Severe Portal Hypertension Research Articles

Spleen and Liver Volumetrics as Surrogate Markers of Hepatic Venous Pressure Gradient in Patients With Noncirrhotic Portal Hypertension.

Noncirrhotic portal hypertension (NCPH) is a rare disease that may lead to serious clinical consequences. Currently, noninvasive tools for the assessment of NCPH are absent. We investigated the utility of spleen and liver volumetrics as a marker of the presence and severity of portal hypertension in this population. A cohort of NCPH patients evaluated between 2003 and 2015 was retrospectively studied. The association of spleen and liver volumes with the hepatic venous pressure gradient (HVPG) level was evaluated using locally weighted scatterplot smoothing curves. A cohort of patients with viral hepatitis‐related liver disease was used as controls. Of the 86 patients with NCPH evaluated during the study period, 75 (mean age, 35 ± 17; 73% males) were included in the final analysis. Patients with portal hypertension had significantly higher spleen and liver to body mass index (BMI) ratios compared to patients with HVPG <5 mm Hg (39.5 ± 27.9 versus 22.8 ± 10.6 cm3/kg/m2, P = 0.003; 91.1 ± 40.1 versus 71.4 ± 16.7 cm3/kg/m2, P = 0.014, for spleen/BMI and liver/BMI, respectively). In contrast to the patients with viral hepatitis, a positive linear correlation was observed in the NCPH cohort between spleen/BMI and liver/BMI (above a cutoff of 25 and 80 cm3/kg/m2, respectively) and HVPG level. Additionally, only in the NCPH cohort was an increase in spleen/BMI range quartile predictive of a higher prevalence of portal hypertension and clinically significant portal hypertension (trend, P = 0.014 and 0.031, respectively). Conclusion: Spleen and liver volumetrics may have utility in the assessment of NCPH as a noninvasive biomarker that can be performed using routine radiologic examinations. Further studies are needed to validate these findings. (Hepatology Communications 2018; 00:000‐000)

Successfully in Situ Right-Left Split Liver Transplantation

Introduction In-situ or ex-vivo left lateral segmentectomy and right trisegmentectomy split-liver transplantation had become and standard practice in Argentina. Over the last 10 years more than 150 split procedures has been performed, but until recently none in-situ right-left split was performed. We aim to report the first case done at a single institution. Material and Method Report of an in-situ right-left split liver procurement performed more than 1 thousand kilometers far from the transplant center. Follow by the engraftment into an adult recipient (54 years) with a non respectable metastatic NET and a pediatric recipient (14 years), with cystic fibrosis and severe portal hypertension (24 mmHg). Results After grafts allocations, our liver procurement team flew to the donor hospital, with the necessary devices to perform the in-situ liver parenchymal transection. Donor was hemodynamically stable without inotropic drugs. After midline incision, hiliar dissection was performed, to identify the right hepatic artery, right portal vein and bile duct; Intraoperative cholangiography showed normal billiary anatomy. A bulldog clamp was placed in the right portal and hepatic artery to delineate the transaction line. The cava and middle hepatic veins were left to left graft (LG). Billiary tree and common hepatic artery were left in the right graft (RG). HTK solution was used for preservation. Operative time for the procurement was 3.5 hours. Right graft weight 980 grs. and left graft 450 grs. The RG was used in an adult recipient and the LG in a pediatric recipient, CIT were: 475 min and 430 min respectevily. GRWR for the RG and LG were 1.53 and 1.67 respectively. The LG required re-exploration for intra-abdominal hemorrhage, and postop. ascitis was present and medically treated; in spite of a reduction in the portal pressure to 17 mmHg). Recipients were discharge on postop. day: 7 and 14 respectively. Conclusions Right and left split-liver transplantation should be considered as a source to expand the cadaveric donor liver pool. A trained committed surgical team is needed to successfully perform these procedures. The adequate donor and recipient selection will increase motivation to routinely use it for adolescents or adult recipients.

Non-invasive aspartate aminotransferase to platelet ratio index correlates well with invasive hepatic venous pressure gradient in cirrhosis.

