Preventive strategies in hepatology: Role of multiparametric assessment of portal hypertension in chronic liver disease

Figure 3 Liver stiffness measurement and dynamic change of liver stiffness. A: Use of the liver stiffness measurement (LSM) according to the rule five for transient elastography (TE) and rule of four for acoustic radiation force impulse (ARFI) to determine compensated advanced chronic liver disease (cACLD) and clinically significant portal hypertension (CSPH). Patients with an LSM < 10 kPa excludes cACLD in the absence of other clinical/imaging signs. LSM values between 10 kPa and 15 kPa for TE and 9 kPa and 13 kPa for ARFI are suggestive of cACLD. LSM measured by vibration-controlled TE (VCTE) > 15 kPa and > 13 kPa by ARFI are considered a high likelihood of cACLD for all etiologies. LSM ≤ 15 kPa for VCTE and ≤ 13 kPa for ARFI plus platelets ≥ 150 × 10⁹/L exclude CSPH for most etiologies. Patients with intermediate values of LSM between 15 kPa and 25 kPa for VCTE and 13 kPa and 21 kPa for ARFI are in the gray zone of CSPH. The best cutoff to determine the presence of CSPH is an LSM ≥ 25 kPa (specificity and positive predictive value > 90%) in alcoholic liver disease, chronic hepatitis B, chronic hepatitis C, and patients without obesity with hepatic steatosis; B: A dynamic change in liver stiffness is considered significant if there is a reduction of ≥ 20%, particularly when accompanied by an LSM < 20 kPa or any decrease that brings the LSM to < 10 kPa. TE: Transient elastography; cACLD: Compensated advanced chronic liver disease; CSPH: Clinically significant portal hypertension; LSM: Liver stiffness measurement; ALD: Alcohol-associated liver disease; ARFI: Acoustic radiation force impulse; HCV: Hepatic C virus; SVR: Sustained virological response.