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Dong J, Liu C, Zhang M, Yu H, Zhao D, Bai X, Zheng M, Liu Y, Ji J, Li R, Shen W, Cai J. Prediction Modelling for Gastroesophageal Variceal Bleeding in Patients With Chronic Hepatitis B Using Four-dimensional Flow MRI. J Clin Exp Hepatol 2025; 15:102403. [PMID: 39296664 PMCID: PMC11405793 DOI: 10.1016/j.jceh.2024.102403] [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: 08/28/2023] [Accepted: 08/07/2024] [Indexed: 09/21/2024] Open
Abstract
Background/Aims In this study, we aim to develop a model for predicting gastroesophageal varices (GEV) bleeding in patients with chronic hepatitis B (CHB) by utilizing hemodynamic parameters obtained through four-dimensional flow MRI (4D flow MRI). Methods This study conducted a prospective enrollment of CHB patients suspected of GEV from October 2021 to May 2022. The severity of varices and bleeding risk were evaluated using clinical findings and upper gastrointestinal endoscopy, and patients were classified into high-risk and non-high-risk groups. The study utilized serological examination, ultrasonographic examination, and 4D flow MRI. Relevant parameters were selected through univariate and multivariate analyses, and a prediction model was established using binary logistic regression analysis. The model was combined with the Baveno Ⅵ/Ⅶ and Expanded Baveno Ⅵ/Ⅶ criteria to evaluate diagnostic efficacy and the risk of avoiding endoscopic examination. Results A total of 40 CHB patients were enrolled and categorized into the high-risk group (n = 15) and the non-high-risk group (n = 25). The spleen diameter and regurgitant fraction (R%) were independent predictors of variceal bleeding and a predictive model was established. The combination of this prediction model and the Baveno Ⅵ/Ⅶ criteria achieved high diagnostic efficiency, enabling 45.00% (18/40) of patients to be exempted from the unnecessary endoscopic procedure and the high-risk misclassification rate (0%) was less than 5%. Conclusion The prediction model generated by 4D flow MRI has the potential to assess the likelihood of varices and can be supplemented by the Baveno VI/VII criteria to improve diagnostic accuracy in CHB patients.
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Affiliation(s)
- Jinghui Dong
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Changchun Liu
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Mengmeng Zhang
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Hailong Yu
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Di Zhao
- Senior Department of Hepatology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Xu Bai
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Meng Zheng
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Yuan Liu
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Jiachen Ji
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, Tsinghua Univercity, Beijing 100084, China
| | - Rui Li
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, Tsinghua Univercity, Beijing 100084, China
| | - Wen Shen
- Department of Radiology, Tianjin First Center Hospital, Tianjin 300192, China
| | - Jianming Cai
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
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Morais R, Moreira J, Gaspar R, Santos-Antunes J, Marques M, Coelho R, Alves R, Ferreira-Silva J, Dias E, Pereira P, Lopes S, Cardoso H, Sousa-Pinto B, Faria-Ramos I, Gullo I, Carneiro F, Liberal R, Macedo G. Higher frequency of gastric neoplasia in advanced chronic liver disease patients: Impact of screening endoscopy in an intermediate-high risk country. Dig Liver Dis 2024; 56:2133-2142. [PMID: 38811247 DOI: 10.1016/j.dld.2024.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 04/28/2024] [Accepted: 04/29/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND The Baveno VII guidelines were proposed to identify which patients could safely avoid screening esophagogastroduodenoscopy (EGD) for gastroesophageal varices. We aimed to evaluate the frequency of gastric neoplasia in compensated advanced chronic liver disease (cACLD) patients who underwent EGD for screening of gastroesophageal varices (GOEV) compared to a healthy population. METHODS Retrospective study that enrolled all cACLD patients who underwent EGD for GOEV screening (January 2008-June 2018) in a tertiary reference center. cACLD patients were compared with asymptomatic healthy individuals who underwent EGD in a private hospital setting (April 2017-March 2018). RESULTS We evaluated 1845 patients (481 cACLD patients, 1364 healthy individuals). A significantly higher frequency of gastric neoplasia was observed in patients with cACLD compared to healthy individuals (4.0% vs. 1.0 %; p < 0.001). Rare histopathological subtypes (WHO Classification) accounted for 28.7 % of gastric carcinoma cases in the cACLD cohort. Seven cases of gastric neoplasia (36.8 % of gastric neoplasia cases in the cACLD patients) were diagnosed in patients who, according to the Baveno VII criteria, would have not been submitted to EGD. CONCLUSION We found an increased frequency of gastric neoplasia in patients with cACLD in comparison with healthy individuals. In countries with intermediate-high risk for GC, continuing to perform EGD could be beneficial.
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Affiliation(s)
- Rui Morais
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal.
| | - João Moreira
- Faculty of Medicine of the University of Porto (FMUP), Portugal
| | - Rui Gaspar
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - João Santos-Antunes
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal; i3S - Instituto de Investigação e Inovação em Saúde and Institute of Molecular Pathology and Immunology, University of Porto (Ipatimup), Portugal
| | - Margarida Marques
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Rosa Coelho
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Rosa Alves
- Internal Medicine Department, Centro Hospitalar Barreiro Montijo, Portugal
| | - Joel Ferreira-Silva
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Emanuel Dias
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Pedro Pereira
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Susana Lopes
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Hélder Cardoso
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Bernardo Sousa-Pinto
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences; Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS@RISE-Health Research Network, Faculty of Medicine, University of, Porto, Porto, Portugal
| | - Isabel Faria-Ramos
- Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Irene Gullo
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Department of Pathology, Centro Hospitalar Universitário de São João, Portugal; i3S - Instituto de Investigação e Inovação em Saúde and Institute of Molecular Pathology and Immunology, University of Porto (Ipatimup), Portugal
| | - Fátima Carneiro
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Department of Pathology, Centro Hospitalar Universitário de São João, Portugal; i3S - Instituto de Investigação e Inovação em Saúde and Institute of Molecular Pathology and Immunology, University of Porto (Ipatimup), Portugal
| | - Rodrigo Liberal
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Guilherme Macedo
- Faculty of Medicine of the University of Porto (FMUP), Portugal; Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
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Yang JO, Chittajallu P, Benhammou JN, Patel A, Pisegna JR, Tabibian J, Dong TS. Validation of a Machine Learning Algorithm, EVendo, for Predicting Esophageal Varices in Hepatocellular Carcinoma. Dig Dis Sci 2024; 69:3079-3084. [PMID: 38896359 PMCID: PMC11341647 DOI: 10.1007/s10620-024-08449-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/12/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Treatment with atezolizumab and bevacizumab has become standard of care for advanced unresectable hepatocellular carcinoma (HCC) but carries an increased gastrointestinal bleeding risk. Therefore, patients are often required to undergo esophagogastroduodenoscopy (EGD) to rule out esophageal varices (EV) prior to initiating therapy, which can delay care and lead to unnecessary procedural risks and health care costs. In 2019, the EVendo score was created and validated as a noninvasive tool to accurately screen out patients who were at low risk for having EV that required treatment. We sought to validate whether the EVendo score could be used to accurately predict the presence of EV and varices needing treatment (VNT) in patients with HCC. METHODS This was a retrospective multicenter cohort study of patients with HCC from 9/2004 to 12/2021. We included patients who underwent EGDs within 1 year after their HCC diagnosis. We collected clinical parameters needed to calculate an EVendo score at the time of EGD and compared the EVendo model prediction to the gold standard endoscopic report in predicting presence of VNT. RESULTS 112 with HCC were recruited to this study, with 117 qualifying EGDs. VNT occurred in 39 (33.3%) patients. The EVendo score had a sensitivity of 97.4% and a negative predictive value of 96.9%, supporting the validity in applying EVendo in predicting VNT in HCC. CONCLUSION In this study, we validated the use of the EVendo score in ruling out VNT in patients with HCC. The application of the EVendo score could safely defer about 30% of EGDs for EV screening in HCC patients. Although additional validation cohorts are needed, this suggests that EVendo score can potentially be applied in patients with HCC to avoid unnecessary EGDs, which can ultimately mitigate healthcare costs and delays in initiating HCC treatment with atezolizumab and bevacizumab.
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Affiliation(s)
- Jamie O Yang
- UCLA Department of Medicine, Los Angeles, CA, USA
| | - Punya Chittajallu
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Jihane N Benhammou
- UCLA Department of Medicine, Los Angeles, CA, USA
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
- Comprehensive Liver Research Center, UCLA, Los Angeles, USA
| | - Arpan Patel
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, USA
- Comprehensive Liver Research Center, UCLA, Los Angeles, USA
| | - Joseph R Pisegna
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, USA
- Comprehensive Liver Research Center, UCLA, Los Angeles, USA
| | - James Tabibian
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, USA
- Olive View, UCLA Medical Center, Sylmar, USA
| | - Tien S Dong
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA.
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, USA.
- Santa Monica Digestive Diseases, 1223 16th Street, Suite 3100, Santa Monica, CA, 90404, USA.
- Comprehensive Liver Research Center, UCLA, Los Angeles, USA.
- Goodman-Luskin Microbiome Center, UCLA, Los Angeles, USA.
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Morais R, Liberal R, Macedo G. Screening Endoscopy in Patients With Advanced Chronic Liver Disease - Is It All About Varices? Clin Gastroenterol Hepatol 2024:S1542-3565(24)00511-1. [PMID: 38871153 DOI: 10.1016/j.cgh.2024.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Rui Morais
- Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal; Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal; Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal; Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
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Ismail M. Prediction of High-Risk Varices in Patients with Compensated Advanced Chronic Liver Disease in Saudi Arabia. Clin Exp Gastroenterol 2023; 16:117-127. [PMID: 37489180 PMCID: PMC10363351 DOI: 10.2147/ceg.s410041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023] Open
Abstract
Purpose Liver stiffness and low platelet count can predict portal hypertension and high-risk varices (HRVs) in patients with cirrhosis. Thus, screening endoscopy may not be required for all patients with compensated advanced chronic liver disease (cACLD). However, data from Saudi Arabia are limited. This study aimed to validate the Baveno VI and expanded Baveno VI criteria for screening endoscopy and identify the risk factors associated with HRVs in patients with cACLD in Saudi Arabia. Patients and Methods We analyzed data from 215 patients with cACLD diagnosed on transient elastography (LSM > 10 kPa) and had paired platelet count and screening upper endoscopy performed within one year of diagnosis. HRVs or varices needing treatment (VNTs) were defined as medium-to-large esophageal varices (EVs), small EVs with red flags, or gastric varices. Sensitivity, specificity, and area under the receiver operating characteristic curve were calculated. Univariate and multivariate logistic regression analyses identified HRV risk factors. Results The Baveno VI criteria spared 50.7% of endoscopies, missing 3.7% of VNTs, while the expanded Baveno VI criteria spared 63.7% of endoscopies, missing 5.1% VNTs. An LSM <20 kPa and platelet count > 150,000/µL were associated with HRV in 8.1% and 8.3%, respectively. While an LSM <25 kPa and platelet count > 110,000/µL were associated with HRV in 9.7% and 9%, respectively. The Baveno VI criteria had sensitivity and specificity of 76% and 55%, while the expanded criteria had 67% and 69%, respectively. Baveno VI criteria performed better in hepatitis C virus patients than nonalcoholic fatty liver disease patients. Multivariate logistic regression analysis revealed platelet count and LSM as predictors of HRV. Conclusion The Baveno VI criteria effectively identified HRVs in cACLD patients from Saudi Arabia, reducing unnecessary endoscopies. Although the expanded criteria avoided more endoscopies, it led to a higher rate of missed HRVs.
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Affiliation(s)
- Mona Ismail
- Division of Gastroenterology, Department of Internal Medicine, King Fahd Hospital of the University, Alkhobar, Saudi Arabia
- College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
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Yang LB, Gao X, Li H, Tantai XX, Chen FR, Dong L, Dang XS, Wei ZC, Liu CY, Wang Y. Non-invasive model for predicting high-risk esophageal varices based on liver and spleen stiffness. World J Gastroenterol 2023; 29:4072-4084. [PMID: 37476583 PMCID: PMC10354583 DOI: 10.3748/wjg.v29.i25.4072] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/20/2023] [Accepted: 06/02/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Acute bleeding due to esophageal varices (EVs) is a life-threatening complication in patients with cirrhosis. The diagnosis of EVs is mainly through upper gastrointestinal endoscopy, but the discomfort, contraindications and complications of gastrointestinal endoscopic screening reduce patient compliance. According to the bleeding risk of EVs, the Baveno VI consensus divides varices into high bleeding risk EVs (HEVs) and low bleeding risk EVs (LEVs). We sought to identify a non-invasive prediction model based on spleen stiffness measurement (SSM) and liver stiffness measurement (LSM) as an alternative to EVs screening. AIM To develop a safe, simple and non-invasive model to predict HEVs in patients with viral cirrhosis and identify patients who can be exempted from upper gastrointestinal endoscopy. METHODS Data from 200 patients with viral cirrhosis were included in this study, with 140 patients as the modelling group and 60 patients as the external validation group, and the EVs types of patients were determined by upper gastrointestinal endoscopy and the Baveno VI consensus. Those patients were divided into the HEVs group (66 patients) and the LEVs group (74 patients). The effect of each parameter on HEVs was analyzed by univariate and multivariate analyses, and a non-invasive prediction model was established. Finally, the discrimination ability, calibration ability and clinical efficacy of the new model were verified in the modelling group and the external validation group. RESULTS Univariate and multivariate analyses showed that SSM and LSM were associated with the occurrence of HEVs in patients with viral cirrhosis. On this basis, logistic regression analysis was used to construct a prediction model: Ln [P/(1-P)] = -8.184 -0.228 × SSM + 0.642 × LSM. The area under the curve of the new model was 0.965. When the cut-off value was 0.27, the sensitivity, specificity, positive predictive value and negative predictive value of the model for predicting HEVs were 100.00%, 82.43%, 83.52%, and 100%, respectively. Compared with the four prediction models of liver stiffness-spleen diameter to platelet ratio score, variceal risk index, aspartate aminotransferase to alanine aminotransferase ratio, and Baveno VI, the established model can better predict HEVs in patients with viral cirrhosis. CONCLUSION Based on the SSM and LSM measured by transient elastography, we established a non-invasive prediction model for HEVs. The new model is reliable in predicting HEVs and can be used as an alternative to routine upper gastrointestinal endoscopy screening, which is helpful for clinical decision making.
