Baveno-VII criteria to predict decompensation and initiate non-selective beta-blocker in compensated advanced chronic liver disease patients

Abstract

Background/aims: The utility of Baveno-VII criteria of clinically significant portal hypertension (CSPH) to predict decompensation in compensated advanced chronic liver disease (cACLD) patient needs validation. We aim to validate the performance of CSPH criteria to predict the risk of decompensation in an international real-world cohort of cACLD patients.

Methods: cACLD patients were stratified into three categories (CSPH excluded, grey zone, and CSPH). The risks of decompensation across different CSPH categories were estimated using competing risk regression for clustered data, with death and hepatocellular carcinoma as competing events. The performance of "treating definite CSPH" strategy to prevent decompensation using non-selective beta-blocker (NSBB) was compared against other strategies in decision curve analysis.

Results: One thousand one hundred fifty-nine cACLD patients (36.8% had CSPH) were included; 7.2% experienced decompensation over a median follow-up of 40 months. Non-invasive assessment of CSPH predicts a 5-fold higher risk of liver decompensation in cACLD patients (subdistribution hazard ratio, 5.5; 95% confidence interval, 4.0-7.4). "Probable CSPH" is suboptimal to predict decompensation risk in cACLD patients. CSPH exclusion criteria reliably exclude cACLD patients at risk of decompensation, regardless of etiology. Among the grey zone, the decompensation risk was negligible among viral-related cACLD, but was substantially higher among the non-viral cACLD group. Decision curve analysis showed that "treating definite CSPH" strategy is superior to "treating all varices" or "treating probable CSPH" strategy to prevent decompensation using NSBB.

Conclusion: Non-invasive assessment of CSPH may stratify decompensation risk and the need for NSBB in cACLD patients.

Keywords: Hypertension, portal; Liver cirrhosis; Portal hypertension.

Figure 1.

Consolidated Standards of Reporting Trials diagram. cACLD, compensated advanced chronic liver disease; HCC, hepatocellular carcinoma; LSM, liver stiffness measurement; NSBB, non-selective beta-blocker; CSPH, clinically significant portal hypertension.

Figure 2.

Clinical outcomes according to the non-invasive diagnosis of clinically significant portal hypertension in compensated advanced chronic liver disease patients. Liver decompensation was defined as the presence of ascites, variceal bleeding and hepatic encephalopathy. Liver-related events was defined as the presence of liver decompensation, hepatocellular carcinoma or death. CSPH, clinically significant portal hypertension; sHR, subdistribution hazard ratio; CI, confidence interval; NA, not applicable.

Figure 3.

Cumulative incidence of decompensation based on etiology (virus-related vs. non-viral related). The 3-year cumulative incidence of decompensation among non-virus-related cACLD (CSPH excluded, 0%; low probability, 15.0%; high probability, 14.3%; CSPH, 22.2%) was higher than virus-related cACLD patients (CSPH excluded, 0%; low probability, 0.3%; high probability, 1.8%; CSPH, 9.0%). CSPH, clinically significant portal hypertension; sHR, subdistribution hazard ratio; CI, confidence interval; NA, not applicable; cACLD, compensated advanced chronic liver disease.

Figure 4.

Decision curve analysis demonstrating the benefit of initiating non-selective beta-blocker based on various strategies such as treating “high-risk varices” (pink), “all esophageal varices” (red), “treat definite CSPH” (green), “treat probable CSPH” (turquoise) and “treat none” (brown), across different threshold risk of annual decompensation. The area under the curve between different lines and the brown line (treat none) reflect the estimated benefit of each treatment strategy. At a treatment threshold between 5–10% of decompensation rate, treating “definite CSPH” is the best strategy to initiate non-selective beta-blocker to prevent decompensation. CSPH, clinically significant portal hypertension.