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Clinical Outcomes in Patients with Advanced Chronic Liver Disease and Hepatic Venous Pressure Gradient ≤ 10 mm Hg

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Abstract

Background and Aims

Clinically significant portal hypertension (CSPH), defined as hepatic venous pressure gradient (HVPG) ≥ 10 mmHg predicts clinical decompensation (CD) in cirrhosis. A proportion of cirrhosis patients have HVPG 6–10 mmHg. Their natural history is largely unknown.

Design

Consecutive patients with advanced chronic liver disease (aCLD) [histological cirrhosis(n = 196) or liver stiffness measurement (LSM) > 15 kPa(n = 65)] and HVPG 6-10 mmHg were included. Primary objective was to study their natural course and patterns of CD. We also analyzed the predictors of CD at presentation and on follow-up and response to carvedilol.

Results

Of 261 patients with HVPG 6-10 mmHg, 129(49.4%) had CD at first presentation; 78(29.9%) had single and 51(19.5%) had ≥ 2 CD. The most common CDs were ascites(n = 77) and jaundice(n = 65). A baseline HVPG ≥ 8 mmHg was independently associated with greater risk of CD [HR:1.7; p-0.002, AUROC:0.85(95%CI-0.81–0.91)]. New CD developed in 14.4% patients with compensated aCLD (median duration-23.1 months). Despite comparable baseline HVPG, patients developing new CD had higher HVPG on follow-up(15.3 ± 3.7 vs. 8 ± 2.1 mmHg; p < 0.001). Baseline LSM > 26.6 kPa, portosystemic shunt and serum albumin independently predicted new CD. Overall HVPG response to carvedilol(n = 60) was 23.3%, independent of baseline CD and HVPG. Five-year mortality was higher with ≥ 2 CD compared to single or no CD (23.5, 10 and 3%, respectively; p < 0.001).

Conclusion

Nearly one-half of aCLD patients with HVPG 6–10 mmHg had CD, justifying the need to redefine CSPH. Interventions to reduce portal pressure in patients with HVPG ≥ 8 mmHg might improve long-term outcomes.

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Abbreviations

CSPH:

Clinically significant portal hypertension

CD:

Clinical decompensation

HVPG:

Hepatic venous pressure gradient

aCLD:

Advanced chronic liver disease

HE:

Hepatic encephalopathy

VB:

Variceal bleed

AKI:

Acute kidney injury

HCC:

Hepatocellular carcinoma

INR:

International normalization ratio

UGIE:

Upper gastrointestinal endoscopy

WHVP:

Wedged hepatic venous pressure

FHVP:

Free hepatic venous pressure

AKIN:

Acute kidney injury network

CTP:

Child–Turcotte–Pugh

MELD:

Model for end-stage liver disease

UGIE:

Upper gastrointestinal endoscopy

LSM:

Liver stiffness measurement

IQR:

Interquartile range

HR:

Hazard ratio

OR:

Odd’s ratio

CI:

Confidence interval

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Authors and Affiliations

  1. Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India

    Ankur Jindal, Shiv K. Sarin & Manoj Kumar

  2. Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, 110070, India

    Guresh Kumar

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  1. Ankur Jindal
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  2. Shiv K. Sarin
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  3. Manoj Kumar
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  4. Guresh Kumar
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Contributions

Study Design- AJ, SKS, Patient recruitment- AJ, Data acquisition- AJ, Statistical analysis- AJ, GK, Manuscript drafting- AJ, MK and SKS, Manuscript revision and approval- SKS

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Correspondence to Shiv K. Sarin.

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Fig S1 Flow chart showing patient disposition at baseline and follow-up (DOCX 81 kb)

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Jindal, A., Sarin, S.K., Kumar, M. et al. Clinical Outcomes in Patients with Advanced Chronic Liver Disease and Hepatic Venous Pressure Gradient ≤ 10 mm Hg. Dig Dis Sci 67, 5280–5289 (2022). https://doi.org/10.1007/s10620-021-07334-2

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  • DOI: https://doi.org/10.1007/s10620-021-07334-2

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