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Affiliation(s)
- Long-Bao Yang
- Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Xin Gao
- Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Hong Li
- Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Xin-Xing Tantai
- Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Fen-Rong Chen
- Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Lei Dong
- Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Xu-Sheng Dang
- Department of Emergency, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Zhong-Cao Wei
- Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Chen-Yu Liu
- Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Yan Wang
- Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
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Thabut D, Weil D, Bouzbib C, Rudler M, Cassinotto C, Castéra L, Serste T, Oberti F, Ganne-Carrié N, de Lédinghen V, Bourlière M, Bureau C. Non-invasive diagnosis and follow-up of portal hypertension. Clin Res Hepatol Gastroenterol 2022; 46:101767. [PMID: 34332128 DOI: 10.1016/j.clinre.2021.101767] [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] [Received: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Dominique Thabut
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France.
| | - Delphine Weil
- Service d'hépatologie, CHRU Besançon, Besançon, France
| | - Charlotte Bouzbib
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Marika Rudler
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Christophe Cassinotto
- Radiologie diagnostique et interventionnelle Saint Eloi, CHU Montpellier, Montpellier, France
| | - Laurent Castéra
- Service d'Hépatologie, Hôpital Beaujon, Université de Paris, APHP, Paris, France
| | - Thomas Serste
- Service d'hépato-gastroentérologie, CHU Saint-Pierre, Bruxelles, France
| | - Frédéric Oberti
- Service d'hépato-gastroentérologie et oncologie digestive, CHU Angers, Angers, France
| | - Nathalie Ganne-Carrié
- Service d'hépatologie, Hôpital Avicenne, APHP, Université Sorbonne Paris Nord, Bobigny & INSERM UMR 1138, Centre de Recherche des Cordeliers, Université de Paris, France
| | - Victor de Lédinghen
- Service d'hépato-gastroentérologie et d'oncologie digestive, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac & INSERM U1053, Université de Bordeaux, Bordeaux, France
| | - Marc Bourlière
- Service d'hépato-gastroentérologie, Hôpital Saint Joseph & INSERM UMR 1252 IRD SESSTIM Aix Marseille Université, Marseille, France
| | - Christophe Bureau
- Service d'hépatologie, Hôpital Rangueil, CHU Toulouse, Toulouse, France
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Tan M, Zhang W, Zhou H, Liu Y, Lu T, Zhang Y, Li C, Yang Y, Wu Y, Hu H, Li Y, Yang F, Lin S. VariScreen secures the screening of high-risk varices in patients with hepatitis B virus-related cirrhosis beyond Baveno VI criteria. Front Physiol 2022; 13:1006657. [PMID: 36237519 PMCID: PMC9551454 DOI: 10.3389/fphys.2022.1006657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/09/2022] [Indexed: 12/07/2022] Open
Abstract
We aimed to validate the performance of the ratio of the platelet count (PLT) to liver stiffness measurement (LSM) in excluding high-risk varices (HRVs) in patients with hepatitis B virus (HBV)-related compensated cirrhosis beyond Baveno VI criteria. A total of 310 patients were assessed. The performances of the PLT:LSM ratio (PLER), PLER adjusted for the international normalized ratio, etiology, age, and sex (PLEASE), and the sequential algorithm for HRV screening (VariScreen) in excluding HRVs were evaluated and compared with those of expanded Baveno VI criteria (LSM <25 kPa and PLT >110×109/L, EB6C); PLT >150×109/L and model for end-stage liver disease score = 6 (P150M6 criterion); PLT >120×109/L and albumin >36 g/L (P120A36 criterion); and albumin-bilirubin (ALBI) grade and PLT score (ALBI-PLT score). Among the enrolled patients, 43 (13.9%) had HRVs. The area under the receiver operating characteristic curve of PLER for predicting HRVs (0.771, 95% confidence interval, 0.720–0.817) was significantly higher than that for PLT and LSM (p < 0.01). PLER was an independent risk factor for HRVs. VariScreen, PLEASE, and PLER could spare 20 (6.5%), 91 (29.4%), and 60 (19.4%) endoscopies, with 0, 3 (3.3%), and 1 (1.7%) HRVs missed, respectively. The EB6C and P120A36 criteria could spare 45 (14.5%) and 36 (11.6%) endoscopies, with 1 (2.2%) and 1 (2.8%) HRVs missed, respectively. The P150M6 criterion and ALBI-PLT score missed 6.8% and 10.3% of HRVs, respectively. We found that PLER performed better than other non-invasive tests. VariScreen secured the screening of HRVs in patients with HBV-related cirrhosis beyond Baveno VI criteria.
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Affiliation(s)
- Min Tan
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Infectious Diseases, Suining Central Hospital, Suining, China
| | - Wuxiang Zhang
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Infectious Diseases, The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi City), Zunyi, China
| | - Hong Zhou
- Department of Infectious Diseases, Suining Central Hospital, Suining, China
| | - Yujuan Liu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Tao Lu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yin Zhang
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Chuan Li
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yanyan Yang
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yunchong Wu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Han Hu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Ying Li
- Department of Infectious Diseases, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Fangwan Yang
- Department of Infectious Diseases, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shide Lin
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- College of Laboratory Medicine, Zunyi Medical University, Zunyi, China
- *Correspondence: Shide Lin,
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9
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McPherson S, Armstrong MJ, Cobbold JF, Corless L, Anstee QM, Aspinall RJ, Barclay ST, Brennan PN, Cacciottolo TM, Goldin RD, Hallsworth K, Hebditch V, Jack K, Jarvis H, Johnson J, Li W, Mansour D, McCallum M, Mukhopadhya A, Parker R, Ross V, Rowe IA, Srivastava A, Thiagarajan P, Thompson AI, Tomlinson J, Tsochatzis EA, Yeoman A, Alazawi W. Quality standards for the management of non-alcoholic fatty liver disease (NAFLD): consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group. Lancet Gastroenterol Hepatol 2022; 7:755-769. [PMID: 35490698 PMCID: PMC7614852 DOI: 10.1016/s2468-1253(22)00061-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 12/12/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is common, affecting approximately 25% of the general population. The evidence base for the investigation and management of NAFLD is large and growing, but there is currently little practical guidance to support development of services and delivery of care. To address this, we produced a series of evidence-based quality standard recommendations for the management of NAFLD, with the aim of improving patient care. A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group produced the recommendations, which cover: management of people with, or at risk of, NAFLD before the gastroenterology or liver clinic; assessment and investigations in secondary care; and management in secondary care. The quality of evidence for each recommendation was evaluated by the Grading of Recommendation Assessment, Development and Evaluation tool. An anonymous modified Delphi voting process was conducted individually by each member of the group to assess the level of agreement with each statement. Statements were included when agreement was 80% or greater. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice. It is hoped that services will review their practice against our recommendations and key performance indicators and institute service development where needed to improve the care of patients with NAFLD.
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Affiliation(s)
- Stuart McPherson
- Liver Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
| | - Matthew J Armstrong
- Liver Unit, Queen Elizabeth University Hospital Birmingham NHS Trust, Birmingham, UK; NIHR Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Jeremy F Cobbold
- Oxford Liver Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; UK NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Lynsey Corless
- Department of Gastroenterology, Hepatology and Endoscopy, Hull University Teaching Hospitals, Hull, UK
| | - Quentin M Anstee
- Liver Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Stephen T Barclay
- Walton Liver Clinic, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Paul N Brennan
- Centre for Regenerative Medicine, University of Edinburgh, Edinburgh BioQuarter, Edinburgh, UK
| | - Tessa M Cacciottolo
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Wellcome Trust/MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Cambridge, UK
| | - Robert D Goldin
- Division of Digestive Diseases, Imperial College, London, UK
| | - Kate Hallsworth
- Liver Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Kathryn Jack
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Helen Jarvis
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; The Bellingham Practice, Northumberland, UK
| | - Jill Johnson
- Liver Unit, Queen Elizabeth University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Wenhao Li
- Barts Liver Centre, Queen Mary University London and Barts Health NHS Trust, London, UK
| | - Dina Mansour
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Queen Elizabeth Hospital, Gateshead NHS Foundation Trust, Gateshead, UK
| | - Mary McCallum
- Digestive Disorders Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Ashis Mukhopadhya
- Digestive Disorders Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital Leeds, Leeds, UK
| | - Valerie Ross
- Barts Liver Centre, Queen Mary University London and Barts Health NHS Trust, London, UK
| | - Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Ankur Srivastava
- North Bristol Liver Unit, Southmead Hospital, North Bristol Trust, Bristol, UK
| | | | - Alexandra I Thompson
- Centre for Liver and Digestive Disorders, The Royal Infirmary, Edinburgh, Edinburgh, UK
| | - Jeremy Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Andrew Yeoman
- Gwent Liver Unit, The Grange University Health Board, Anuerin Bevan Health Board, Wales, UK
| | - William Alazawi
- Barts Liver Centre, Queen Mary University London and Barts Health NHS Trust, London, UK
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10
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Lucijanic M, Madir A, Grgurevic I, Derek L, Unic A, Mustapic S, Zelenika M, Bokun T, Pastrovic F, Podrug K. Use of biochemical parameters for non-invasive screening of oesophageal varices in comparison to elastography-based approach in patients with compensated advanced chronic liver disease. Biochem Med (Zagreb) 2022; 32:020712. [PMID: 35799983 PMCID: PMC9195609 DOI: 10.11613/bm.2022.020712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 04/10/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Oesophageal varices are routinely diagnosed by esophagogastroduodenoscopy (EGD), and their bleeding has high mortality. We aimed to evaluate diagnostic performance of biochemical tests in comparison to elastography-based approaches, as non-invasive alternatives to EGD, for ruling-out high risk oesophageal varices (HRV). Material and methods Retrospective analysis of patients (N = 861) who underwent liver stiffness measurement (LSM) by transient elastography (TE) in a single centre over 5-year period, with available results of EGD (within 3 months from LSM). Only patients with suspicion of compensated advanced chronic liver disease (cACLD) defined by LSM ≥ 10 kPa were included comprising the final cohort of 73 subjects. Original and expanded Baveno VI criteria (B6C), controlled attenuation parameter (CAP), platelet count (PLT), aspartate aminotransferase to PLT ratio index (APRI), Fibrosis-4 index (FIB4), model for end stage liver disease (MELD) score were evaluated against the results of EGD that served as the reference method. Results Analysed patients had median age 62 years, 59/73 (0.81) were males, 54/73 (0.74) had alcoholic/non-alcoholic fatty liver disease, and 21/73 (0.29) had HRV. In multivariate logistic regression analysis only LSM and PLT were independently associated with HRV. The best performing tests for ruling-out HRV (% of spared EGD; % of missed HRV) were respectively: LSM < 20 kPa (53.4%; 0%), B6C (38%; 0%), Expanded B6C (47.9%; 4.8%); PLT > 214x109/L (21.9%; 0%); FIB4 ≤ 1.8 (21.4%; 0%), APRI ≤ 0.34 (12.3%; 0%). CAP, MELD = 6 alone or combined with PLT > 150(x109/L) did not show acceptable performance. Conclusion The best performing biochemical tests for ruling-out HRV in our cohort of patients were PLT and FIB-4, but they were still outperformed by elastography-based approaches.