Hepatic venous pressure gradient (HVPG) is the best recommended tool to measure portal pressure, but is invasive. HVPG helps in prognosticating cirrhosis and predictits complications. Aminotransferase to platelet ratio index (APRI) is a simple non-invasive marker of hepatic fibrosis. We aimed to correlate APRI with HVPG and to determine the usefulness of APRI in predicting complication of cirrhosis. APRI and HVPG were measured in consecutive patients of cirrhosis aged 18 to 70 years. Spearman's rho was used to estimate their correlation; acut-off valueof APRI topredict severe portal hypertension (HVPG > 12mmHg) was determined. This study, conducted between August 2011 and December 2014, included 277 patients, median age 51 (range: 16-90) years, 84% males. Etiology of cirrhosis was alcohol in 135 (49%), cryptogenic/nonalcoholic steatohepatitis (NASH) in 104 (38%), viral in 34 (12%), and others in 4 (1%). Median Child-Turcott-Pugh (CTP) and model for end-stage liver disease (MELD) scores were 7 (5-11) and 11 (6-33), respectively. Median HVPG was 17.0 (1.5-33) mmHg and median APRI was 1.09 (0.21-12.22). There was positive correlation between APRI andHVPG (Spearman's rho 0.450, p < 0.001). The area under the receiver operating characteristic (ROC) curve of APRI for predicting severe portal hypertension was 0.763 (p < 0.01). Youden's index defined the cut-off of APRI for predicting HVPG > 12mmHg was 0.876 with a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 71%, 78%, 94%, 38%, and 73%, respectively. APRI also correlated well with CTP, variceal size, bleeding status, ascites but not with MELD. APRI score of 0.876 has an acceptable accuracy topredictsevere portal hypertension (HVPG > 12mmHg). High APRI also correlated with severity of cirrhosis and its complications. Thus, APRI may be used as a simple, bedside, non-invasive, and inexpensive tool for evaluating portal hypertension and complications of cirrhosis.

Predictors of clinical outcomes in cirrhosis patients.

The current review aims to explain the different systems available to clinicians for predicting clinical outcomes in patients with cirrhosis. Cirrhosis is the final stage of chronic liver disease and is associated with high morbidity and mortality. The most commonly utilized tools to predict outcomes in patients with cirrhosis include the following: assessing severity of portal hypertension using hepatic venous pressure gradient (HVPG) measurements, using scoring systems such as the Model for End-stage Liver Disease (MELD) and Child-Pugh-Turcotte (CPT) scores, and recently, clinical staging systems based on cirrhosis-related clinical complications. Assessing portal pressure with HVPG measurements provides valuable prognostic information, yet is costly, time-consuming, and invasive. MELD and CPT scores can be calculated quickly and not only assess liver function, but also yield predictive information. However, they represent only one point in time, and do not take into account the full clinical picture. Clinical staging systems have traditionally been focused on compensated and decompensated stages, with newer models assessing the influence of cirrhosis-related complications. However, these are not commonly utilized. Predicting clinical outcomes in patients with cirrhosis is challenging, and is likely best accomplished with a combination of objective data (such as MELD and HVPG provide) in addition to the clinical course of cirrhosis.

The efficacy of surgical shunts to treat severe portal hypertension after a Kasai procedure for biliary atresia

BackgroundTo assess the outcome of patients with biliary atresia (BA) who underwent a surgical shunt (SS) for severe portal hypertension (PH) following a Kasai procedure. MethodsWe collected and analyzed the data and outcomes of patients with BA who underwent SS for severe PH following a Kasai procedure between 1974 and 2014, focusing on complications related to the procedure, overall survival (OS), and transplant-free survival (TFS). ResultsSS was performed at a median age of 5.5 years [2–13.5] in 38 patients. Conjugated bilirubin level (cBL) was ≤20 μmol/l in 24 patients at time of SS. Median follow-up was 15 years [1–32]. OS at 5 and 10 years was 91% and 87% respectively. TFS at 5 and 10 years was 84% and 70% respectively. Long-term complications included hepatic encephalopathy in 9 patients, and hepatopulmonary syndrome in 3. At last follow-up, 10/14 patients without LT and 18/ 24 who had a delayed LT at a median delay of 11 years [1.5–22] were alive. ConclusionSurgical shunt for severe portal hypertension in biliary atresia may delay the need for liver transplantation. However complications are indications for transplantation. Level of evidenceType of study: Therapeutic.Level of evidence III.

Portal hypertension and hypersplenism in extrahepatic portal venous obstruction: Are they related?

