Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
Dig Dis Sci. 2022 Nov;67(11):5280-5289. doi: 10.1007/s10620-021-07334-2. Epub 2022 Feb 3.
Clinically significant portal hypertension (CSPH), defined as hepatic venous pressure gradient (HVPG) ≥ 10 mmHg predicts clinical decompensation (CD) in cirrhosis. A proportion of cirrhosis patients have HVPG 6-10 mmHg. Their natural history is largely unknown.
Consecutive patients with advanced chronic liver disease (aCLD) [histological cirrhosis(n = 196) or liver stiffness measurement (LSM) > 15 kPa(n = 65)] and HVPG 6-10 mmHg were included. Primary objective was to study their natural course and patterns of CD. We also analyzed the predictors of CD at presentation and on follow-up and response to carvedilol.
Of 261 patients with HVPG 6-10 mmHg, 129(49.4%) had CD at first presentation; 78(29.9%) had single and 51(19.5%) had ≥ 2 CD. The most common CDs were ascites(n = 77) and jaundice(n = 65). A baseline HVPG ≥ 8 mmHg was independently associated with greater risk of CD [HR:1.7; p-0.002, AUROC:0.85(95%CI-0.81-0.91)]. New CD developed in 14.4% patients with compensated aCLD (median duration-23.1 months). Despite comparable baseline HVPG, patients developing new CD had higher HVPG on follow-up(15.3 ± 3.7 vs. 8 ± 2.1 mmHg; p < 0.001). Baseline LSM > 26.6 kPa, portosystemic shunt and serum albumin independently predicted new CD. Overall HVPG response to carvedilol(n = 60) was 23.3%, independent of baseline CD and HVPG. Five-year mortality was higher with ≥ 2 CD compared to single or no CD (23.5, 10 and 3%, respectively; p < 0.001).
Nearly one-half of aCLD patients with HVPG 6-10 mmHg had CD, justifying the need to redefine CSPH. Interventions to reduce portal pressure in patients with HVPG ≥ 8 mmHg might improve long-term outcomes.
临床上显著的门静脉高压症（CSPH）定义为肝静脉压力梯度（HVPG）≥10mmHg 可预测肝硬化的临床失代偿（CD）。一部分肝硬化患者的 HVPG 为 6-10mmHg。其自然史在很大程度上尚不清楚。
连续纳入患有晚期慢性肝病（aCLD）的患者[组织学肝硬化（n=196）或肝硬度测量（LSM）>15kPa（n=65）]和 HVPG 为 6-10mmHg 的患者。主要目的是研究他们的自然病程和 CD 模式。我们还分析了首次就诊时和随访时 CD 的预测因素以及对卡维地洛的反应。
在 261 名 HVPG 为 6-10mmHg 的患者中，129 名（49.4%）在首次就诊时患有 CD；78 名（29.9%）有单次 CD，51 名（19.5%）有≥2 次 CD。最常见的 CD 是腹水（n=77）和黄疸（n=65）。基线 HVPG≥8mmHg 与 CD 风险增加独立相关[HR：1.7；p-0.002，AUROC：0.85（95%CI-0.81-0.91）]。代偿性 aCLD 患者中 14.4%的患者新发 CD（中位时间-23.1 个月）。尽管基线 HVPG 相似，但新发 CD 患者的 HVPG 在随访时更高（15.3±3.7 与 8±2.1mmHg；p<0.001）。基线 LSM>26.6kPa、门体分流和血清白蛋白独立预测新发 CD。总体上，卡维地洛治疗（n=60）的 HVPG 反应率为 23.3%，与基线 CD 和 HVPG 无关。与单发性或无 CD 相比，≥2 次 CD 的 5 年死亡率更高（分别为 23.5%、10%和 3%；p<0.001）。
近一半 HVPG 为 6-10mmHg 的 aCLD 患者患有 CD，这证明需要重新定义 CSPH。降低 HVPG≥8mmHg 患者门静脉压力的干预措施可能会改善长期预后。