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Affiliation(s)
- Marko Lucijanic
- Department of Hematology, University Hospital Dubrava, Zagreb, Croatia
| | - Anita Madir
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Ivica Grgurevic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, Zagreb, Croatia
| | - Lovorka Derek
- Clinical Department for Laboratory Diagnostics, University Hospital Dubrava, Zagreb, Croatia
| | - Adriana Unic
- Department of Clinical Chemistry, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
| | - Sanda Mustapic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, Zagreb, Croatia
| | - Marko Zelenika
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, Zagreb, Croatia
| | - Tomislav Bokun
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, Zagreb, Croatia
| | - Frane Pastrovic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, Zagreb, Croatia
| | - Kristian Podrug
- Department of Gastroenterology and Hepatology, University Hospital Split, Split, Croatia
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11
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Wong YJ, Li J, Liu C, Chen Z, Chan YH, Putera M, Teh KB, Ang TL, Zhao L, Yan Z, Kumar R, Li X, Qi X. CHESS-ALARM score to stratify decompensation risk in compensated advanced chronic liver disease patients: An international multicenter study. J Gastroenterol Hepatol 2022; 37:1043-1051. [PMID: 35253271 DOI: 10.1111/jgh.15819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM A combination of platelet and elastography (PE criteria) was proposed to identify compensated advanced chronic liver disease (cACLD) patients at risk of liver decompensation. We aim to validate and refine PE criteria by developing a new predictive score to predict decompensation in Asian cACLD patients. METHODS An international cohort of 633 cACLD patients with liver stiffness measurement (LSM) and esophagogastroduodenoscopy performed were included. We validated PE criteria to predict first liver decompensation using competing risk analysis, with death and hepatocellular carcinoma as competing events. We developed a predictive model using proportional subdistribution hazard regression. Prognostic accuracy was compared with the model of end-stage liver disease (MELD), albumin-bilirubin (ALBI), and ALBI-FIB-4 score using time-dependent area under operative characteristic curve (tAUC). RESULTS Sixty patients developed decompensation over the median follow-up of 39 months. Favorable Baveno VI status ruled out cACLD patients at risk of liver decompensation. LSM > 25 kPa was suboptimal to predict cACLD patients who will develop liver decompensation. We developed CHESS-ALARM score by incorporating age, platelet, and gender into LSM. CHESS-ALARM score (tAUC = 0.86, 95% confidence interval [CI]: 0.79-0.94) has significantly higher accuracy than MELD (tAUC: 0.61), ALBI (tAUC: 0.62), ALBI-FIB-4 (tAUC: 0.70), and LSM > 25 kPa (tAUC: 0.54) to predict liver decompensation at 5 years (P < 0.05 for all). Patients with CHESS-ALARM score ≥ -0.37 had an 11-fold higher risk of decompensation (subdistribution hazard ratio = 11.2, 95% CI: 5.1-24.5). CONCLUSION CHESS-ALARM score can be readily incorporated into clinical practice of cACLD patients to estimate individual risk of liver decompensation; however, more data are required in morbidly obese cACLD patients of nonviral etiology.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Duke-NUS Academic Medical Program, SingHealth, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jia Li
- Department of Gastroenterology and Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Chuan Liu
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Zhaojin Chen
- Biostatistic Unit, Yong Loo Lin School of Medicine, Singapore
| | - Yiong Huak Chan
- Biostatistic Unit, Yong Loo Lin School of Medicine, Singapore
| | - Martin Putera
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kok Ban Teh
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Duke-NUS Academic Medical Program, SingHealth, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lili Zhao
- Department of Gastroenterology and Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Zhongfang Yan
- Department of Radiology, Tianjin Second People's Hospital, Tianjin, China
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Duke-NUS Academic Medical Program, SingHealth, Singapore
| | - Xin Li
- Department of Clinical Nutrition, Tianjin Second People's Hospital, Tianjin, China
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
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12
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Liang XE, Hu XM, Wang HY, Dai L, Lin XY, Chen JJ, Chen YP, Wen B, Jiang RL. Ultrasonic spleen thickness-based indexes surpass Baveno VI criteria in high-risk gastroesophageal varices detection. Hepatol Int 2022; 16:649-657. [PMID: 35412215 DOI: 10.1007/s12072-022-10327-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/03/2022] [Indexed: 11/26/2022]
Abstract
AIMS To evaluate the efficiency of ultrasonic spleen thickness (UST), routine variables and (expanded) Baveno VI criteria for high-risk gastroesophageal varices (HRGOV) detection in cirrhotic patients. METHODS In total, 305 cirrhotic patients were retrospectively enrolled in the deriving cohort and 328 cirrhotic patients with hepatitis B sustained viral response were prospectively enrolled in the validation cohort. HRGOV was defined as medium and severe gastroesophageal varices (GOV), mild GOV with red signs or Child-Pugh C. The cut-offs for HRGOV were determined by likelihood ratio indicating strong evidences. Algorithms of Spleen thickness-Age-Liver stiffness measurement (LSM, by Fibroscan®)-Albumin (SALA) and Spleen thickness-Platelet-Albumin (SPA) were derived by multivariate analyses. RESULTS The area under receiver operating characteristics curve of SALA, SPA, UST, platelet, and LSM were 0.849, 0.835, 0.808, 0.746, and 0.655 in the deriving cohort, and improved to 0.901, 0.904, 0.858, 0.876, and 0.811 in the validation cohort, respectively. While SALA, SPA, UST, platelet, Baveno VI criteria (BVI), and expanded BVI spared 46.6%, 38.0%, 29.2%, 21.0%, 12.1%, and 23.6% esophagogastroduodenoscopy in the deriving cohort, these numbers were improved to 68.1%, 66.8%, 27.1%, 37.8%, 36.0%, and 61.0% in the validating cohort, respectively; however, the negative likelihood ratio of expanded BVI was up to 0.16. SPA spared less esophagogastroduodenoscopy than SALA, which can be supplemented by stepwise applying UST and SPA. Sequentially combining UST and SALA, BVI and SALA exempted additional 10-5% endoscopies. CONCLUSIONS SPA, without LSM, improves HRGOV detection comparing with BVI. UST based algorithms combination can achieve the best efficiency especially in sustained virus response hepatitis B.
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Affiliation(s)
- Xie-Er Liang
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou North Avenue, Guangzhou, 510515, Guangdong, China
| | - Xiao-Min Hu
- Hepatology Unit, Shenzhen Hospital, Southern Medical University, No. 1333 Xinhu Road, Shenzhen, 518110, Guangdong, China
| | - Hai-Yu Wang
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou North Avenue, Guangzhou, 510515, Guangdong, China
| | - Lin Dai
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou North Avenue, Guangzhou, 510515, Guangdong, China
| | - Xiao-Yu Lin
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou North Avenue, Guangzhou, 510515, Guangdong, China
| | - Jin-Jun Chen
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou North Avenue, Guangzhou, 510515, Guangdong, China
| | - Yong-Peng Chen
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou North Avenue, Guangzhou, 510515, Guangdong, China.
- Hepatology Unit, Shenzhen Hospital, Southern Medical University, No. 1333 Xinhu Road, Shenzhen, 518110, Guangdong, China.
| | - Biao Wen
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou North Avenue, Guangzhou, 510515, Guangdong, China.
- Department of Gastroenterology, The First Affiliated Hospital of Chengdu Medical College, No. 278 Baoguang Road, Chengdu, 610000, Sichuan, China.
| | - Rong-Long Jiang
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou North Avenue, Guangzhou, 510515, Guangdong, China.
- Hepatology Unit, Shenzhen Hospital, Southern Medical University, No. 1333 Xinhu Road, Shenzhen, 518110, Guangdong, China.
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13
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Ciancio A, Ribaldone DG, Salamone R, Bruno M, Caronna S, Debernardi Venon W, Giordanino C, Mondardini A, Musso A, Pennazio M, Rolle E, Sacco M, Sprujevnik T, De Angelis C, Saracco GM. Screening and surveillance of oesophageal varices in patients with HCV-positive liver cirrhosis successfully treated by direct-acting antiviral agents. Liver Int 2022; 42:1121-1131. [PMID: 35220668 PMCID: PMC9311418 DOI: 10.1111/liv.15210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 01/10/2022] [Accepted: 02/07/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS limited evidence is available to guide hepatologists regarding endoscopic surveillance of oesophageal varices (EV) in Hepatitis C Virus (HCV)-positive cirrhotic patients achieving a sustained virologic response. To address these issues, we conducted a long-term prospective study on 427 HCV-positive cirrhotic patients successfully treated by Direct Antiviral Agents (DAAs). METHODS Patients were divided into two groups according to their baseline Baveno VI status: Group 1 (92, 21.5%, favourable Baveno VI status) and Group 2 (335, 78.5%, unfavourable Baveno VI status). Each patient underwent baseline endoscopy and was endoscopically monitored for a median follow-up of 65.2 months according to Baveno VI recommendations. RESULTS About 4.3% of Group 1 patients showed baseline EV compared with 30.1% of Group 2 patients (p < .0001). No patients belonging to Group 1 without baseline EV developed EV at follow-up endoscopy compared with 6.5% in Group 2 patients (p = .02); 69/107 (64.5%) patients with baseline EV showed small varices. During the endoscopic follow-up, EV disappeared/improved in 36 (33.6%), were stable in 39 (36.4%) and worsened in 32 (29.9%) patients, all belonging to Group 2 (p = .001). Improvement in Baveno VI status was observed in 118/335 (35.2%, p < .0001) of Group 2 patients and among those without pre-therapy EV, none developed EV throughout the follow-up. CONCLUSIONS HCV-positive cirrhotic patients cured by DAAs showing baseline favourable Baveno VI status and no worsening during follow-up can safely avoid endoscopic screening and surveillance. Patients having unfavourable Baveno VI status without baseline EV who improve their status may suspend further endoscopic surveillance.
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Affiliation(s)
- Alessia Ciancio
- Gastro‐hepatoloy Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | | | - Rossella Salamone
- Gastro‐hepatoloy Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | - Mauro Bruno
- Gastro‐hepatoloy Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | - Stefania Caronna
- Gastro‐hepatoloy Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | | | - Chiara Giordanino
- Gastro‐hepatoloy Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | | | - Alessandro Musso
- Gastro‐hepatoloy Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | - Marco Pennazio
- Gastro‐hepatoloy Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | - Emanuela Rolle
- Gastro‐hepatoloy Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | - Marco Sacco
- Gastro‐hepatoloy Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | - Tatiana Sprujevnik
- Gastro‐hepatoloy Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | - Claudio De Angelis
- Gastro‐hepatoloy Unit, Department of Medical SciencesUniversity of TurinTurinItaly
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14
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Abstract
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.
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15
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El-Kassas M, Elakel W, Alboraie M, Ezzat R, Abdelhakam S, Hassany M, Ali-Eldin Z, Sherief AF, Yosry A, El-Serafy M, El-Sayed MH, Waked I, Doss W, Esmat G. Egyptian revalidation of non-invasive parameters for predicting esophageal varices in cirrhotic patients: A retrospective study. Arab J Gastroenterol 2022; 23:120-124. [PMID: 35473688 DOI: 10.1016/j.ajg.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 03/27/2022] [Accepted: 04/15/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS In resource-limited countries, non-invasive tests for assessing liver fibrosis are a potential alternative to costly endoscopic screening for esophageal varices. We aimed to validate several non-invasive parameters for predicting the presence of varices. PATIENTS AND METHODS Between September 2006 and August 2017, a total of 46,014 patients who underwent upper gastrointestinal endoscopy as one of the perquisites for receiving hepatitis C virus (HCV) therapy were enrolled and divided into group I (without varices) and group II (with varices). Non-invasive parameters of fibrosis, namely Lok index, Bonacini score, liver stiffness, FIB-4, Baveno, and extended Baveno criteria, were validated. RESULTS Lok index, Bonacini score, liver stiffness, and FIB-4 had areas under the receiver operating characteristic curve (AUCs) of >0.6 (all P < 0.01 for the null hypothesis that the AUC was 0.5) for determination of the presence/absence of varices, with cutoff values of 0.80, 6.5, 21.9 kPa, and 2.94, and sensitivities of 74%, 74%, 66%, and 83%, respectively. The expanded Baveno VI criteria performed better than the Baveno VI criteria (spared endoscopy rate 81% versus 63%). CONCLUSION The use of non-invasive methods is of limited value in predicting esophageal varices. The limited accuracy of ≤60% may delay the use of appropriate primary prophylaxis against variceal bleeding in a large proportion of cirrhotic patients.
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Affiliation(s)
- Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt; National Committee for Control of Viral Hepatitis, Egypt
| | - Wafaa Elakel
- National Committee for Control of Viral Hepatitis, Egypt; Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Alboraie
- National Committee for Control of Viral Hepatitis, Egypt; Department of Internal Medicine, Al-Azhar University, Cairo, Egypt
| | - Reem Ezzat
- Internal Medicine Department, Assiut University, Assiut, Egypt
| | - Sara Abdelhakam
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed Hassany
- National Committee for Control of Viral Hepatitis, Egypt; National Hepatology & Tropical Medicine Research Institute, Cairo, Egypt
| | - Zainab Ali-Eldin
- Internal Medicine Department, Faculty of Medicine, Ain Shams University, Egypt
| | - Ahmed F Sherief
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ayman Yosry
- National Committee for Control of Viral Hepatitis, Egypt; Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Magdy El-Serafy
- National Committee for Control of Viral Hepatitis, Egypt; Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Manal Hamdy El-Sayed
- National Committee for Control of Viral Hepatitis, Egypt; Pediatrics Department, Hematology-Oncology Division, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Imam Waked
- National Committee for Control of Viral Hepatitis, Egypt; National Liver Institute, Menofia, Egypt
| | - Wahid Doss
- National Committee for Control of Viral Hepatitis, Egypt; Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Gamal Esmat
- National Committee for Control of Viral Hepatitis, Egypt; Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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16
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Asesio N, Pollo-Flores P, Caliez O, Munteanu M, Ngo A, Ngo Y, Poynard T, Thabut D, Rudler M. Baveno VI criteria as a prognostic factor for clinical complications in patients with compensated cirrhosis. Dig Liver Dis 2022; 54:645-653. [PMID: 34583904 DOI: 10.1016/j.dld.2021.09.004] [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: 05/13/2021] [Revised: 08/16/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Combination of liver stiffness measurement and platelets count is a tool to safely rule out varices needing treatment (VNT) in patients with compensated advanced chronic liver disease (cACLD). AIMS to evaluate 4-year liver-related complications and survival in low-risk patients according to Baveno VI criteria. METHODS we conducted a monocentric retrospective analysis of prospectively collected data of all consecutive patients, with cirrhosis (LSM≥12.5 kPa) and without previous complication, evaluated between 2012 and 2015. Liver-related complications and survival were compared between 2 groups of patients: favourable (LSM< 20 kPa and platelet count>150.000/mm3) and unfavourable Baveno VI status patients (LSM ≥ 20 kPa or platelet count ≤150.000/mm3). RESULTS 455 patients with cACLD were analysed. Two hundred patients had favourable Baveno VI criteria, 3.6% with VNT. The 4-year probability of being free of acute decompensation was higher in low-risk patients (94.4 ± 1.8% vs. 85.7%±2.6%, p = 0.018). Unfavourable Baveno status was independently associated with acute decompensation. The probability of being free of HCC was significantly higher in low-risk patients (94.2 ± 1.8% vs. 87.6 ± 2.4%, p = 0.048). Liver-related mortality was not different between the 2 groups (p = 0.56). CONCLUSION The Baveno VI criteria could predict clinical outcome in cACLD.
