Szakács Zsolt, Erőss Bálint, Soós Alexandra, Mátrai Péter, Szabó Imre, Pétervári Erika, Bajor Judit, Farkas Nelli, Hegyi Péter, Illés Anita, Solymár Margit, Balaskó Márta, Sarlós Patrícia, Szűcs Ákos, Czimmer József, Vincze Áron, Pár Gabriella
Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.
János Szentágothai Research Center, University of Pécs, Pécs, Hungary.
Front Physiol. 2019 Aug 13;10:1028. doi: 10.3389/fphys.2019.01028. eCollection 2019.
The Baveno VI Consensus Workshop defined criteria (liver stiffness measured by transient elastography <20 kPa and platelet count >150 × 10 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. 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 -statistics. 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%; = 45.5%), pooled SER was 32.8% (24.8-41.4%; = 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%; = 39.8%) with a SER of 30.5% (25.2-36.2%; = 96.1%) while Se, Sp, and AUC were 97% (93-99%), 35% (27-44%), and 80% (77-84%), respectively. 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 × 10 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.
巴韦诺VI共识研讨会确定了相关标准（通过瞬时弹性成像测量的肝脏硬度<20 kPa且血小板计数>150×10⁹细胞/L），以识别那些代偿期晚期慢性肝病（cACLD）患者，这些患者不太可能有需要治疗的静脉曲张（VNTs），并且可以安全地避免静脉曲张筛查内镜检查。这项荟萃分析旨在量化这些标准在肝脏硬度>10 kPa的疑似cACLD患者以及无论肝脏硬度如何的代偿期慢性肝病（cCLD）患者中的安全性和有效性。在九个数据库中进行了系统检索，以查找讨论cACLD或cCLD并针对静脉曲张筛查内镜检查测试巴韦诺标准的研究。主要的安全性和有效性终点分别为漏诊VNT率和避免内镜检查率（SER）；采用随机效应模型计算。使用分层汇总接受者操作特征模型计算合并敏感性、特异性和曲线下面积（AUC）。对于所有结局指标，计算95%置信区间。使用Q统计量检验异质性。检索得到13项研究，包括4464例报告疑似cACLD的患者。合并漏诊VNT率为0.3%（0.1 - 0.6%；I² = 45.5%），合并SER为32.8%（24.8 - 41.4%；I² = 97.0%）。巴韦诺标准的敏感性、特异性和AUC分别为97%（95 - 98%）、41%（27 - 57%）和96%（94 - 97%）。在丙型和乙型肝炎病毒、非酒精性脂肪性肝病/脂肪性肝炎或酒精所致的cACLD亚组中，漏诊VNT率分别为0.0%（0.0 - 0.3%）、1.2%（0.4 - 2.2%）、0.0%（0.0 - 1.3%）或0.0%（0.0 - 0.4%），而SER分别为24.2%（20.5 - 28.1%）、24.9%（21.7 - 28.4%）、38.6%（10.9 - 70.8%）或27.0%（16.9 - 38.4%）。如果将研究人群扩大到cCLD，27项研究包括7534例患者。漏诊VNT率为0.2%（0.1 - 0.5%；I² = 39.8%），SER为30.5%（25.2 - 36.2%；I² = 96.1%），而敏感性、特异性和AUC分别为97%（93 - 99%）、35%（27 - 44%）和80%（77 - 84%）。巴韦诺标准的应用显著减少了不必要的静脉曲张筛查内镜检查数量，同时是安全的：肝脏硬度<20 kPa且血小板计数>150×10⁹细胞/L的cACLD患者发生VNTs的可能性非常低（即0.3%）。这些标准在cCLD患者中保持了较低的漏诊VNT率，但诊断性能较低。
