Interobserver and interequipment variability of hepatic, splenic, and renal arterial Doppler resistance indices in normal subjects and patients with cirrhosis

doi:10.1016/S0168-8278(97)80141-9

Journal of Hepatology

Volume 27, Issue 6, December 1997, Pages 986-992

https://doi.org/10.1016/S0168-8278(97)80141-9 Get rights and content

Abstract

Background/Aims: Doppler arterial resistance indices are used to evaluate alterations in arterial hemodynamics in the liver, spleen, and kidney. The purpose of this study was to determine the interobserver and interequipment variability of hepatic, splenic, and renal arterial Doppler resistance indices, and the influence of a cooperative training program of the operators on the reproducibility of the results.

Methods: In the first part of the study, hepatic (PI-L, RI-L), splenic (PI-S, RI-S), and renal (PI-K, RI-K) pulsatility and resistive indices were measured by echo-color-Doppler in eight control subjects and ten patients with cirrhosis by three operators using three different machines. In the second part of the study, measurements were taken by the three operators in nine controls and nine patients with cirrhosis, after cooperative training, with a single machine.

Results: Significant interobserver variability was present for all parameters except RI-L. Significant inter-equipment variability was present for all parameters except PI-S and RI-S. Only 0–3% of variance was equipment- or operator-related, while 58–72% was patient-related. Hepatic and renal coefficients of variation were similar in patients with cirrhosis and controls, while splenic coefficients of variation were higher in patients with cirrhosis than in controls. After training, differences among operators disappeared for all variables except RI-K, and the operator-related component of variance nearly disappeared for all parameters.

Conclusions: Hepatic, splenic, and renal arterial resistance indices show small but significant interobserver and interequipment variability. Interobserver variability can be decreased to non-significant levels by a common training program. Thus, these indices can be widely applied to the study of arterial circulation in these organs.