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Affiliation(s)
- Nicolas Asesio
- Hepatology Department, La Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital 75013 Paris, France
| | - Priscila Pollo-Flores
- Hepatology Department, La Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital 75013 Paris, France; CAPES (coordenação de aperfeiçoamento de pessoal de nível superior), Fluminense's Federal University (UFF), Rio de Janeiro, Brasil
| | - Olivier Caliez
- Hepatology Department, La Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital 75013 Paris, France
| | | | - An Ngo
- BioPredictive, Paris, France
| | - Yen Ngo
- BioPredictive, Paris, France
| | - Thierry Poynard
- Hepatology Department, La Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital 75013 Paris, France; BioPredictive, Paris, France; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Dominique Thabut
- Hepatology Department, La Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital 75013 Paris, France; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Marika Rudler
- Hepatology Department, La Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital 75013 Paris, France; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.
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Colwill M, Lake L, El-Sayed A, King J, Kader R, Shakweh E, Caracostea A, China L, Maurice J. Unlocking the benefits of the Baveno VI guidance when screening for varices: an audit of clinical practice across London. Future Healthc J 2022; 9:41-44. [PMID: 35372760 PMCID: PMC8966789 DOI: 10.7861/fhj.2021-0130] [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: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Michael Colwill
- Epsom and St Helier University Hospitals NHS Trust, London, UK
| | | | - Ahmed El-Sayed
- London North West University Healthcare NHS Trust, London, UK
| | | | | | | | | | - Louise China
- Royal Free London NHS Foundation Trust, London, UK
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Alswat K, Alanazi M, Bashmail A, Alkhamash M, Alqahtani SA, Al-Hamoudi W, Abdo AA. Validation of the EVendo score for the prediction of varices in cirrhotic patients. Saudi J Gastroenterol 2022; 28:378-384. [PMID: 35229755 PMCID: PMC9752538 DOI: 10.4103/sjg.sjg_624_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Screening endoscopy for varices may be deferred when the calculated EVendo score is ≤3.90. This novel score has not been validated in an external cohort. This study aimed to assess the performance of the EVendo score and compare it with the Baveno VI criteria. METHODS We identified and calculated this score in all cirrhotic patients who underwent screening endoscopy for the first time with laboratory tests and liver stiffness measurements within 6 months of the endoscopy date. RESULTS In total, 103 patients were included. An EVendo score of ≤3.90 identified patients with no gastroesophageal varices (GEV) and varices needing treatment (VNT) with sensitivities of 82% and 83% and specificities of 57% and 34%, respectively. The negative predictive value for VNT was 94%. A comparison with the Baveno VI criteria in Child-Turcotte-Pugh-A patients showed spared endoscopy and missed VNT rates with EVendo score cutoffs of ≤3.9 and ≤4.5 and the Baveno VI criteria of 25%, 33%, and 16.6% and 1.7%, 1.7%, and 0%, respectively. CONCLUSIONS EVendo score is reliable in clinical practice for predicting GEV and VNT. The number of spared endoscopies was higher than that with the Baveno VI criteria; however, there were more missed VNT cases.
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Affiliation(s)
- Khalid Alswat
- Liver Disease Research Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Address for correspondence: Dr. Khalid Alswat, Liver Disease Research Center, Department of Medicine, College of Medicine, King Saud University, P.O. Box 2925 (59), Riyadh 11461, Saudi Arabia. E-mail:
| | - Mohammed Alanazi
- Liver Disease Research Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmed Bashmail
- Liver Disease Research Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Maram Alkhamash
- Liver Disease Research Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saleh A. Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA,Liver Transplant Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Waleed Al-Hamoudi
- Liver Disease Research Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Liver Transplant Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Ayman A. Abdo
- Liver Disease Research Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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19
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Ferreira-Silva J, Gaspar R, Liberal R, Cardoso H, Macedo G. Transient splenic elastography predicts high-risk esophageal varices in patients with non-cirrhotic portal hypertension. Scand J Gastroenterol 2021; 56:1462-1466. [PMID: 34428123 DOI: 10.1080/00365521.2021.1968485] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Non-cirrhotic portal hypertension (NCPH) comprise a group of diseases that cause portal hypertension without cirrhosis, leading to a high risk of hemorrhage from esophageal varices. There are no non-invasive predictors of high-risk varices (HRV) described in the literature for NCPH. This study aimed to evaluate whether transient splenic elastography (TSE) can predict HRV in patients with NCPH. METHODS Prospective study of patients with NCPH who underwent a single timepoint evaluation with transient liver and spleen elastography, ultrasonography, upper endoscopy, and laboratory tests. The study was performed from January to September 2020. Patients were divided into two groups based on the presence of HRV. The relation between TSE, transient liver elastography (TLE), spleen size, and platelet count to the presence of HRV was evaluated. RESULTS Of 42 patients with NCPH, 50% (21/42) presented HRV. In univariate analysis, TSE (median, 58.4 vs. 28.3, p = 0.009) and spleen size (median, 17.5 vs. 14.5 cm, p = 0.013) were associated with HRV. No statistically significant relationship was found between the presence of HRV and platelet count or TLE. In multivariate analysis, TSE was the only variable related to HRV (OR 1.21, 95% CI 1.02-1.38). TSE had a good performance in predicting HRV in our population (AUROC 0.878; 95% CI 0.751-1000). TSE > 35.4 kPa presents 93.3% sensitivity, 60.0% specificity, and 90.9% negative predictive value. CONCLUSION In our population of patients with NCPH, TSE is useful in predicting HRV. TLE, spleen size, and platelet count were not related to HRV.
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Affiliation(s)
- Joel Ferreira-Silva
- Gastroenterology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Rui Gaspar
- Gastroenterology Department, Centro Hospitalar Universitário de São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar Universitário de São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Hélder Cardoso
- Gastroenterology Department, Centro Hospitalar Universitário de São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar Universitário de São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
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20
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Agarwal A, Pathak P, Gupta S, Kumar R, Shalimar. Baveno criteria perform better than expanded Baveno and Rete Sicilia Selezione Terapia-Hepatitis C virus criteria for predicting varices needing treatment. Indian J Gastroenterol 2021; 40:590-597. [PMID: 33991311 DOI: 10.1007/s12664-020-01141-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopy is the gold standard for the detection and staging of varices. Baveno, expanded Baveno, and Rete Sicilia Selezione Terapia-hepatitis C virus (RESIST-HCV) criteria predict varices non-invasively in patients with cirrhosis. We assessed the performance of these criteria for predicting varices needing treatment (VNT). METHODS Consecutive patients with compensated cirrhosis due to viral etiologies evaluated between January 2014 and May 2017 were included in this retrospective analysis of a prospectively maintained database. VNTs were defined as either large varies or small varices with red color signs on endoscopy. Performance characteristics to predict VNTs were estimated for the three criteria and spared endoscopy rate (SER) and missed VNT rates were determined. RESULTS Two hundred and ninety-five treatment-naïve cirrhosis patients, etiology hepatitis B (n = 154) or hepatitis C (n = 141), mean age 43.1 ± 13.2 years, 127 (43.1%) males were included. The median liver stiffness measurement (LSM) and platelet counts were 19.7 (interquartile range [IQR]: 14.8-28.8) kPa and 119 (IQR: 80-160) × 103/mm3, respectively. The SER and missed VNT rates were as follows-for Baveno criteria: 18.3% and 6.2%; expanded Baveno: 35.3% and 29.2%; and for RESIST-HCV criteria: 37.3% and 22.9%. The sensitivity, specificity, positive predictive value, and negative predictive value were 93.7%, 21.9%, 18.9%, and 94.7% for Baveno criteria; 70.8%, 42.3%, 19.3%, and 88.1% for expanded Baveno; and 77.1%, 44.5%, 21.3%, and 90.9% for RESIST-HCV criteria, respectively. CONCLUSION Baveno criteria are useful to avoid screening endoscopies in patients with cirrhosis of viral etiologies. In contrast, although expanded Baveno criteria and RESIST-HCV criteria spare more endoscopies, a high missed VNT rate limits their applicability.
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Affiliation(s)
- Ashish Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Piyush Pathak
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Swatantra Gupta
- Department of Gastroenterology and Hepatology, Dr. Rajendra Prasad Medical College, Kangra, Tanda 176 001, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, 801 507, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India.
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21
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Wong YJ, Kew GS, Tan PS, Chen Z, Putera M, Yip WA, Ang TL, Fock KM, Lee GH, Hsiang J, Huang DQ, Kwek A, Muthiah MD, Kumar R, Tan M, Tan J, Thurairajah PH, Teo EK, Tai BC, Lim SG. Novel albumin, bilirubin and platelet criteria for the exclusion of high-risk varices in compensated advanced chronic liver disease: A validation study. Clin Res Hepatol Gastroenterol 2021; 45:101598. [PMID: 33780835 DOI: 10.1016/j.clinre.2020.101598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/27/2020] [Accepted: 12/01/2020] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Guan Sen Kew
- Division of Gastroenterology and Hepatology, National University Health System, Singapore
| | - Poh Seng Tan
- Division of Gastroenterology and Hepatology, National University Health System, Singapore
| | - Zhaojin Chen
- Biostatistic Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Martin Putera
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Wenjun Alexander Yip
- Division of Gastroenterology and Hepatology, National University Health System, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Guan Huei Lee
- Division of Gastroenterology and Hepatology, National University Health System, Singapore
| | - John Hsiang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Gastroenterology and Hepatology, Sengkang General Hospital, Singapore
| | - Daniel Q Huang
- Division of Gastroenterology and Hepatology, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Mark D Muthiah
- Division of Gastroenterology and Hepatology, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Malcolm Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Prem Harichander Thurairajah
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Division of Gastroenterology and Hepatology, National University Health System, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Seng Gee Lim
- Division of Gastroenterology and Hepatology, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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22
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Agarwal S, Sharma S, Kumar M, Venishetty S, Bhardwaj A, Kaushal K, Gopi S, Mohta S, Gunjan D, Saraya A, Sarin SK. Development of a machine learning model to predict bleed in esophageal varices in compensated advanced chronic liver disease: A proof of concept. J Gastroenterol Hepatol 2021; 36:2935-2942. [PMID: 34050561 DOI: 10.1111/jgh.15560] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/19/2021] [Accepted: 05/26/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Risk stratification beyond the endoscopic classification of esophageal varices (EVs) to predict first episode of variceal bleeding (VB) is currently limited in patients with compensated advanced chronic liver disease (cACLD). We aimed to assess if machine learning (ML) could be used for predicting future VB more accurately. METHODS In this retrospective analysis, data from patients of cACLD with EVs, laboratory parameters and liver stiffness measurement (LSM) were used to generate an extreme-gradient boosting (XGBoost) algorithm to predict the risk of VB. The performance characteristics of ML and endoscopic classification were compared in internal and external validation cohorts. Bleeding rates were estimated in subgroups identified upon risk stratification with combination of model and endoscopic classification. RESULTS Eight hundred twenty-eight patients of cACLD with EVs, predominantly related to non-alcoholic fatty liver disease (28.6%), alcohol (23.7%) and hepatitis B (23.1%) were included, with 455 (55%) having the high-risk varices. Over a median follow-up of 24 (12-43) months, 163 patients developed VB. The accuracy of machine learning (ML) based model to predict future VB was 98.7 (97.4-99.5)%, 93.7 (88.8-97.2)%, and 85.7 (82.1-90.5)% in derivation (n = 497), internal validation (n = 149), and external validation (n = 182) cohorts, respectively, which was better than endoscopic classification [58.9 (55.5-62.3)%] alone. Patients stratified high risk on both endoscopy and model had 1-year and 3-year bleeding rates of 31-43% and 64-85%, respectively, whereas those stratified as low risk on both had 1-year and 3-year bleeding rates of 0-1.6% and 0-3.4%, respectively. Endoscopic classification and LSM were the major determinants of model's performance. CONCLUSION Application of ML model improved the performance of endoscopic stratification to predict VB in patients with cACLD with EVs.
