Liver, Pancreas and Biliary TractBaveno VI criteria as a prognostic factor for clinical complications in patients with compensated cirrhosis
Introduction
Advanced chronic liver disease is a serious condition with a high risk of mortality due to acute decompensations mostly associated with portal hypertension (PHT) [1]. The occurrence of a portal hypertension-related complication is an important turning point in the natural history of cirrhosis. The mortality rate at 2 years ranges from 2% for patients with compensated cirrhosis to more than 50% when the disease is decompensated [2]. All clinical events, such as ascites, hepatic encephalopathy (HE) or variceal bleeding (VB) are associated with a poor prognosis [3], [4], [5].
Until 2015, international recommendations included systematic upper endoscopy screening for VNT (varices needing treatment) in all patients with cirrhosis [1,3,[6], [7], [8]]. However, the majority of endoscopies were futile, since VNT were diagnosed in less than 30% of these patients. Several non-invasive methods have been developed in order to better identify patients requiring endoscopic screening [9], [10], [11], [12], [13], [14], [15]. In 2015, compensated advanced chronic liver disease (cACLD) was defined during the Baveno VI consensus meeting, i.e. patients with chronic liver disease and a liver stiffness measurement (LSM) >10 kPa. More, the Baveno VI guidelines recommend using LSM and platelets count to rule out VNT [16]. They state that endoscopy may be avoided in low-risk patients defined by a LSM <20 kPa and a platelets count >150.000/mm3 (favourable Baveno VI status). These criteria have been validated in more than 3000 patients with a percentage of spared endoscopies of at least 20% [17], [18], [19], [20], [21], [22], and less than 5% of missed VNT. Thereafter, new criteria with more restrictive thresholds of platelet count 〈 110.000/mm3 and LSM 〉 25 kPa (Expanded-Baveno VI) were validated in numerous cohorts and could lead to safely avoid more endoscopies than initial recommendations with a minimal risk of missing VNT [20,[23], [24], [25], [26]].
Longitudinal studies evaluating further risk of acute decompensation according to the Baveno VI status are lacking. In patients with cACLD, hepatic venous pressure gradient measurement (HVPG) is considered as the gold standard technique to assess clinically significant portal hypertension and to predict further decompensation [16]. However, its availability and invasiveness restrict its use in common practice [27,28]. Individualized prediction of endpoints such as clinical decompensation and death by non-invasive diagnostic methods and development of risk algorithms similar to these used in cardiovascular medicine (e.g., Framingham risk score [29] might be beneficial in the future in compensated cirrhosis [8].
The aims of this study were to describe clinical outcomes and survival in patients, with cACLD and without history of acute decompensation, at low risk according to Baveno VI criteria, especially regarding further development of VB, HE, ascites, and hepatocellular carcinoma (HCC). We also aimed to evaluate similar outcomes according to the Expanded-Baveno VI criteria.
Section snippets
Patients selection
A retrospective analysis of prospectively collected data was conducted in our Fibrosis Unit, in Pitié-Salpêtrière hospital, Paris, France. The Local Ethical Committee approved this analysis and all participants signed an informed consent regarding enrolment in the study. We analysed all data obtained in consecutive patients evaluated cACLD between January 2012 and December 2015. LSM and blood analysis were performed for these patients on the same day. Inclusion criteria were: Age≥18, reliable
Statistical analyses
Data were presented by means and standard deviations/median and interquartile ranges for normally/non normally distributed continuous variables, frequencies and percentages for categorical data. Characteristics of patients were compared using chi-2 (for categorical variables) and independent-samples t/Wilcoxon test (for normally/non normally distributed continuous variables). Survival rates were calculated using the Kaplan–Meier method, and compared using the log-rank test. Hazard Ratios (HR)
Patients’ characteristics
During the study period, 1094 patients with LSM≥12.5 kPa were evaluated. Among them, 639 patients with a history of previous acute decompensation or HCC were excluded. 455 patients met inclusion criteria and were analysed in the study (Fig. 1). At inclusion, 255 had an unfavourable Baveno VI status and 200 a favourable Baveno VI status. The main characteristics of the patients, according to Baveno VI status, are depicted in Table 1. Of the included patients, chronic hepatitis C (CHC)-related
Discussion
In this retrospective study of prospectively collected data, we highlighted that the probability of developing at least one portal hypertension-related complications was statistically lower when patients were initially at low-risk as defined in Baveno VI consensus. Likewise, during the 4-year follow-up, the survival went along the same trend for these patients.
The Baveno VI conference introduced simple criteria for the triage of patients with cACLD and selected patients for upper screening
Authorship
Nicolas Asesio: acquisition of data; analysis and interpretation of data; drafting. Priscila Pollo-Flores: acquisition of data; analysis and interpretation of data; drafting. Olivier Caliez: statistical analysis. Mona Munteanu: acquisition of data, critical revision of manuscript. Thierry Poynard: critical revision of the manuscript. Yen Ngo: acquisition of data. An Ngo: acquisition of data. Dominique Thabut: study concept and design; analysis and interpretation of data; study supervision.
Declaration of Competing Interest
None declared.
Acknowledgement
CAPES.
References (38)
- et al.
Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension
J Hepatol
(2010) - et al.
Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies
J Hepatol
(2006) - et al.
Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database
Gastrointest Endosc
(2007) - et al.
Ruling out esophageal varices in NAFLD cirrhosis: can we do without endoscopy?
J. Hepatol.
(2018) - et al.
Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension
J Hepatol
(2015) - et al.
Validation of the Baveno VI criteria to identify low risk cirrhotic patients not requiring endoscopic surveillance for varices
J Hepatol
(2016) - et al.
Non-invasive prediction of esophageal varices by stiffness and platelet in non-alcoholic fatty liver disease cirrhosis
J Hepatol
(2018) - et al.
Emerging non-invasive approaches for diagnosis and monitoring of portal hypertension
Lancet Gastroenterol Hepatol
(2018) - et al.
β blockers to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension (PREDESCI): a randomised, double-blind, placebo-controlled, multicentre trial
Lancet
(2019) - et al.
Hepatic venous pressure gradient predicts development of hepatocellular carcinoma independently of severity of cirrhosis
J Hepatol
(2009)