Liver volume index predicts the risk of esophageal variceal hemorrhage in cirrhotic patients on propranolol prophylaxis

Abstract

Background/aims: Non-selective β-blockers (NSBBs) are used for primary prevention of esophageal variceal hemorrhage (VH) in patients with portal hypertension, but a significant number of patients develop VH while on NSBB therapy. In this study, we sought to determine whether liver volume can predict the risk of primary prophylaxis failure in cirrhotic patients on NSBB therapy.

Methods: A retrospective cohort of 309 patients on prophylactic propranolol was analyzed. Liver volume was measured in portal venous phase images of multidetector computed tomography. Predictors of VH were assessed using a Cox proportional hazards model with competing-risks analysis. A nomogram was developed for estimation of the risk of primary prophylaxis failure.

Results: During a median follow-up of 36 months, 37 patients on propranolol developed VH. Liver volume index, the ratio of measured-to-expected liver volume, was an independent predictor of VH (adjusted hazard ratio [HR], 2.70; 95% confidence interval [CI], 1.37 to 5.33; p = 0.004) as were the presence of large varices and the absence of ascites. A nomogram-based volume score of > 0.6 was predictive of prophylaxis failure (HR, 7.54; 95% CI, 2.88 to 19.73; p < 0.001). Time-dependent receiver operating characteristic curve analysis revealed that a nomogram-based risk score had significantly better discriminatory power than the North Italian Endoscopy Club index in predicting prophylaxis failure at 6 and 8 years.

Conclusion: Liver volume index is an independent predictor of first VH and a nomogram-based volume score stratifies the VH risk in cirrhotic patients on propranolol prophylaxis.

Keywords: Adrenergic beta-antagonists; Cone-beam computed tomography; Decision support techniques; Esophageal and gastric varices.

Figure 1.

Flow of patient selection. VBL, variceal band ligation; CT, computed tomography.

Figure 2.

Cumulative incidence of esophageal variceal hemorrhage during primary prophylaxis with propranolol. The cumulative incidence was corrected for deaths as a competing event according to Fine-Gray Model.

Figure 3.

Nomogram for prediction of primary prophylaxis failure. Points of volume index, ascites, and variceal size are read on perpendicular spot on the upper scale and summed to obtain the risk score. The 2- and 4-year probability of primary prophylaxis failure is predicted according to the risk score.

Figure 4.

Performance of the nomogram for predicting primary prophylaxis failure. Kaplan-Meier analysis showed significantly increased risk for esophageal variceal hemorrhage in patients with risk score > 100 (p < 0.001).

Figure 5.

Time-dependent receiver operating characteristic (ROC) plot for predicting propranolol prophylaxis failure. Compared to North Italian Endoscopy Club (NIEC) (A) or revised NIEC score (B), the area under curve (AUC) of nomogram score (C) was significantly larger at 6 and 8 years.