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Affiliation(s)
- Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Sanchit Sharma
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Kumar
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shantan Venishetty
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankit Bhardwaj
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kanav Kaushal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Srikanth Gopi
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Srikant Mohta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
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23
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Zhao W, Xue N, Cui P, Liu L, Wang Y, Zhang X, Tang Y, Du H, Nan Y. Plasma YAP1 predicts esophageal varices and the risk of variceal bleeding in liver cirrhosis. Biomark Med 2021; 15:1411-1422. [PMID: 34533050 DOI: 10.2217/bmm-2020-0573] [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: 11/21/2022] Open
Abstract
Aim: To explore the predictive value of plasma YAP1 for esophageal varices (EV) and high-risk EV (HRV) in patients with liver cirrhosis. Materials & methods: A total of 208 patients with liver cirrhosis were enrolled and categorized into four groups. Correlation analysis, logistic regression analysis and receiver operating characteristic curve analysis were performed to evaluate the diagnostic performance of plasma YAP1 for EV and HRV. Results: Plasma YAP1 levels were significantly elevated with the occurrence and progression of EV in cirrhotic patients. The multivariate logistic regression analysis revealed that plasma YAP1 is an independent predictor for EV and HRV. For predicting EV and HRV, the YAP1 cut-off values of 5.43 and 6.98 ng/ml yielded the area under the receiver operating characteristic curves of 0.944 and 0.955, respectively. Conclusion: Plasma YAP1 is a potential novel noninvasive biomarker for predicting EV and HRV in patients with liver cirrhosis.
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Affiliation(s)
- Wen Zhao
- Department of Traditional & Western Medical Hepatology, Third Hospital of Hebei Medical University, Hebei Key Laboratory of Mechanism of Liver Fibrosis in Chronic Liver Diseases, Shijiazhuang, 050051, China
| | - Ningning Xue
- Department of Traditional & Western Medical Hepatology, Third Hospital of Hebei Medical University, Hebei Key Laboratory of Mechanism of Liver Fibrosis in Chronic Liver Diseases, Shijiazhuang, 050051, China
| | - Po Cui
- Department of Traditional & Western Medical Hepatology, Third Hospital of Hebei Medical University, Hebei Key Laboratory of Mechanism of Liver Fibrosis in Chronic Liver Diseases, Shijiazhuang, 050051, China
| | - Lingdi Liu
- Department of Traditional & Western Medical Hepatology, Third Hospital of Hebei Medical University, Hebei Key Laboratory of Mechanism of Liver Fibrosis in Chronic Liver Diseases, Shijiazhuang, 050051, China
| | - Yiqi Wang
- Department of Traditional & Western Medical Hepatology, Third Hospital of Hebei Medical University, Hebei Key Laboratory of Mechanism of Liver Fibrosis in Chronic Liver Diseases, Shijiazhuang, 050051, China
| | - Xiaoxiao Zhang
- Department of Traditional & Western Medical Hepatology, Third Hospital of Hebei Medical University, Hebei Key Laboratory of Mechanism of Liver Fibrosis in Chronic Liver Diseases, Shijiazhuang, 050051, China
| | - Yuhui Tang
- Department of Traditional & Western Medical Hepatology, Third Hospital of Hebei Medical University, Hebei Key Laboratory of Mechanism of Liver Fibrosis in Chronic Liver Diseases, Shijiazhuang, 050051, China
| | - Huijuan Du
- Department of Traditional & Western Medical Hepatology, Third Hospital of Hebei Medical University, Hebei Key Laboratory of Mechanism of Liver Fibrosis in Chronic Liver Diseases, Shijiazhuang, 050051, China
| | - Yuemin Nan
- Department of Traditional & Western Medical Hepatology, Third Hospital of Hebei Medical University, Hebei Key Laboratory of Mechanism of Liver Fibrosis in Chronic Liver Diseases, Shijiazhuang, 050051, China
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24
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Vuille-Lessard É, Rodrigues SG, Berzigotti A. Noninvasive Detection of Clinically Significant Portal Hypertension in Compensated Advanced Chronic Liver Disease. Clin Liver Dis 2021; 25:253-289. [PMID: 33838850 DOI: 10.1016/j.cld.2021.01.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Élise Vuille-Lessard
- Hepatology, University Clinic for Visceral Surgery and Medicine (UVCM), Inselspital, University Hospital of Bern, Freiburgstrasse, 3010 Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland
| | - Susana G Rodrigues
- Hepatology, University Clinic for Visceral Surgery and Medicine (UVCM), Inselspital, University Hospital of Bern, Freiburgstrasse, 3010 Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland
| | - Annalisa Berzigotti
- Hepatology, University Clinic for Visceral Surgery and Medicine (UVCM), Inselspital, University Hospital of Bern, Freiburgstrasse, 3010 Bern, Switzerland; Department of Biomedical Research, University of Bern, Switzerland.
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Corma-Gómez A, Macías J, Morano L, Rivero A, Téllez F, Ríos MJ, Santos M, Serrano M, Palacios R, Merino D, Real LM, De Los Santos I, Vera-Méndez FJ, Galindo MJ, Pineda JA. Liver Stiffness-Based Strategies Predict Absence of Variceal Bleeding in Cirrhotic Hepatitis C Virus-Infected Patients With and Without Human Immunodeficiency Virus Coinfection After Sustained Virological Response. Clin Infect Dis 2021; 72:e96-e102. [PMID: 33211801 DOI: 10.1093/cid/ciaa1726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/13/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In the setting of hepatitis C virus (HCV) active infection, liver stiffness (LS)-based strategies identify patients with low risk of developing esophageal variceal bleeding (VB) episodes, in whom unnecessary upper esophagogastroduodenoscopy (UGE) screening can be safely avoided. However, after sustained virological response (SVR), data on the accuracy of the criteria predicting this outcome in HCV-infected patients with cirrhosis, with or without human immunodeficiency virus (HIV) coinfection, are very limited. METHODS This was a multicenter prospective cohort study, where HCV-monoinfected patients and HIV/HCV-coinfected individuals were included if they had (1) SVR with direct-acting antiviral-based therapy; (2) LS ≥9.5 kPa previous to treatment; and (3) LS measurement at the SVR time-point ≥14 kPa. Diagnostic accuracy of HEPAVIR, expanded Baveno VI, and HIV cirrhosis criteria, at the time of SVR, was evaluated. Missed VB episodes, negative predictive values (NPVs), and number of spared UGEs were specifically assessed. RESULTS Four hundred thirty-five patients were included, 284 (65%) coinfected with HIV. Seven (1.6%) patients developed a first episode of VB after SVR. In patients without a previous VB episode, HEPAVIR, expanded Baveno VI and HIV cirrhosis criteria achieved NPV for first VB episode after SVR of 99.5% (95% confidence interval [CI], 97.1%-100%), 100% (95% CI 97.8%-100%), and 100% (95% CI 98%-100%) while sparing 45%, 39%, and 44% of UGEs, respectively. When considering HIV coinfection, the performance of the 3 criteria was similar, both in HCV-monoinfected and HIV/HCV-coinfected individuals. CONCLUSIONS After SVR, predictive LS-based strategies accurately identify HCV-infected patients, HIV coinfected or not, with low risk of developing VB during follow-up. In these specific patients, using HIV cirrhosis criteria maximize the number of spared UGEs while missing no VB episode.
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Affiliation(s)
- Anaïs Corma-Gómez
- Unit of Infectious Diseases and Microbiology, Hospital Universitario de Valme, Seville, Spain
| | - Juan Macías
- Unit of Infectious Diseases and Microbiology, Hospital Universitario de Valme, Seville, Spain
| | - Luis Morano
- Unit of Infectious Pathology, Hospital Universitario Alvaro Cunqueiro, Vigo, Spain
| | - Antonio Rivero
- Unit of Infectious Diseases, Hospital Universitario Reina Sofia, Instituto Maimonides de Investigación Biomedica de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - Francisco Téllez
- Unit of Infectious Diseases, Hospital Universitario de Puerto Real, Facultad de Medicina, Universidad de Cadiz, Cádiz, Spain
| | - Maria José Ríos
- Unit of Infectious Diseases, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Marta Santos
- Unit of Internal Medicine, University Hospital Jerez, Cadiz, Spain
| | - Miriam Serrano
- Unit of Infectious Diseases, Hospital Universitario de Gran Canaria Dr Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Rosario Palacios
- Unit of Infectious Diseases and Microbiology, Hospital Virgen de la Victoria, Málaga, Spain
| | - Dolores Merino
- Unit of Infectious Diseases, Hospital Juan Ramón Jiménez, Huelva, Spain
| | - Luis Miguel Real
- Unit of Immunology, Biochemistry, Molecular Biology and Surgery, Faculty of Medicine, University of Malaga, Málaga, Spain
| | - Ignacio De Los Santos
- Unit of Internal Medicine and Infectious Diseases, Hospital La Princesa, Madrid, Spain
| | - Francisco J Vera-Méndez
- Section of Infectious Medicine/Service of Internal Medicine, Hospital General Universitario Santa Lucía, Cartagena, Spain
| | - Maria José Galindo
- Unit of Infectious Diseases, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Juan A Pineda
- Unit of Infectious Diseases and Microbiology, Hospital Universitario de Valme, Seville, Spain
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Chang PE, Tan CK, Cheah CC, Li W, Chow WC, Wong YJ. Validation of the Expanded Baveno-VI Criteria for Screening Gastroscopy in Asian Patients with Compensated Advanced Chronic Liver Disease. Dig Dis Sci 2021; 66:1343-1348. [PMID: 32440746 DOI: 10.1007/s10620-020-06334-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/08/2020] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Pik-Eu Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Chee-Kiat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Chang-Chuen Cheah
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Yu-Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.
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Dajti E, Alemanni LV, Marasco G, Montagnani M, Azzaroli F. Approaches to the Diagnosis of Portal Hypertension: Non-Invasive or Invasive Tests? Hepat Med 2021; 13:25-36. [PMID: 33776492 PMCID: PMC7987277 DOI: 10.2147/hmer.s278077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/19/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Elton Dajti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luigina Vanessa Alemanni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Giovanni Marasco
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Marco Montagnani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Francesco Azzaroli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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Validation of original, expanded Baveno VI, and stepwise & platelet-MELD criteria to rule out varices needing treatment in compensated cirrhosis from various etiologies. Ann Hepatol 2021; 19:209-213. [PMID: 31607647 DOI: 10.1016/j.aohep.2019.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 07/31/2019] [Accepted: 08/07/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION AND OBJECTIVES The Baveno VI criteria to rule out varices needing treatment (VNT) was introduced in 2015. Soon after, the expanded Baveno VI and stepwise platelet-MELD criteria were proposed to be equal/more accurate in ruling out VNT; however, neither has been widely validated. We aimed to validate all 3 criteria in compensated cirrhosis from assorted causes. MATERIALS AND METHODS We conducted a cross-sectional study including all adult compensated cirrhotic patients who underwent endoscopic surveillance at our center from 2014 to 2018 and had transient elastography (TE), and laboratory data for criteria calculation within 6 months of endoscopies. Exclusion criteria were previous decompensation, unreliable/invalid TE results, and liver cancer. The diagnostic performances of all criteria were evaluated. RESULTS A total of 128 patients were included. The major cirrhosis etiologies were hepatitis C and B (37.5% and 32.8%, respectively). VNT was observed in 7.8%. All criteria yielded high negative predictive values (NPVs)>95%, missed VNT was observed in 2%, 2.7%, and 2.8% in the original, expanded Baveno VI, and platelet-MELD criteria, respectively. The expanded Baveno VI and the platelet-MELD criteria yielded significantly better specificities and could spare more endoscopies than the original Baveno VI criteria. CONCLUSIONS All 3 criteria showed satisfactorily high NPVs in ruling out VNT in compensated cirrhosis from various causes. The expanded Baveno VI and the platelet-MELD criteria could spare more endoscopies than the original Baveno VI criteria. From a public health standpoint, the platelet-MELD criteria might be useful in a resource-limited setting where TE is not widely available.
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Hydes T, Moore M, Stuart B, Kim M, Su F, Newell C, Cable D, Hales A, Sheron N. Can routine blood tests be modelled to detect advanced liver disease in the community: model derivation and validation using UK primary and secondary care data. BMJ Open 2021; 11:e044952. [PMID: 33574154 PMCID: PMC7925927 DOI: 10.1136/bmjopen-2020-044952] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES Most patients are unaware they have liver cirrhosis until they present with a decompensating event. We therefore aimed to develop and validate an algorithm to predict advanced liver disease (AdvLD) using data widely available in primary care. DESIGN, SETTING AND PARTICIPANTS Logistic regression was performed on routinely collected blood result data from the University Hospital Southampton (UHS) information systems for 16 967 individuals who underwent an upper gastrointestinal endoscopy (2005-2016). Data were used to create a model aimed at detecting AdvLD: 'CIRRhosis Using Standard tests' (CIRRUS). Prediction of a first serious liver event (SLE) was then validated in two cohorts of 394 253 (UHS: primary and secondary care) and 183 045 individuals (Care and Health Information Exchange (CHIE): primary care). PRIMARY OUTCOME MEASURES Model creation dataset: cirrhosis or portal hypertension. Validation datasets: SLE (gastro-oesophageal varices, liver-related ascites or cirrhosis). RESULTS In the model creation dataset, 931 SLEs were recorded (5.5%). CIRRUS detected cirrhosis or portal hypertension with an area under the curve (AUC) of 0.90 (95% CI 0.88 to 0.92). Overall, 3044 (0.8%) and 1170 (0.6%) SLEs were recorded in the UHS and CHIE validation cohorts, respectively. In the UHS cohort, CIRRUS predicted a first SLE within 5 years with an AUC of 0.90 (0.89 to 0.91) continuous, 0.88 (0.87 to 0.89) categorised (crimson, red, amber, green grades); and AUC 0.84 (0.82 to 0.86) and 0.83 (0.81 to 0.85) for the CHIE cohort. In patients with a specified liver risk factor (alcohol, diabetes, viral hepatitis), a crimson/red cut-off predicted a first SLE with a sensitivity of 72%/59%, specificity 87%/93%, positive predictive value 26%/18% and negative predictive value 98%/99% for the UHS/CHIE validation cohorts, respectively. CONCLUSION Identification of individuals at risk of AdvLD within primary care using routinely available data may provide an opportunity for earlier intervention and prevention of liver-related morbidity and mortality.
