序贯应用 Baveno VII 标准和 VITRO 评分可提高临床显著门静脉高压症的诊断率。
The Sequential Application of Baveno VII Criteria and VITRO Score Improves Diagnosis of Clinically Significant Portal Hypertension.
机构信息
Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Lab for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
出版信息
Clin Gastroenterol Hepatol. 2023 Jul;21(7):1854-1863.e10. doi: 10.1016/j.cgh.2022.09.032. Epub 2022 Oct 14.
BACKGROUND & AIMS: Baveno VII proposed liver stiffness measurement (LSM)/platelet count (PLT)-based criteria ('ruled out,' LSM ≤15 kPa plus PLT ≥150 G/L; 'ruled in': LSM ≥25 kPa) for clinically significant portal hypertension (CSPH) in compensated advanced chronic liver disease (cACLD). However, a substantial proportion of patients remains 'unclassified.'
METHODS
Patients with evidence of cACLD (LSM ≥10 kPa) undergoing hepatic venous pressure gradient (HVPG) measurement at the Vienna General Hospital 2004 to 2021 (derivation [2004-2016], n = 221; validation [2017-2021], n = 81) were included. The performance of noninvasive tests (NITs) including von Willebrand factor antigen to PLT ratio (VITRO) for the detection of CSPH (HVPG ≥10 mmHg) were evaluated.
RESULTS
Overall, viral hepatitis was the predominant (50.7%) etiology, followed by alcoholic liver disease (15.2%) and nonalcoholic steatohepatitis (13.2%); CSPH prevalence was 62.3%. In the derivation cohort, 45.7% were 'unclassified' according to Baveno VII criteria; in this group, VITRO showed an excellent diagnostic performance for the detection of CSPH (area under the receiver operating curve, 0.909; 95% confidence interval, 0.823-0.965). VITRO ≤1.5 and ≥2.5 ruled out (sensitivity, 97.7%; negative predictive value, 97.5%) and ruled in (specificity, 94.7%; positive predictive value, 91.2%), respectively, CSPH in patients who were 'unclassifiable' by Baveno VII criteria. The application of a sequential Baveno VII-VITRO algorithm reallocated 73% and 70% of 'unclassified' patients to the 'ruled in' and 'ruled out' group, respectively, while maintaining high sensitivity and negative predictive value and specificity and positive predictive value in the derivation and validation cohort, respectively. No patient allocated to the 'CSPH ruled out' group by the Baveno VII-VITRO algorithm developed decompensation within 5 years, whereas 5-year decompensation rates were negligible (4%) and substantial (23.9%) among 'unclassified' and 'CSPH ruled in' patients, respectively.
CONCLUSIONS
The sequential application of VITRO in patients with cACLD who were 'unclassifiable' with regard to CSPH by Baveno VII criteria substantially decreased the number of 'unclassifiable' patients to <15% and refined prognostication.
背景与目的
Baveno VII 提出了基于肝硬度测量（LSM）/血小板计数（PLT）的标准（“排除”，LSM≤15kPa 加 PLT≥150G/L；“纳入”，LSM≥25kPa）用于代偿性晚期慢性肝病（cACLD）中的临床显著门静脉高压（CSPH）。然而，仍有相当一部分患者“无法分类”。
方法
本研究纳入了 2004 年至 2021 年在维也纳总医院接受肝静脉压力梯度（HVPG）测量的有 cACLD 证据（LSM≥10kPa）的患者（推导队列[2004-2016]，n=221；验证队列[2017-2021]，n=81）。评估了非侵入性检测（NITs），包括血管性血友病因子抗原与血小板比值（VITRO）在检测 CSPH（HVPG≥10mmHg）中的性能。
结果
总体而言，病毒性肝炎是主要病因（50.7%），其次是酒精性肝病（15.2%）和非酒精性脂肪性肝炎（13.2%）；CSPH 的患病率为 62.3%。在推导队列中，根据 Baveno VII 标准，45.7%的患者“无法分类”；在这一组中，VITRO 显示出对 CSPH 检测的优异诊断性能（受试者工作特征曲线下面积，0.909；95%置信区间，0.823-0.965）。VITRO≤1.5 和≥2.5 分别排除（敏感性，97.7%；阴性预测值，97.5%）和纳入（特异性，94.7%；阳性预测值，91.2%）CSPH，在 Baveno VII 标准“无法分类”的患者中。Baveno VII-VITRO 算法的应用分别将 73%和 70%的“无法分类”患者重新分配到“纳入”和“排除”组，同时在推导和验证队列中保持高敏感性和阴性预测值以及特异性和阳性预测值。在 Baveno VII-VITRO 算法中被归类为“排除 CSPH”的患者，在 5 年内没有发生失代偿，而“无法分类”和“纳入 CSPH”患者的 5 年失代偿率分别为微不足道（4%）和显著（23.9%）。
结论
在 Baveno VII 标准“无法分类”CSPH 的 cACLD 患者中，连续应用 VITRO 可将“无法分类”患者的数量减少到<15%，并改善预后。
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