Case Control Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 21, 2019; 25(35): 5323-5333
Published online Sep 21, 2019. doi: 10.3748/wjg.v25.i35.5323
Liver stiffness and serum markers for excluding high-risk varices in patients who do not meet Baveno VI criteria
Hong Zhou, Jun Long, Han Hu, Cai-Yun Tian, Shi-De Lin
Hong Zhou, Jun Long, Han Hu, Cai-Yun Tian, Shi-De Lin, Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
Hong Zhou, Department of Infectious Diseases, Suining Central Hospital, Suining 629000, Sichuan Province, China
Author contributions: Zhou H and Long J contributed equally to this work; Zhou H, Long J, Hu H, Tian CY, and Lin SD performed the research; Zhou H and Lin SD wrote the manuscript; Long J and Lin SD performed the biostatistics analysis; Hu H, Tian CY, and Lin SD analyzed the data; all authors discussed the results and commented on the manuscript.
Supported by the National Natural Science Foundation of China, No. 81860114.
Institutional review board statement: This study was approved by the Institutional Review Board of Affiliated Hospital of Zunyi Medical University, Guizhou Province, China.
Informed consent statement: All patients were informed in writing of the use of their data for clinical research purposes and accepted.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest in this study.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Shi-De Lin, MD, Occupational Physician, Professor, Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, 201 Dalian Street, Zunyi 563003, Guizhou Province, China. linshide6@zmu.edu.cn
Telephone: +86-851-28609183 Fax: +86-851-28609183
Received: May 29, 2019
Peer-review started: May 30, 2019
First decision: July 21, 2019
Revised: July 30, 2019
Accepted: August 24, 2019
Article in press: July 21, 2019
Published online: September 21, 2019
Abstract
BACKGROUND

The Baveno VI criteria for predicting esophageal varices, i.e., liver stiffness measurement (LSM) < 20 kPa and platelet (PLT) count > 150 × 109/L, identify patients who can safely avoid gastroscopy screening. However, they require further refinement.

AIM

To evaluate the utility of LSM and serum markers of liver fibrosis in ruling out high-risk varices (HRV) in patients who do not meet Baveno VI criteria.

METHODS

Data from 132 patients with hepatitis B virus (HBV)-related compensated liver cirrhosis who did not meet the Baveno VI criteria were retrospectively reviewed. MedCalc 15.8 was used to calculate receiver operating characteristic (ROC) curves, and the accuracy of LSM, PLT count, aspartate aminotransferase (AST)-to-PLT ratio index, Fibrosis-4, and the Lok index in predicting HRV were evaluated according to the area under each ROC curve (AUROC). The utility of LSM, PLT, and serum markers of liver fibrosis stratified by alanine transaminase (ALT) and total bilirubin (TBil) levels was evaluated for ruling out HRV.

RESULTS

In all patients who did not meet the Baveno VI criteria, the independent risk factors for HRV were LSM and ALT. Only the AUROC of Lok index was above 0.7 for predicting HRV, and at a cutoff value of 0.4531 it could further spare 24.2% of gastroscopies without missing HRVs. The prevalence of HRV was significantly lower in patients with ALT or TBil ≥ 2 upper limit of normal (ULN) (14.3%) than in patients with both ALT and TBil < 2 ULN (34.1%) (P = 0.018). In the 41 patients with ALT and TBil < 2 ULN, LSM had an AUROC for predicting HRV of 0.821. LSM < 20.6 kPa spared 39.0% of gastroscopies without missing HRVs. In the 91 patients with ALT or TBiL ≥ 2 ULN, the Lok index and PLT had AUROCs of 0.814 and 0.741, respectively. Lok index ≤ 0.5596 or PLT > 100 × 109/L further spared 39.6% and 43.9% of gastroscopies, respectively, without missing HRVs.

CONCLUSION

In HBV-related compensated cirrhosis patients who do not meet Baveno VI criteria, the LSM, PLT, or Lok index cutoff stratified by ALT and TBil accurately identifies more patients without HRV.

Keywords: Baveno VI, Esophageal varices, Liver cirrhosis, Liver stiffness measurement, Serum markers of liver fibrosis

Core tip: In patients with hepatitis B virus (HBV)-related compensated cirrhosis who did not meet the Baveno VI criteria, the prevalence of high-risk varices among patients with alanine transaminase (ALT) or total bilirubin (TBil) ≥ 2 upper limit of normal (ULN) was significantly lower compared to patients with ALT and TBil < 2 ULN. In the 41 patients with ALT and TBil < 2 ULN, liver stiffness measurement (LSM) < 20.6 kPa spared 39.0% of gastroscopies without missing high-risk varices (HRVs). In the 91 patients with ALT or TBiL ≥ 2 ULN, Lok index ≤ 0.5596 or platelet (PLT) > 100 × 109/L further spared 39.6% and 43.9% of gastroscopies, respectively, without missing HRVs.