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Affiliation(s)
- Theresa Hydes
- School of Primary Care and Population Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Michael Moore
- School of Primary Care and Population Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Beth Stuart
- School of Primary Care and Population Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Miranda Kim
- School of Primary Care and Population Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Fangzhong Su
- School of Primary Care and Population Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Colin Newell
- Human Development and Health, University of Southampton Faculty of Medicine, Southampton, Southampton, UK
- Southampton Biomedical Research Centre, Southampton, UK
| | - David Cable
- Informatics, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - Alan Hales
- School of Primary Care and Population Sciences, University of Southampton, Southampton, Hampshire, UK
- AH IT Solutions, Southampton, Hampshire, UK
| | - Nick Sheron
- The Institute of Hepatology, Foundation for Liver Research, London, UK
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Wang B, Zhou J, Wu X, Sun Y, Li L, Li P, Li M, Jiang W, Xu M, Feng B, Xu X, Cheng J, Xie W, Han T, Wang X, Li H, Piao H, Wu S, Shi Y, Chen S, Kong Y, Ma H, Ou X, Jia J, You H. Screening varices in patients with HBV-related cirrhosis on antiviral therapy: Platelet alone or together with LSM. Liver Int 2021; 41:369-377. [PMID: 33277803 DOI: 10.1111/liv.14752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/04/2020] [Accepted: 11/30/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Bingqiong Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Jialing Zhou
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Xiaoning Wu
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yameng Sun
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Lei Li
- Department of Gastroenterology and Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Ping Li
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Minghui Li
- Liver Disease Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Wei Jiang
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mingyi Xu
- Department of Gastroenterology and Hepatology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bo Feng
- Hepatology Institute, Peking University People's Hospital, Beijing, China
| | - Xiaoyuan Xu
- Department of Infectious Disease, Peking University First Hospital, Beijing, China
| | - Jilin Cheng
- Department of Gastroenterology, Shanghai Public Health Clinical Center, Shanghai, China
| | - Wen Xie
- Liver Disease Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Tao Han
- Department of Hepatology, Tianjin Third Central Hospital, Tianjin Medical University, Tianjin, China
| | - Xiaozhong Wang
- Department of Hepatology, Xinjiang Uygur Autonomous Region Traditional Chinese Medicine Hospital, Urumqi, Xinjiang, China
| | - Hai Li
- Department of Gastroenterology, Tianjin Xiqing Hospital, Tianjin, China
| | - Hongxin Piao
- Department of Infectious Diseases, Affiliated Hospital of Yanbian University, Yanji, China
| | - Shanshan Wu
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yiwen Shi
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Shuyan Chen
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yuanyuan Kong
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Hong Ma
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Xiaojuan Ou
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Hong You
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
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Validation and comparison of non-invasive prediction models based on liver stiffness measurement to identify patients who could avoid gastroscopy. Sci Rep 2021; 11:150. [PMID: 33420233 PMCID: PMC7794348 DOI: 10.1038/s41598-020-80136-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022] Open
Abstract
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.
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Kang Y, Park S, Kim S, Han SJ, Koh H. Validating the BAVENO VI criteria to identify low risk biliary atresia patients without endoscopy for esophageal varix. Clin Res Hepatol Gastroenterol 2021; 45:101437. [PMID: 32417223 DOI: 10.1016/j.clinre.2020.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Portoenterostomy is the initial surgical treatment for biliary atresia (BA); however, no curative therapy exists for BA. Varix bleeding is a major complication of end-stage liver disease and must be determined in patients with BA, necessitating routine surveillance using esophagogastroduodenoscopy (EGD). We attempted to validate criteria to identify BA patients requiring EGD. METHODS From January 2007 to December 2017, we selected BA patients who underwent Kasai surgery, transient elastography (TE), and EGD at Severance hospital. In total, 190 cases were included; laboratory tests and EGDs were carried out from 3 months before TE to 3 months after TE. RESULTS Based on the cut-off value (<10) of the liver stiffness measurement (LSM), 35 (81.4%) patients with low-risk varix (LRV) and 8 (18.6%) with high-risk varix (HRV) were identified. Based on platelet counts (>150,000), 87 (77.68%) patients with LRV and 25 (22.32%) with HRV were identified. Based on this, the BAVENO VI criteria, which identify patients who can safely avoid screening EGD, missed 9/68 (13.24%) of HRV patients. The expanded BAVENO VI criteria missed 21/68 (30.88%) of HRV patients. However, the criteria using LSM <10 and platelet count >150,000 missed identifying only 4/68 (5.88%) HRV patients. CONCLUSIONS The BAVENO criteria may be as useful in children with BA as in adults with liver cirrhosis. Regular laboratory tests, imaging studies, and EGD may avoid missing diagnoses of varices in BA patients. However, LSM<10 and platelet count>150,000 may provide more accurate criteria and help identify patients who does not need endoscopy.
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Affiliation(s)
- Yunkoo Kang
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea; Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Pediatric Liver Disease Research Group, Seoul, Republic of Korea
| | - Sowon Park
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Pediatric Liver Disease Research Group, Seoul, Republic of Korea
| | - Seung Kim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Pediatric Liver Disease Research Group, Seoul, Republic of Korea
| | - Seok Joo Han
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Pediatric Liver Disease Research Group, Seoul, Republic of Korea
| | - Hong Koh
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Pediatric Liver Disease Research Group, Seoul, Republic of Korea.
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Validation and Refinement of the Baveno VI Criteria for Ruling Out High-Risk Varices. Gastroenterol Res Pract 2020; 2020:4217512. [PMID: 33376483 PMCID: PMC7744238 DOI: 10.1155/2020/4217512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/02/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Bangaru S, Benhammou JN, Tabibian JH. Noninvasive scores for the prediction of esophageal varices and risk stratification in patients with cirrhosis. World J Hepatol 2020; 12:908-918. [PMID: 33312418 PMCID: PMC7701959 DOI: 10.4254/wjh.v12.i11.908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/13/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Saroja Bangaru
- Internal Medicine, Gastroenterology, University of California at Los Angeles, Los Angeles, CA 90025, United States
| | - Jihane N Benhammou
- The Vatche and Tamar Manoukian Division of Digestive Diseases, University of California at Los Angeles, Los Angeles, CA 90095, United States
| | - James H Tabibian
- Department of Medicine, Olive View-University of California at Los Angeles Medical Center, Sylmar, CA 91342, United States
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States.
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Samanta T, Biswas K, Ghosh S, Gupta MK, Basu R, Purkait R, Naskar A, Butta S, Das D, Ganguly S. Validation of Revised Baveno VI Criteria for Screening of Varices Needing Treatment in Children with Cirrhosis. Clin Exp Gastroenterol 2020; 13:503-509. [PMID: 33177858 PMCID: PMC7652065 DOI: 10.2147/ceg.s276182] [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: 08/12/2020] [Accepted: 09/19/2020] [Indexed: 11/23/2022] Open
Abstract
Background Baveno VI criteria for screening varices needing treatment (VNT) have not yet been validated in an exclusive pediatric and adolescent set of the population, in whom baseline parameters differ in relation to adults. Therefore, our primary objective was to validate Baveno VI and its expanded form in children below 18 years of age. The secondary aim was to elicit whether any revision of the above criteria with a target of not missing more than 5% VNT could be more accurate for this age group. Materials and Methods The work was carried out in two medical institutes, over a span of 3 years. Consecutively enrolled patients below 18 years of age, with compensated cirrhosis confirmed by liver biopsy, were evaluated for related blood parameters, transient elastography (TE) and esophagogastroduodenoscopy. Results Out of the 33 recruited patients, five (15.15%) met the criteria for VNT. The sensitivity, specificity, PPV and NPV of Baveno VI and Expanded Baveno VI were observed as 60%, 92.3%, 60% and 92.3%, and 20%, 100%, 100% and 88%, respectively. We found that the Revised Baveno VI criteria with TE <19 kPa and platelet count of >175×109 cells/L, with sensitivity 100%, specificity 79%, PPV 45%, NPV 100% and accuracy of 82%, are more appropriate for this age group. Conclusion We propose that further multicentrer studies with a larger sample size should be conducted before incorporating Revised Baveno VI criteria for high-risk varices in patients below 18 years in future guidelines.
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Affiliation(s)
- Tryambak Samanta
- Department of Medical Gastroenterology, Medical College, Kolkata 73, India
| | - Kalidas Biswas
- Department of Medical Gastroenterology, Medical College, Kolkata 73, India
| | - Saubhik Ghosh
- Department of Medical Gastroenterology, Medical College, Kolkata 73, India
| | - Manoj Kumar Gupta
- Department of Medical Gastroenterology, Medical College, Kolkata 73, India
| | - Rajarshi Basu
- Department of Pediatrics, Nil Ratan Sircar Medical College, Kolkata 14, India
| | - Radheshyam Purkait
- Department of Pediatrics, Nil Ratan Sircar Medical College, Kolkata 14, India
| | - Abhisek Naskar
- Department of Pediatrics, Nil Ratan Sircar Medical College, Kolkata 14, India
| | - Shristi Butta
- Department of Pathology, Nil Ratan Sircar Medical College, Kolkata 14, India
| | - Debasis Das
- Department of Community Medicine, Medical College, Kolkata 73, India
| | - Sutapa Ganguly
- Department of Pediatrics, KPC Medical College, Kolkata, India
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Deciding Among Noninvasive Tools for Predicting Varices Needing Treatment in Chronic Liver Disease: An Analysis of Asian Cohort. Am J Gastroenterol 2020; 115:1650-1656. [PMID: 32516202 DOI: 10.14309/ajg.0000000000000722] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Kang SH, Baik SK, Kim MY. Application of Baveno Criteria and Modified Baveno Criteria with Shear-wave Elastography in Compensated Advanced Chronic Liver Disease. J Korean Med Sci 2020; 35:e249. [PMID: 32743990 PMCID: PMC7402928 DOI: 10.3346/jkms.2020.35.e249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/04/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND We aimed to validate Baveno VI and expanded Baveno VI criteria using two dimensional shear-wave elastography (2D-SWE) in compensated advanced chronic liver disease (cACLD) patients with alcohol as the main etiology. METHODS Clinical data from 305 patients with cACLD who underwent a liver stiffness measurement (LSM) with 2D-SWE and endoscopy were consecutively collected. RESULTS Among 305 patients, high-risk varix (HRV) was identified in 21.3% (n = 65). The main etiology was alcoholic liver disease (51.8%), followed by hepatitis B virus (29.8%) and hepatitis C virus (9.1%). Baveno VI criteria spared endoscopy in 118 of the 305 (38.7%) patients, and 7 (5.9%) were missed with HRV. Expanded Baveno VI criteria spared more endoscopies (60.0%), but missed more HRV (9.8%) compared with Baveno VI criteria. The other classification described as the modified Baveno VI criteria were LSM < 25 kPa and PLT ≥ 150 × 10³/mm³. In total, 131 of the 305 (43.0%) patients were within the modified Baveno VI criteria, of whom seven (5.3%) had missed HRV. After adding spleen diameter < 12 cm to the modified Baveno VI criteria, the number of spared endoscopies increased by 106/305 (34.8%), with three (2.8%) presenting with HRV, indicating a risk of missing HRV. CONCLUSION Baveno VI and expanded Baveno VI criteria with 2D-SWE were insufficient with an HRV miss rate of over 5%. The modified Baveno VI criteria with spleen diameters < 12 cm with 2D-SWE spared more endoscopies with a minimal risk of missing HRV in cACLD patients with alcohol as the main etiology.
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Affiliation(s)
- Seong Hee Kang
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regenerative Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regenerative Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea.
