Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
J Hepatol. 2024 May;80(5):744-752. doi: 10.1016/j.jhep.2023.12.028. Epub 2024 Jan 11.
BACKGROUND & AIMS: Non-invasive tests to assess the probability of clinically significant portal hypertension (CSPH) - including the ANTICIPATE±NASH models based on liver stiffness measurement and platelet count±BMI, and the von Willebrand factor antigen to platelet count ratio (VITRO) - have fundamentally changed the management of compensated advanced chronic liver disease (cACLD). However, their prognostic utility has not been compared head-to-head to the gold standard for prognostication in cACLD, i.e. the hepatic venous pressure gradient (HVPG).
Patients with cACLD (liver stiffness measurement ≥10 kPa) who underwent advanced characterization via same-day HVPG/non-invasive test assessment from 2007-2022 were retrospectively included. Long-term follow-up data on hepatic decompensation was recorded.
Four hundred and twenty patients with cACLD of varying etiologies, with a CSPH prevalence of 67.6%, were included. The cumulative incidence of hepatic decompensation at 1 and 2 years was 4.7% and 8.0%, respectively. HVPG, VITRO, and ANTICIPATE±NASH-CSPH-probability showed similar time-dependent prognostic value (AUROCs 0.683-0.811 at 1 year and 0.699-0.801 at 2 years). In competing risk analyses adjusted for MELD score and albumin, HVPG (adjusted subdistribution hazard ratio [aSHR] 1.099 [95% CI 1.054-1.150] per mmHg; p <0.001), or VITRO (aSHR 1.134 [95% CI 1.062-1.211] per unit; p <0.001), or ANTICIPATE±NASH-CSPH-probability (aSHR 1.232 [95% CI 1.094-1.387] per 10%; p <0.001) all predicted first decompensation during follow-up. Previously proposed cut-offs (HVPG ≥10 mmHg vs. <10 mmHg, VITRO ≥2.5 vs. <2.5, and ANTICIPATE-CSPH probability ≥60% vs. <60%) all accurately discriminated between patients at negligible risk and those at substantial risk of hepatic decompensation.
The prognostic performance of ANTICIPATE±NASH-CSPH-probability and VITRO is comparable to that of HVPG, supporting their utility for identifying patients who may benefit from medical therapies to prevent first hepatic decompensation.
Non-invasive tests have revolutionized the diagnosis and management of clinically significant portal hypertension in patients with compensated advanced chronic liver disease (cACLD). However, limited data exists regarding the prognostic utility of non-invasive tests in direct comparison to the gold standard for prognostication in cACLD, i.e. the hepatic venous pressure gradient. In our study including 420 patients with cACLD, the ANTICIPATE±NASH model and VITRO yielded similar AUROCs to hepatic venous pressure gradient for hepatic decompensation within 1 to 2 years. Thus, non-invasive tests should be applied and updated in yearly intervals in clinical routine to identify patients at short-term risk, thereby identifying patients who may benefit from treatment aimed at preventing hepatic decompensation.
非侵入性检测方法可用于评估临床显著门静脉高压（CSPH）的概率，包括基于肝硬度测量和血小板计数与 BMI 的 ANTICIPATE±NASH 模型，以及血管性血友病因子抗原与血小板计数比值（VITRO），这些检测方法已经从根本上改变了代偿性晚期慢性肝病（cACLD）的管理方式。然而，它们的预后效用尚未与 cACLD 预后的金标准（即肝静脉压力梯度[HVPG]）进行直接比较。
回顾性纳入了 2007 年至 2022 年期间接受 cACLD（肝硬度测量≥10kPa）先进特征评估的患者，这些患者同时接受了 HVPG/非侵入性检测评估。记录了与肝失代偿相关的长期随访数据。
共纳入了 420 例不同病因的 cACLD 患者，其中 CSPH 的患病率为 67.6%。1 年和 2 年时肝失代偿的累积发生率分别为 4.7%和 8.0%。HVPG、VITRO 和 ANTICIPATE±NASH-CSPH 概率显示出相似的时间依赖性预后价值（1 年时 AUROC 为 0.683-0.811，2 年时 AUROC 为 0.699-0.801）。在调整 MELD 评分和白蛋白的竞争风险分析中，HVPG（调整后的亚分布危险比[aSHR]每 mmHg 增加 1.099[95%CI 1.054-1.150]；p<0.001）或 VITRO（aSHR 1.134[95%CI 1.062-1.211]每单位；p<0.001）或 ANTICIPATE±NASH-CSPH 概率（aSHR 1.232[95%CI 1.094-1.387]每 10%增加；p<0.001）均预测了随访期间的首次失代偿。先前提出的截断值（HVPG≥10mmHg 与 HVPG<10mmHg，VITRO≥2.5 与 VITRO<2.5，以及 ANTICIPATE-CSPH 概率≥60%与 ANTICIPATE-CSPH 概率<60%）均能准确区分肝失代偿风险低和高的患者。
ANTICIPATE±NASH-CSPH 概率和 VITRO 的预后性能与 HVPG 相当，支持它们在识别可能从预防首次肝失代偿的药物治疗中获益的患者方面的效用。
非侵入性检测方法已经彻底改变了代偿性晚期慢性肝病（cACLD）患者中临床显著门静脉高压的诊断和管理方式。然而，关于非侵入性检测方法在与 cACLD 预后的金标准（即肝静脉压力梯度）的直接比较中的预后效用，数据有限。在我们包括 420 例 cACLD 患者的研究中，ANTICIPATE±NASH 模型和 VITRO 在 1 至 2 年内预测肝失代偿的 AUROC 与肝静脉压力梯度相似。因此，应在临床常规中每年应用和更新非侵入性检测方法，以识别短期风险患者，从而识别可能从预防肝失代偿的治疗中获益的患者。
