Olivas Pol, Soler-Perromat Alexandre, Tellez Luis, Carrión José Antonio, Alvarado-Tapias Edilmar, Ferrusquía-Acosta José, Lens Sabela, Guerrero Antonio, Falgà Ángeles, Vizcarra Pamela, Orts Lara, Perez-Campuzano Valeria, Shalaby Sarah, Torres Sonia, Baiges Anna, Turon Fanny, García-Pagán Juan Carlos, García-Criado Ángeles, Hernández-Gea Virginia
Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Fundacióde Recerca Clínic Barcelona - Institut de Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), Barcelona, Catalonia, Spain.
Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
JHEP Rep. 2024 Jul 18;6(10):101170. doi: 10.1016/j.jhepr.2024.101170. eCollection 2024 Oct.
BACKGROUND & AIMS: Etiologic factor removal (ER) drives recompensation and improves portal hypertension in cirrhosis. Esophageal varices (EV) and portosystemic shunts (PSS) have been found in patients despite hepatic venous pressure gradient (HVPG) dropping below 10 mmHg after ER, questioning HVPG accuracy in reflecting true portal pressure in the setting of ER. We aim to evaluate the correlation of HVPG with direct portal pressure (DPP) in patients with persistence of EV after ER despite HVPG <10 mmHg.
This is a bicentric 'proof of concept' study evaluating HVPG and ultrasound-guided percutaneous DPP in patients with HCV or alcohol-related cirrhosis with persistent varices and HVPG <10 mmHg after at least 5 years of ER.
Seven patients with HCV and three with alcohol-related cirrhosis with persistent varices and HVPG <10 mmHg after at least 5 years of ER were included. At evaluation, all patients had a patent portal vein and were compensated. The median platelet count was 129.5 (IQR 95-145) × 10/ml, and the median liver stiffness measurement was 16.15 (IQR 14.4-22.3) kPa. In five patients, EV remained the same size (two large and three small), and five downsized to small after ER. Wedge hepatic vein pressure (median 19 [IQR 16.5-20] mmHg) and portal pressure (median 18 [IQR 15-19.5] mmHg) had an excellent correlation (R = 0.93, <0.0001). Portal pressure gradient (PPG) confirmed the absence of clinically significant portal hypertension as identified by HVPG across all the patients.
HVPG accurately reflects PPG in the context of HCV and alcohol-related cirrhosis regression. After ER, EV may persist despite HVPG <10 mmHg. The benefit of prophylaxis in patients with EV and HVPG <10 mmHg is unknown. Future studies with clinical endpoints are needed to validate our findings.
Despite a favorable evolution after the removal of the etiologic factor, varices persist in some patients, and there is a lack of concise guidelines for the evaluation and management of portal hypertension in this population. Our research underscores the persistence of varices in the absence of clinically significant portal hypertension and significantly demonstrates the accuracy of hepatic venous pressure gradient (HVPG) in reflecting portal vein pressure in this specific patient group. These findings emphasize the crucial role of HVPG in the assessment of portal hypertension after etiologic factor removal and lay the groundwork for further investigation into clinical outcomes and the necessity of non-selective beta-blockers in individuals with persistent varices after the removal of etiologic factor.
病因去除（ER）可促使肝硬化患者实现代偿，并改善门静脉高压。尽管在病因去除后肝静脉压力梯度（HVPG）降至10 mmHg以下，但仍有患者出现食管静脉曲张（EV）和门体分流（PSS），这对HVPG在病因去除情况下反映真实门静脉压力的准确性提出了质疑。我们旨在评估在病因去除后尽管HVPG<10 mmHg但仍存在EV的患者中，HVPG与直接门静脉压力（DPP）之间的相关性。
这是一项双中心的“概念验证”研究，评估了丙型肝炎病毒（HCV）或酒精性肝硬化患者的HVPG和超声引导下经皮直接门静脉压力，这些患者存在持续性静脉曲张，且在至少5年的病因去除后HVPG<10 mmHg。
纳入了7例HCV患者和3例酒精性肝硬化患者，这些患者在至少5年的病因去除后存在持续性静脉曲张且HVPG<10 mmHg。在评估时，所有患者的门静脉均通畅且处于代偿状态。血小板计数中位数为129.5（四分位间距95 - 145）×10/ml，肝脏硬度测量中位数为16.15（四分位间距14.4 - 22.3）kPa。5例患者的EV大小保持不变（2例大静脉曲张和3例小静脉曲张），5例在病因去除后缩小为小静脉曲张。肝静脉楔压（中位数19[四分位间距16.5 - 20]mmHg）与门静脉压力（中位数18[四分位间距15 - 19.5]mmHg）具有良好的相关性（R = 0.93，<0.0001）。门静脉压力梯度（PPG）证实所有患者均不存在HVPG所确定的具有临床意义的门静脉高压。
在HCV和酒精性肝硬化消退的情况下，HVPG能准确反映PPG。病因去除后，尽管HVPG<10 mmHg，EV仍可能持续存在。对于EV且HVPG<10 mmHg的患者，预防的益处尚不清楚。需要开展以临床终点为指标的未来研究来验证我们的发现。
尽管在去除病因后病情有良好进展，但仍有部分患者存在静脉曲张，且对于该人群门静脉高压的评估和管理缺乏简明指南。我们的研究强调了在无临床显著门静脉高压情况下静脉曲张的持续存在，并显著证明了肝静脉压力梯度（HVPG）在反映这一特定患者群体门静脉压力方面的准确性。这些发现强调了HVPG在病因去除后门静脉高压评估中的关键作用，并为进一步研究临床结局以及病因去除后仍有持续性静脉曲张的个体使用非选择性β受体阻滞剂的必要性奠定了基础。