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Garcovich M, Di Stasio E, Zocco MA, Riccardi L, Ainora ME, Annicchiarico BE, Gibiino G, Santopaolo F, Gasbarrini A, Pompili M. Assessing Baveno VI criteria with liver stiffness measured using a new point-shear wave elastography technique (BAVElastPQ study). Liver Int 2020; 40:1952-1960. [PMID: 32510772 DOI: 10.1111/liv.14558] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 05/21/2020] [Accepted: 05/31/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS To date, no study has explored the potential role of ElastPQ, a novel point-SWE technique, in the assessment of clinically significant portal hypertension. The aim of our study was to determine a liver stiffness (LS) cut-off value measured by ElastPQ and laboratory parameters that could help to identify those patients who can safely avoid screening endoscopy. METHODS Data were collected on 1422 patients who underwent ElastPQ measurement from January 2013 to January 2016 in our Department. Inclusion criteria were a LS value of ≥7 kPa, an upper gastrointestinal endoscopy within 12 months and a diagnosis of compensated chronic liver disease. Exclusion criteria were history of decompensated liver disease, evidence of porto-spleno-mesenteric vein thrombosis and non-cirrhotic portal hypertension. Varices were graded as low-risk varices (grade <2) or varices needing treatment (VNT, grade ≥2). RESULTS The study included 195 patients (120 [61%] HCV, 171 [88%] Child-Pugh A). Varices were present in 35% cases, with 10% prevalence of VNT. According to ROC curve analysis, LS measurement and platelet count were evaluated as predictors of VNT. Overall, 75/195 (38%) met the 'BAVElastPQ' criteria (that is, LS < 12 kPa and platelet count >150 000/μL). Within this group, 11/75 (15%) had any grade of varices and only 1/75 (1%) had VNT. The BAVElastPQ criteria gave sensitivity of 0.95, specificity of 0.42, positive predictive value of 0.15 and negative predictive value of 0.99. CONCLUSIONS The BAVElastPQ criteria correctly identified 99% of patients without VNT. By applying such criteria, we could have potentially avoided 38% of surveillance endoscopies in our cohort.
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Affiliation(s)
- Matteo Garcovich
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enrico Di Stasio
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Biochemistry and Clinical Biochemistry, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria A Zocco
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura Riccardi
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria E Ainora
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Brigida E Annicchiarico
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giulia Gibiino
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Santopaolo
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maurizio Pompili
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Gaete MI, Díaz LA, Arenas A, González K, Cattaneo M, Fuster F, Henríquez R, Soza A, Arrese M, Barrera F, Arab JP, Benítez C. Baveno VI and Expanded Baveno VI criteria successfully predicts the absence of high-risk gastro-oesophageal varices in a Chilean cohort. Liver Int 2020; 40:1427-1434. [PMID: 31916360 DOI: 10.1111/liv.14373] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/02/2019] [Accepted: 01/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Baveno VI and expanded Baveno VI criteria have been recommended to circumvent the need for endoscopy screening in patients with a very low probability of varices needing treatment (VNT). AIM To validate these criteria in a Latin American population. METHODS The ability of Baveno VI criteria (liver stiffness measurement (LSM) <20 kPa and platelet count >150 × 103/μL) and expanded Baveno VI criteria (LSM < 25kPa and platelet count >110 × 103/μL) to exclude the presence of VNT was tested in a prospectively recruited cohort of patients with Child-Pugh A liver cirrhosis and with no previous variceal haemorrhage who attended the liver clinics of three major hospitals in Chile. RESULTS Three hundred patients were included. The median (IQR) age was 61 [18-86] years, median MELD was 8.0 (6-17), median LSM was 17.2 (10.2-77) kPa and median platelet count was 137 (23-464) × 103 /μL. The main aetiology was non-alcoholic fatty liver disease (67.3%). VNT were present in 18% of patients. The Baveno VI criteria had a sensitivity of 98.1% and a specificity of 38.2%, potentially sparing 31.3% of upper endoscopies with a very low risk of missing VNT (1.1%). The expanded Baveno VI criteria had a sensitivity of 90.7% and a specificity of 61%, potentially sparing 51.3% of upper endoscopies with a risk of missing VNT of 3.6%. Both criteria were independently associated with the absence of VNT. CONCLUSION We validated the Baveno VI and expanded Baveno VI criteria in Chilean population, potentially sparing 31.3% and 51.3% of endoscopies, respectively, with a very low risk of missing VNT. Fondecyt 1191183.
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Affiliation(s)
- María I Gaete
- School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis A Díaz
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alex Arenas
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Digestive Diseases Unit, Hospital Sótero del Río, Santiago, Chile
| | - Katherine González
- Department of Gastroenterology, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Máximo Cattaneo
- Department of Gastroenterology, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Francisco Fuster
- Digestive diseases unit, Hospital Dr. Gustavo Fricke, Viña del Mar, Chile
| | - Romina Henríquez
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alejandro Soza
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marco Arrese
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Barrera
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan P Arab
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlos Benítez
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Giannini EG, De Maria C, Crespi M, Demarzo MG, Fazio V, Grasso A, Torre F, Bodini G, Marabotto E, Furnari M. Course of oesophageal varices and performance of noninvasive predictors following Hepatitis C Virus clearance in compensated advanced chronic liver disease. Eur J Clin Invest 2020; 50:e13231. [PMID: 32291753 DOI: 10.1111/eci.13231] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/25/2020] [Accepted: 03/19/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND In patients with hepatitis C virus (HCV) and compensated advanced chronic liver disease (cACLD), there is evidence that sustained virological response (SVR) to direct-acting antivirals (DAA) may ameliorate portal hypertension, although both the course of oesophageal varices and the performance of their noninvasive predictors following DAA-induced SVR are less defined. In this study, our aim was to assess the variation in oesophageal varices status in HCV patients with cACLD who obtained an SVR to DAAs and to evaluate the diagnostic performance of noninvasive predictors of varices after HCV cure. MATERIAL AND METHODS Sixty-three HCV patients with cACLD and SVR to DAAs were prospectively followed up, and oesophageal varices surveillance was carried out according to the Baveno VI indications. Appearance and disappearance of varices, accuracy performance of their noninvasive predictors (Baveno/expanded Baveno VI criteria, platelet count/spleen diameter ratio) and number of endoscopies spared with their application were calculated. RESULTS Following SVR, varices developed or disappeared in 12.1% and 17.4% of patients, respectively. The negative predictive value for varices of the Baveno VI, expanded Baveno VI criteria and platelet count/spleen diameter ratio following SVR was 88.2% (65.6-96.7), 83.3% (66.3-92.7) and 80.7% (67.1-89.5), respectively. Their application would have saved 30.4%, 42.9% and 55.4% of endoscopies, with no varices needing treatment missed using both Baveno VI criteria. CONCLUSIONS In HCV patients with cACLD, following SVR to DAA, the expanded Baveno VI criteria provide the best balance between utility (diagnostic accuracy and endoscopies avoided) and safety (varices needing treatment missed) for varices surveillance.
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Affiliation(s)
- Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, IRCCS-Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Costanza De Maria
- Gastroenterology Unit, Department of Internal Medicine, IRCCS-Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Mattia Crespi
- Gastroenterology Unit, Department of Internal Medicine, IRCCS-Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Maria Giulia Demarzo
- Gastroenterology Unit, Department of Internal Medicine, IRCCS-Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Valentina Fazio
- Gastroenterology Unit, Department of Internal Medicine, San Paolo Hospital, Savona, Italy
| | - Alessandro Grasso
- Gastroenterology Unit, Department of Internal Medicine, San Paolo Hospital, Savona, Italy
| | - Francesco Torre
- Gastroenterology Unit, Department of Internal Medicine, IRCCS-Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, IRCCS-Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, IRCCS-Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Manuele Furnari
- Gastroenterology Unit, Department of Internal Medicine, IRCCS-Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
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Protopapas AA, Mylopoulou T, Papadopoulos VP, Vogiatzi K, Goulis I, Mimidis K. Validating and expanding the Baveno VI criteria for esophageal varices in patients with advanced liver disease: a multicenter study. Ann Gastroenterol 2020; 33:87-94. [PMID: 31892803 PMCID: PMC6928480 DOI: 10.20524/aog.2019.0429] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/17/2019] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION According to the Baveno VI workshop, patients with compensated advanced liver disease, platelet count (PLT) >150,000/μL and liver stiffness measurement (LSM) <20 kPa can avoid screening endoscopy for high-risk varices (HRVs). The purpose of this study was to validate these criteria in a multicenter Greek cohort and consider other approaches that may further decrease the number of endoscopies. METHODS We prospectively enrolled patients with advanced liver disease (defined as LSM >12 kPa) and evaluated them according to the Baveno VI criteria. Exclusion criteria were splanchnic vein thrombosis, use of β-blockers, and esophageal varices. Screening endoscopy was conducted within 6 months of liver stiffness and laboratory measurements. RESULTS One-hundred seven consecutive patients were enrolled in the study to undergo LSM and screening endoscopy. Of these, 13 met the Baveno VI criteria (12.1%); none of the latter had HRVs. Additional parameters were examined, among which the quotient PLT/log10LSM exhibited the largest area under the curve; concerning the latter, values ≤122,000 μL-1 x kPa-1 predicted high-risk varices with 100% sensitivity and negative predictive value (NPV), preventing 20.6% of patients from unneeded screening endoscopy (P=0.003). Moreover, values ≤92,000 μL-1 x kPa-1 exhibited 86% sensitivity and 94% NPV, preventing 44.9% of patients from unneeded screening endoscopy (P=0.001), while maintaining a tolerable percentage of overlooked patients with HRVs (6.3%). CONCLUSIONS The Baveno VI criteria were successfully validated in our study. The quotient PLT/log10LSM can be used to further decrease the number of screening endoscopies in patients with advanced liver disease.
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Affiliation(s)
- Adonis A. Protopapas
- Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki (Adonis A. Protopapas, Ioannis Goulis)
| | - Theodora Mylopoulou
- First Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis (Theodora Mylopoulou, Kiriaki Vogiatzi, Konstantinos Mimidis)
| | | | - Kiriaki Vogiatzi
- First Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis (Theodora Mylopoulou, Kiriaki Vogiatzi, Konstantinos Mimidis)
| | - Ioannis Goulis
- Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki (Adonis A. Protopapas, Ioannis Goulis)
| | - Konstantinos Mimidis
- First Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis (Theodora Mylopoulou, Kiriaki Vogiatzi, Konstantinos Mimidis)
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Stefanescu H, Marasco G, Calès P, Fraquelli M, Rosselli M, Ganne-Carriè N, de Ledinghen V, Ravaioli F, Colecchia A, Rusu C, Andreone P, Mazzella G, Festi D. A novel spleen-dedicated stiffness measurement by FibroScan® improves the screening of high-risk oesophageal varices. Liver Int 2020; 40:175-185. [PMID: 31444849 DOI: 10.1111/liv.14228] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/23/2019] [Accepted: 08/20/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Several non-invasive tests (NITs) have been developed to diagnose oesophageal varices (EV), including the recent Baveno VI criteria to rule out high-risk varices (HRV). Spleen stiffness measurement (SSM) with the standard FibroScan® (SSM@50Hz) has been evaluated. However, the EV grading could be underestimated because of a ceiling threshold (75 kPa) of the SSM@50Hz. The aims were to evaluate SSM by a novel spleen-dedicated FibroScan® (SSM@100Hz) for EV diagnosis compared with SSM@50Hz, other validated NITs and Baveno VI criteria. METHODS This prospective multicentre study consecutively enrolled patients with chronic liver disease; blood data, endoscopy, liver stiffness measurement (LSM), SSM@50Hz and SSM@100Hz were collected. RESULTS Two hundred and sixty patients met inclusion criteria. SSM@100Hz success rate was significantly higher than that of SSM@50Hz (92.5% vs 76.0%, P < .001). SSM@100Hz accuracy for the presence of EV (AUC = 0.728) and HRV (AUC = 0.756) was higher than in other NITs. SSM@100Hz AUC for large EV (0.782) was higher than SSM@50Hz (0.720, P = .027). AUC for HRV with SSM@100Hz (0.780) was higher than with LSM (0.615, P < .001). The spared endoscopy rate of Baveno VI criteria (8.1%) was significantly increased by the combination to SSM@50Hz (26.5%) or SSM@100Hz (38.9%, P < .001 vs others). The missed HRV rate was, respectively, 0% and 4.7% for combinations. CONCLUSIONS SSM@100Hz is a new performant non-invasive marker for EV and HRV providing a higher accuracy than SSM@50Hz and other NITs. The combination of Baveno VI criteria and SSM@100Hz significantly increased the spared endoscopy rate compared to Baveno VI criteria alone or combined with SSM@50Hz. Clinical trial number: NCT02180113.
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Affiliation(s)
- Horia Stefanescu
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Paul Calès
- Hepato-Gastroenterology Department, University hospital, Angers, France
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Rosselli
- Institute for Liver and Digestive Health, Royal Free Hospital, University College of London, London, UK
| | - Nathalie Ganne-Carriè
- INSERM UMR 1162, Hepato-Gastroenterology Department, APHP Jean Verdier Hospital, University Paris 13, Paris, France
| | | | - Federico Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Antonio Colecchia
- Gastroenterology Unit, University Hospital Borgo Trento, Verona, Italy
| | - Corina Rusu
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Pietro Andreone
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giuseppe Mazzella
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Li Q, Wu Y, Zhu Q, Meng F, Lin S, Liu B, Li B, Tang S, Yang Y, Li Y, Yuan S, Chen Y, Qi X. External validation of Liaoning score for predicting esophageal varices in liver cirrhosis: a Chinese multicenter cross-sectional study. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:755. [PMID: 32042771 PMCID: PMC6990029 DOI: 10.21037/atm.2019.11.78] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Our previous study developed Liaoning score as a non-invasive approach for predicting esophageal varices (EVs) in liver cirrhosis. This nationwide multicenter cross-sectional study aimed to externally validate the diagnostic accuracy of Liaoning score and further evaluate its performance for predicting high-risk EVs. METHODS Cirrhotic patients with acute gastrointestinal bleeding (GIB) without history of endoscopic variceal therapy who underwent endoscopic examinations at their admissions were included. Liaoning score and several non-invasive liver fibrosis scores, including aspartate aminotransferase (AST) to platelet ratio index (APRI), AST to alanine aminotransferase ratio (AAR), fibrosis 4 index (FIB-4), King, and Lok scores, were evaluated. Area under curves (AUCs), cut-off value, sensitivity, and specificity were calculated. RESULTS Overall, 612 patients were included. The prevalence of EVs and high-risk EVs was 96.2% and 95.6%, respectively. In overall patients, the AUCs of Liaoning score for predicting EVs and high-risk EVs were higher than non-invasive liver fibrosis scores (0.737 versus 0.626-0.721; 0.734 versus 0.611-0.719). The cut-off value of Liaoning score for high-risk EVs was 0.477 with a sensitivity of 81.96% and a specificity of 65.22%. In patients with hematemesis, Liaoning score could significantly predict EVs and high-risk EVs (AUCs =0.708 and 0.702, respectively), but not non-invasive liver fibrosis scores. The cut-off value of Liaoning score for high-risk EVs was 0.437 with a sensitivity of 83.16% and a specificity of 60%. CONCLUSIONS Liaoning score should be a non-invasive alternative for predicting EVs and high-risk EVs in cirrhotic patients with acute GIB.
