The need of HVPG-guided beta-blocker therapy for NASH cirrhosis with varices – Answer is still up in the air

Abstract

Portal pressure (PP) is a key predictor of the development of liver decompensation and mortality in patients with advanced chronic liver disease (aCLD). Among the methods of portal pressure assessment, hepatic venous pressure gradient (HVPG) measurement is the gold-standard method to assess the presence of clinically significant portal hypertension (CSPH) which is defined as HVPG ≥ 10 mmHg [ [1] de Franchis R. Faculty B.V.I. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015; 63: 743-752 Google Scholar ]. The assessment of response to non-selective beta-blockers (NSBB) therapy is another indication for HVPG, which also helps in the prognostication of the patients with aCLD [ [1] de Franchis R. Faculty B.V.I. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015; 63: 743-752 Google Scholar , [2] Garcia-Tsao G. Abraldes J.G. Berzigotti A. Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017; 65: 310-335 Google Scholar ]. We read the recently published original article by Paternostro et al. [ [3] Paternostro R. Becker J. Hofer B.S. Panagl V. Schiffke H. Simbrunner B. et al. The prognostic value of HVPG-response to non-selective beta-blockers in patients with NASH cirrhosis and varices. Dig Liver Dis. 2022; 54: 500-508 Google Scholar ], analyzing the prognostic value of HVPG-response to (NSBB) in patients with NASH-related cirrhosis and varices. The authors reported that 55.3% of the patients achieved HVPG-response to NSBB. Presence of diabetes (adjusted odds ratio (aOR) 0.16, p = 0.038) and baseline mean arterial pressure (MAP) (aOR:1.07, p = 0.044) were independent predictors of NSBB- response. Child-Pugh stage B/C, MELD ≥ 15, and HVPG ≥ 20 mmHg but not HVPG response, predicted the composite endpoint of bleeding or decompensation at 90 days and 2 years. While this study adds to the limited existing literature on efficacy and outcomes of NSBB induced HVPG-response in patients with NASH cirrhosis, some issues need to be addressed. The prognostic value of HVPG-response to non-selective beta-blockers in patients with NASH cirrhosis and varicesDigestive and Liver DiseaseVol. 54Issue 4PreviewNon-alcoholic steatohepatitis has become a leading cause of cirrhosis. The prognostic value of (HVPG)-guided NSBB prophylaxis remains to be investigated in the setting of NASH cirrhosis. Full-Text PDF Open Access