno VI criteria. We appraised the confidence in estimates using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

We identified 30 studies (8469 participants). Pooled values of Baveno VI criteria for HRVs (26 studies) were a sensitivity of 0.97 (95% CI, 0.95-0.98) and a specificity of 0.32 (95% CI, 0.26-0.39). Pooled sensitivity of Εxpanded Baveno VI criteria for HRVs (12 studies) was 0.90 (95% CI, 0.85-0.93) and specificity was 0.51 (95% CI, 0.45-0.57). In 1000 patients with cACLD, with a prevalence of HRVs of 20%, Baveno VI criteria would prevent endoscopy in 262 patients, but 6 patients with HRVs would be missed. Instead, use of the Εxpanded Baveno VI criteria would result in 428 patients avoiding endoscopy, but 20 patients with HRVs would be missed. The credibility of our findings is moderate or low, mainly owing to the retrospective design of most studies.

CONCLUSIONS

Baveno VI criteria have high diagnostic accuracy as a triage test for screening for HRVs in patients with cACLD. Expanded Baveno VI criteria could reduce the proportion of unnecessary endoscopies further, nevertheless with a higher rate of missed HRVs.