Do Patients with Viral Cirrhosis and Clinically Significant Portal Hypertension After Effective Viral Suppression Really Have Better Outcomes in Comparison to Those with Non- viral Cirrhosis? A Pragmatic Study

Abstract

Background: The strategy of using beta-blockers in clinically significant portal hypertension (CSPH) has been shown to reduce development of all-cause decompensations, especially ascites. However, it’s unclear if this would hold relevant to patients with viral cirrhosis who achieve effective viral suppression. Aim: To identify the relevance of treating CSPH in patients with viral cirrhosis with viral remission by comparing their outcomes with to those of non-viral cirrhosis in a real-world cohort. Methods: In this retrospective analysis, patients with viral [hepatis B virus (HBV) or hepatitis C virus (HCV) related] cirrhosis with CSPH [either presence of low-risk varices or with liver stiffness (LSM) ≥15kPa with platelet <150000/mm3] were treated with antivirals. Those with effective viral suppression (sustained virological response at 12 weeks for HCV, undetectable DNA for HBV) were assessed for clinical decompensations on follow-up. The outcomes were compared with non-viral cirrhosis (alcoholic liver disease and non-alcoholic fatty liver disease) with CSPH with and without propensity score matching with no patient receiving beta-blockers in each group. Results: There were significant differences in the baseline between viral (n=119) and non-viral (n=164) subgroups, with patients with viral cirrhosis being younger (mean age 42±12.2 years vs 52±11.5 years, P<0.001) and having less advanced liver disease [mean LSM (viral)-24.9±8.3 kPa vs (non-viral) 32.4±10.9 kPa, P<0.001]. Over a mean duration of 3±0.7 years of follow up, patients with non-viral cirrhosis decompensated more frequently [6.7% (viral) vs 25.6% (non- viral), P<0.001] and had worse survival [3.4% (viral) vs 10.4% (non-viral), P=0.047]. However, upon propensity score matching for baseline LSM, [viral (n= 79) and non-viral (n=85)], the development of ascites (viral- 10.1% vs non-viral- 17.4%, P=0.258) and survival (viral- 5.1% vs non-viral-7%, P=0.859) was comparable in both cohorts. Conclusions: Patients with non-viral cirrhosis have more advanced liver disease, decompensate more frequently and consequently may benefit maximum from treatment of CSPH. However, patients with viral supressed cirrhosis may have similar worse outcomes in advanced disease and should be considered for treatment of CSPH.