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Affiliation(s)
- Qianqian Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Yunhai Wu
- Department of Critical Care Medicine, The Sixth People’s Hospital of Shenyang, Shenyang 110006, China
| | - Qiang Zhu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
| | - Fanping Meng
- Department for Biological Therapy, The Fifth Medical Center of PLA General Hospital, Beijing 100039, China
| | - Su Lin
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
| | - Bang Liu
- Department of Hepatobiliary Disease, 900 Hospital of the Joint Logistics Team (formerly called Fuzhou General Hospital), Fuzhou 350025, China
| | - Bimin Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Shanhong Tang
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu 610083, China
| | - Yida Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Yiling Li
- Department of Gastroenterology, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Shanshan Yuan
- Department of Gastroenterology, Xi’an Central Hospital, Xi’an 710003, China
| | - Yu Chen
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing YouAn Hospital, Capital Medical University, Beijing 100069, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
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Li Q, Wang R, Guo X, Li H, Shao X, Zheng K, Qi X, Li Y, Qi X. Contrast-Enhanced CT May Be a Diagnostic Alternative for Gastroesophageal Varices in Cirrhosis with and without Previous Endoscopic Variceal Therapy. Gastroenterol Res Pract 2019; 2019:6704673. [PMID: 31781196 PMCID: PMC6855090 DOI: 10.1155/2019/6704673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/20/2019] [Accepted: 09/06/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Liver fibrosis blood tests, platelet count/spleen diameter ratio (PSR), and contrast-enhanced CT are diagnostic alternatives for gastroesophageal varices, but they have heterogeneous diagnostic performance among different study populations. Our study is aimed at evaluating their diagnostic accuracy for esophageal varices (EVs) and gastric varices (GVs) in cirrhotic patients with and without previous endoscopic variceal therapy. METHODS Patients with liver cirrhosis who underwent blood tests and contrast-enhanced CT scans as well as endoscopic surveillance should be potentially eligible. EVs needing treatment (EVNTs) and GVs needing treatment (GVNTs) were recorded according to the endoscopic results. Area under the curves (AUCs) were calculated. RESULTS Overall, 279 patients were included. In 175 patients without previous endoscopic variceal therapy, including primary prophylaxis population (n = 70), acute bleeding population (n = 38), and previous bleeding population (n = 67), the diagnostic accuracy of contrast-enhanced CT for EVNTs was higher (AUCs = 0.816-0.876) as compared to blood tests and PSR; by comparison, the diagnostic accuracy of contrast-enhanced CT for GVNTs was statistically significant among primary prophylaxis population (AUC = 0.731, P = 0.0316), but not acute or previous bleeding population. In 104 patients with previous endoscopic variceal therapy (i.e., secondary prophylaxis population), contrast-enhanced CT was the only statistically significant alternative for diagnosing EVNTs and GVNTs but with modest accuracy (AUCs = 0.673 and 0.661, respectively). CONCLUSIONS Contrast-enhanced CT might be a diagnostic alternative for EVNTs in cirrhotic patients, but its diagnostic performance was slightly weakened in secondary prophylaxis population. Additionally, contrast-enhanced CT may be considered for diagnosis of GVNTs in primary prophylaxis population without previous endoscopic variceal therapy and secondary prophylaxis population.
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Affiliation(s)
- Qianqian Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
- Postgraduate College, Dalian Medical University, Dalian 116044, China
| | - Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Xiaodong Shao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Kexin Zheng
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
- Postgraduate College, Jinzhou Medical University, Jinzhou 121001, China
| | - Xiaolong Qi
- CHESS Group, Hepatic Hemodynamic Lab, Institute of Hepatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yingying Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
- Postgraduate College, Jinzhou Medical University, Jinzhou 121001, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
- CHESS Group, Hepatic Hemodynamic Lab, Institute of Hepatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Szakács Z, Erőss B, Soós A, Mátrai P, Szabó I, Pétervári E, Bajor J, Farkas N, Hegyi P, Illés A, Solymár M, Balaskó M, Sarlós P, Szűcs Á, Czimmer J, Vincze Á, Pár G. Baveno Criteria Safely Identify Patients With Compensated Advanced Chronic Liver Disease Who Can Avoid Variceal Screening Endoscopy: A Diagnostic Test Accuracy Meta-Analysis. Front Physiol 2019; 10:1028. [PMID: 31481896 PMCID: PMC6711320 DOI: 10.3389/fphys.2019.01028] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/24/2019] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Alexandra Soós
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Mátrai
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Imre Szabó
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Erika Pétervári
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Judit Bajor
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Nelli Farkas
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
- Hungarian Academy of Sciences-University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Budapest, Hungary
| | - Anita Illés
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Margit Solymár
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Márta Balaskó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Patrícia Sarlós
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Ákos Szűcs
- First Department of Surgery, Semmelweis University, Budapest, Hungary
| | - József Czimmer
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Áron Vincze
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Gabriella Pár
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
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Martínez-Campreciós J, Pons M, Genescà J. Beyond Baveno VI: How far are we? Dig Liver Dis 2019; 51:1141-1143. [PMID: 31345765 DOI: 10.1016/j.dld.2019.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/26/2019] [Accepted: 06/16/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Joan Martínez-Campreciós
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall, d'Hebron, Vall d'Hebron Research Institut (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mònica Pons
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall, d'Hebron, Vall d'Hebron Research Institut (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall, d'Hebron, Vall d'Hebron Research Institut (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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Tosetti G, Primignani M, La Mura V, D'Ambrosio R, Degasperi E, Mezzina N, Viganò M, Rumi M, Fracanzani AL, Lombardi R, Fargion S, Fraquelli M, Aghemo A, Lampertico P. Evaluation of three "beyond Baveno VI" criteria to safely spare endoscopies in compensated advanced chronic liver disease. Dig Liver Dis 2019; 51:1135-1140. [PMID: 30691777 DOI: 10.1016/j.dld.2018.12.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/14/2018] [Accepted: 12/25/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver stiffness measurement (LSM) <20 kPa and platelet count >150,000/mm3 exclude varices needing treatment (VNT) in viral compensated advanced chronic liver disease (cACLD), saving-up to 20-25% endoscopies (Baveno VI criteria). Refinements of such criteria to further reduce endoscopies and an approach without LSM (Platelet 150/MELD 6) were later proposed. AIMS To assess LSM 25/platelet 125, LSM 25/platelet 110 (Expanded-Baveno VI) and Platelet 150/MELD 6 accuracy versus Baveno VI criteria, and the impact of platelet count variability on criteria accuracy in all-etiologies cACLD. METHODS cACLD patients undergoing screening endoscopy with laboratory data within 6 months and LSM within one year. RESULTS Of 442 patients, 31% had varices (7% with VNT). Baveno VI criteria had 100% sensitivity (Se) and negative predictive value (NPV) and spared 19.5% endoscopies. "LSM 25/platelet 125" and "Expanded-Baveno VI" criteria maintained such accuracy, sparing 15% and 24% more endoscopies, respectively (p < 0.001). Platelet 150/MELD 6 was less accurate, misclassifying 10% VNT. Platelet count variability exceeded 8% and one VNT patient was misclassified with both "Expanded-Baveno VI" and "LSM 25/platelet 125" criteria considering the previous platelet count. CONCLUSIONS Both "Expanded-Baveno VI" and "LSM 25/platelet 125" criteria are accurate in cACLD, but the former are more advantageous. Platelet 150/MELD 6 proved inadequate.
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Affiliation(s)
- Giulia Tosetti
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Massimo Primignani
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.
| | - Vincenzo La Mura
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Department of Biomedical Sciences For Health, University of Milan, Milan, Italy
| | - Roberta D'Ambrosio
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Elisabetta Degasperi
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Nicolò Mezzina
- Hepatology Unit, Ospedale San Giuseppe, University of Milan, Milan, Italy
| | - Mauro Viganò
- Hepatology Unit, Ospedale San Giuseppe, University of Milan, Milan, Italy
| | - Mariagrazia Rumi
- Hepatology Unit, Ospedale San Giuseppe, University of Milan, Milan, Italy
| | - Anna Ludovica Fracanzani
- Internal Medicine, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Rosa Lombardi
- Internal Medicine, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Silvia Fargion
- Internal Medicine, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Alessio Aghemo
- Humanitas University Department of Biomedical Sciences, Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Pietro Lampertico
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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Stafylidou M, Paschos P, Katsoula A, Malandris K, Ioakim K, Bekiari E, Haidich AB, Akriviadis E, Tsapas A. 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. Clin Gastroenterol Hepatol 2019; 17:1744-1755.e11. [PMID: 31077823 DOI: 10.1016/j.cgh.2019.04.062] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/23/2019] [Accepted: 04/26/2019] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Maria Stafylidou
- First Department of Internal Medicine, Papageorgiou Hospital, Thessaloniki, Greece.
| | - Paschalis Paschos
- First Department of Internal Medicine, Papageorgiou Hospital, Thessaloniki, Greece; Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Anastasia Katsoula
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Konstantinos Malandris
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Konstantinos Ioakim
- First Department of Internal Medicine, Papageorgiou Hospital, Thessaloniki, Greece
| | - Eleni Bekiari
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Evangelos Akriviadis
- Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece; Harris Manchester College, University of Oxford, Oxford, United Kingdom
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Lee HA, Kim SU, Seo YS, Lee YS, Kang SH, Jung YK, Kim MY, Kim JH, Kim SG, Suk KT, Jung SW, Jang JY, An H, Yim HJ, Um SH. Prediction of the varices needing treatment with non-invasive tests in patients with compensated advanced chronic liver disease. Liver Int 2019; 39:1071-1079. [PMID: 30589490 DOI: 10.1111/liv.14036] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/29/2018] [Accepted: 12/21/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUNDS & AIMS The Baveno VI guidelines proposed criteria including liver stiffness (LS) and platelet count to avoid screening endoscopy in patients with compensated advanced chronic liver disease (cACLD). This study was performed to validate the Baveno IV criteria and to compare its diagnostic accuracy with other non-invasive models. METHODS Patients with cACLD who underwent laboratory tests, upper gastrointestinal endoscopy and abdominal ultrasound within 6 months of transient elastography were included. RESULTS A total of 1218 patients with cACLD were included. VNT occurred in 249 patients (20.4%). With the Baveno VI criteria, the VNT miss rate was 1.9% with a 25.7% saved endoscopy rate. Using two criteria of LS <20 kPa and platelet count >110 × 109 cells/L or LS <25 kPa and platelet count >120 × 109 cells/L, the saved endoscopy rate was 39.1% while maintaining the VNT miss rate <5%. The optimal LS and platelet count-based criteria for predicting VNT differed according to the underlying liver disease. The area under the receiver operating characteristic curve of LS-spleen diameter to platelet score (LSPS) was 0.780 (95% confidence interval: 0.774-0.820), which was significantly higher than other models. The optimal cut-off value of the LSPS for predicting VNT was 1.47. CONCLUSION Liver stiffness and platelet count-based criteria are useful for discriminating patients with very low risk of having VNT among patients with cACLD and are partly affected by the type of underlying liver disease. Conversely, the LSPS is a predictor of VNT in patients with cACLD regardless of the type of underlying liver disease.
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Affiliation(s)
- Han Ah Lee
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young-Sun Lee
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seong Hee Kang
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Soung Won Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hyonggin An
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Soon Ho Um
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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50
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Dajti E, Ravaioli F, Colecchia A, Marasco G, Calès P, Festi D. "Are the Expanded Baveno VI Criteria really safe to screen compensated cirrhotic patients for high-risk varices?". Dig Liver Dis 2019; 51:456-457. [PMID: 30635194 DOI: 10.1016/j.dld.2018.12.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/06/2018] [Accepted: 12/15/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Elton Dajti
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Antonio Colecchia
- Gastroenterology Unit, Borgo Trento University Hospital, Piazzale Aristide Stefani 1, 37126, Verona, Italy.
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Paul Calès
- Hepatology department, University Hospital Angers, 4 Rue Larrey, 49100, Angers, France
| | - Davide Festi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
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