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Although it is possible to find studies that analyze the velocity of blood flow in different arteries, the reliability of Doppler ultrasound on peripheral arteries has not yet been completely established. Our objective was to evaluate intra- and inter-rater reliability of the measurement of blood flow velocity by Doppler ultrasound of brachial, radial, popliteal, and posterior tibial arteries.
Fifty healthy individuals of both genders, aged between 18 and 45 years, were included in the study. For the evaluation of arterial blood flow velocity, a portable Doppler ultrasound device was used to measure the mean and maximum blood flow velocity of posterior tibial, popliteal, brachial, and radial arteries. Two examiners performed assessments of the same volunteers independently and twice, with an interval of 1 week between them.
We found good to very good reliability for measuring the mean and maximum blood flow velocity of the arteries evaluated. The intraclass correlation coefficients ranged between 0.501 and 0.866, standard error of measurement ranged between 0.81 and 9.45 cm/s, and minimum detectable change ranged between 2.25 and 26.13 cm/s.
The assessment of mean and maximum blood flow velocity of the brachial, radial, popliteal, and posterior tibial arteries by means of Doppler ultrasound presents acceptable reliability values, which supports the use of this evaluation method in research and clinical practice.
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Citation Excerpt :
The ratio of liver to spleen volume as measured by computed tomography has also been shown to predict HVPG, however this measure has the disadvantage of requiring ionising radiation [14]. Using Doppler ultrasound, changes in hepatic and splanchnic flow in portal hypertension have been studied, but results have been inconsistent [15], limiting wider use of this technique [16]. To date, all of these imaging modalities have investigated individual pathophysiological components of portal hypertension.
Hepatic venous pressure gradient (HVPG) measurement is currently the only validated technique to accurately evaluate changes in portal pressure. In this study, we evaluate the use of non-contrast quantitative magnetic resonance imaging (MRI) as a surrogate measure of portal pressure.
Thirty patients undergoing HVPG measurement were prospectively recruited. MR parameters of longitudinal relaxation time (T₁), perfusion of the liver and spleen (by arterial spin labelling), and blood flow in the portal, splanchnic and collateral circulation (by phase contrast MRI) were assessed. We estimated the liver stiffness measurement (LSM) and enhanced liver fibrosis (ELF) score. The correlation of all non-invasive parameters with HVPG was evaluated.
The mean (range) HVPG of the patients was 9.8 (1–22) mmHg, and 14 patients (48%) had clinically significant portal hypertension (CSPH, HVPG ⩾10 mmHg). Liver T₁ relaxation time, splenic artery and superior mesenteric artery velocity correlated significantly with HVPG. Using multiple linear regression, liver T₁ and splenic artery velocity remained as the two parameters in the multivariate model significantly associated with HVPG (R = 0.90, p <0.001). This correlation was maintained in patients with CSPH (R = 0.85, p <0.001). A validation cohort (n = 10) showed this linear model provided a good prediction of HVPG. LSM and ELF score correlated significantly with HVPG in the whole population but the correlation was absent in CSPH.
MR parameters related to both hepatic architecture and splanchnic haemodynamics correlate significantly with HVPG. This proposed model, confirmed in a validation cohort, could replace the invasive HVPG measurement.
In patients with cirrhosis, the development and progression of portal hypertension is related to worse outcomes. However, the standard technique of assessing portal pressure is invasive and not widely used in clinical practice. Here, we have studied the use of non-invasive MRI in evaluating portal pressure. The MRI measures of liver architecture and blood flow in the splenic artery correlated well with portal pressure. Therefore, this non-invasive method can potentially be used to assess portal pressure in clinical trials and monitoring treatment in practice.
Doppler ultrasonography helps discriminate between cirrhotic and non-cirrhotic patients with viral B and C hepatitis
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The aim of this study was to define the cutoff values between compensated cirrhosis and non-cirrhotic patients with viral hepatitis B and C, using the criteria of the Doppler parameters of liver vascularity.
Seventy non-cirrhotic patients with viral hepatitis B and C and 30 cirrhotic patients were included in this prospective study. The diagnostic decisiveness properties of the Doppler values in the pre-determination of liver cirrhosis were evaluated using receiver operating characteristics curve analysis.
Taking the cutoff value for hepatic vein waveform index as 0.605, a sensitivity of 80% and a specificity of 77.1% were obtained. The sensitivity was 80%, and the specificity was 68.6% for a mean max portal velocity cutoff value of 18.25 cm/s. When the hepatic artery resistivity index cutoff value was taken as 0.705 for the diagnosis of cirrhosis, the sensitivity was 82.5% and the specificity 72.1%. For a hepatic artery pulsatility index cutoff value of 1.295, a sensitivity of 82.5% and a specificity of 72.1% were found.
It is not possible to diagnose cirrhosis with only hemodynamic changes. However, the cutoff values may be helpful in the selection of patients to undergo the procedure of liver biopsy.
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We evaluated the effect of food intake on LS in patients with different degrees of liver disease.
We evaluated 24 patients (F≤1, n = 11 and F> 1, n = 13). LS (Fibroscan®) and portal blood flow (PBF) (Doppler ultrasound) were studied before and 30 min after ingestion of a standard liquid meal.
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LS increases markedly after ingestion of a standard meal, irrespective of the degree of fibrosis. Our results strongly suggest that LS should be measured in fasting conditions.
El desarrollo de nuevos métodos que permiten la determinación no invasiva de la rigidez hepática ha abierto una nueva era en el manejo de la fibrosis hepática.
El objetivo del trabajo fue evaluar el efecto de ingesta de una comida sobre la rigidez hepática en pacientes con diferentes grados de fibrosis.
Se evaluaron 24 pacientes (F ≤ 1, n = 11, y F > 1, n = 13), que fueron estudiados basalmente y 30 min después de la ingesta de una comida estándar (Ensure Plus^®). La rigidez hepática se midió por Fibroscan^®, y los parámetros hemodinámicos portales, mediante Doppler. La ingesta de una comida ocasionó un aumento del flujo sanguíneo portal (51 ± 10%, p < 0,001). La hiperemia esplácnica fue acompañada por un marcado incremento en la rigidez hepática (7,8 ± 3,3 a 10,3 ± 4,1 kPa, p < 0,001). Este efecto fue similar en pacientes con fibrosis mínima (F ≤ 1) y con fibrosis significativa (F > 1). Los valores de ambos parámetros retornaron a niveles similares a los basales a las 2 h luego de la ingesta.
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Interobserver and interequipment variability of hepatic, splenic, and renal arterial Doppler resistance indices in normal subjects and patients with cirrhosis

Abstract

J Surg Res

Gastroenterology

Hepatology

Gastroenterology

J Hepatol

Hepatology

Ultrasound Med Biol

Renal vasoconstriction in cirrhosis evaluated by duplex Doppler sonography

Hepatology

Diagnosis of functional kidney failure of cirrhosis with Doppler sonography: prognostic value of resistive index

Hepatology

Duplex Doppler evaluation of native kidney dysfunction: obstructive and nonobstructive disease

AJR

Renal dysfunction in hepatic disease: early identification with renal duplex Doppler US in patients who undergo liver transplantation

Radiology

Renal duplex Doppler ultrasonography: a noninvasive predictor of kidney dysfunction and hepatorenal failure in liver disease

Hepatology