Liver, Pancreas and Biliary Tract
Baveno VI criteria as a prognostic factor for clinical complications in patients with compensated cirrhosis

https://doi.org/10.1016/j.dld.2021.09.004Get rights and content

Abstract

Background

Combination of liver stiffness measurement and platelets count is a tool to safely rule out varices needing treatment (VNT) in patients with compensated advanced chronic liver disease (cACLD). Aims: to evaluate 4-year liver-related complications and survival in low-risk patients according to Baveno VI criteria.

Methods

we conducted a monocentric retrospective analysis of prospectively collected data of all consecutive patients, with cirrhosis (LSM≥12.5 kPa) and without previous complication, evaluated between 2012 and 2015. Liver-related complications and survival were compared between 2 groups of patients: favourable (LSM< 20 kPa and platelet count>150.000/mm3) and unfavourable Baveno VI status patients (LSM ≥ 20 kPa or platelet count ≤150.000/mm3).

Results

455 patients with cACLD were analysed. Two hundred patients had favourable Baveno VI criteria, 3.6% with VNT. The 4-year probability of being free of acute decompensation was higher in low-risk patients (94.4 ± 1.8% vs. 85.7%±2.6%, p = 0.018). Unfavourable Baveno status was independently associated with acute decompensation. The probability of being free of HCC was significantly higher in low-risk patients (94.2 ± 1.8% vs. 87.6 ± 2.4%, p = 0.048). Liver-related mortality was not different between the 2 groups (p = 0.56).

Conclusion

The Baveno VI criteria could predict clinical outcome in cACLD.

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.

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