Advances and challenges in cirrhosis and portal hypertension

Abstract

Background: Liver cirrhosis is the fourth cause of death in adults in Western countries, with complications of portal hypertension being responsible for most casualties. In order to reduce mortality, development of accurate diagnostic methods for early diagnosis, effective etiologic treatment, improved pharmacological therapy for portal hypertension, and effective therapies for end-stage liver failure are required.

Discussion: Early detection of cirrhosis and portal hypertension is now possible using simple non-invasive methods, leading to the advancement of individualized risk stratification in clinical practice. Despite previous assumptions, cirrhosis can regress if its etiologic cause is effectively removed. Nevertheless, while this is now possible for cirrhosis caused by chronic hepatitis C, the incidence of cirrhosis due to non-alcoholic steatohepatitis has increased dramatically and effective therapies are not yet available. New drugs acting on the dynamic component of hepatic vascular resistance are being studied and will likely improve the future management of portal hypertension.

Conclusion: Cirrhosis is now seen as a dynamic disease able to progress and regress between the compensated and decompensated stages. This opinion article aims to provide the author's personal view of the current major advances and challenges in this field.

Keywords: Hepatic venous pressure gradient; Liver stiffness; Non-invasive methods; Therapy; Transjugular intrahepatic portosystemic shunt.

Fig. 1

Clinical stages of cirrhosis. The first major classification is based on the absence or presence of complications. Cirrhosis is named ‘compensated’ in the absence of complications, and ‘decompensated’ if complications are present or have been present in the past. In patients with compensated cirrhosis, the presence of clinically significant portal hypertension (HVPG ≥ 10 mmHg) identifies a substage with higher risk of developing any complication (varices, decompensation). The decompensated stage is characterized by a high risk of progression to further decompensation, liver failure, and death. Evidence-based therapy has been developed by targeting the pathophysiological mechanisms driving the transition from a given step to the following one. The major advances in each stage are indicated within the figure

Fig. 2

Logical steps in the clinical management of advanced chronic liver disease/cirrhosis. Improved survival can be achieved through adequate diagnosis and risk stratification, thus allowing a personalized approach to therapy. Some examples of factors to be considered, as well as the major pathophysiological factors driving the therapy of portal hypertension in patients with compensated cirrhosis, are provided