Portal hypertension (PHT) due to extrahepatic portal venous obstruction (EHPVO) is common in developing countries. Hypersplenism is a near-constant feature of EHPVO, but its significance, unlike in cirrhotics, is unknown. We aimed to study the relationship between hypersplenism and the severity of PHT in patients with EHPVO. This prospective study was done at a tertiary care center from January 2014 to August 2015. All patients with EHPVO who underwent a splenectomy and a shunt or devascularization were included. Data regarding clinical profile, preoperative parameters, and intraoperative details were recorded. The correlation was studied between hypersplenism and the intraoperatively measured portal pressures and markers of PHT. Of the 40 patients studied (mean [SD] age 22.4 [8.4]years), hematological hypersplenism was present in 39 (97.5%). The mean (SD) hemoglobin, total leukocyte counts (TLC), and platelet counts were 9.9 (2.4)g/dL, 2971 (1239)cells/mm3, and 66,400 (32047)cells/mm3, respectively. The mean (SD) sonographic spleen volume (SV), splenic weight, and intraoperative portal pressure were 1084.7 (553.9)cm3, 1088.7 (454.7)g, and 35.6 (5.1)mmHg, respectively. The TLC and platelet counts correlated inversely with the portal pressure. Additionally, the platelet counts correlated negatively with eradicated variceal status, SV, and weight; hemoglobin with SV and weight; and TLC with SV. Multivariate analysis showed the platelet counts were an independent predictor of portal pressures and platelet counts ≤ 53,500cells/mm3 indicated significantly high portal pressures. The platelet counts showed a significant inverse correlation with portal pressures in patients with EHPVO and may be used as surrogate markers of PHT. A platelet count ≤ 53,500cells/mm3 is predictive of significantly high pressures.

Ten-year experience of transjugular intrahepatic portosystemic shunt for noncirrhotic portal hypertension

Transjugular intrahepatic portosystemic shunt (TIPS) is considered to be well suited for the treatment of noncirrhotic portal hypertension (NCPHT) because of a usually severe portal hypertension (PHT) and a mild liver failure, but very less data are available. Records of patients referred for TIPS between 2004 and 2015 for NCPHT were reviewed. No patient should have clinical or biological or histological features of cirrhosis. Twenty-five patients with a wide variety of histological lesions (sinusoidal dilatations, granulomatosis, regenerative nodular hyperplasia, obliterative portal venopathy, or subnormal liver) and a wide variety of associated diseases (thrombophilia, sarcoidosis, common variable immunodeficiency, scleroderma, Castleman's disease, early primitive biliary cirrhosis, congenital liver fibrosis, chemotherapy, purinethol intake, and congenital varices) were included. Two complications occurred during the procedure: one periprosthetic hematoma and the other misposition of a covered stent. During the first month, two other patients had an early thrombosis, another had induced encephalopathy, and one died of early rebleeding. Two of these complications occurred in patients with cavernoma. With a mean follow-up of 39 months, 10 patients experienced at least one episode of spontaneous encephalopathy, with three of these patients requiring a stent reduction. Five patients had a recurrence of their initial symptoms, and one had an asymptomatic hemodynamic dysfunction. TIPS is effective in NCPHT but can be technically difficult, especially in the case of cavernoma. Good liver function does not prevent the occurrence of long-term encephalopathy.

Tu1539 - Vibration Controlled Elastography Predicts Severity of Portal Hypertension in Non Cirrhotic Portal Hypertension

Tu1539 - Vibration Controlled Elastography Predicts Severity of Portal Hypertension in Non Cirrhotic Portal Hypertension

Atypical use of ALN inferior vena cava filters as protection devices prior to embolization of a large portosystemic shunt with Amplatzer Vascular Plugs and Glubran 2 cyanoacrylate glue.

Spontaneous portosystemic shunts usually develop as a result of portal hypertension caused by liver cirrhosis, and may subsequently lead to hepatic encephalopathy (1,2). In cases of severe portal hypertension, a part of the portal blood may reverse direction and pass through the portosystemic anastomoses into the systemic venous system.

Portal vein thrombosis: yes or no on anticoagulation therapy.

To describe portal vein thrombosis (PVT) in the setting of cirrhosis especially in relation to its potential impact on liver transplantation. In addition, the safety and efficacy of anticoagulation is reviewed. PVT in cirrhosis occurs in up to 26% of patients awaiting liver transplantation. Different studies have suggested that PVT impacts negatively post-liver transplantation survival, particularly in first year post-liver transplantation and when PVT is complete involving the porto-mesenteric confluence and not allowing physiological anastomosis. Anticoagulation is effective in preventing PVT progression and may achieve partial or complete PVT recanalization. Its use in patients with cirrhosis seems not to be associated with increased bleeding risk. The goal of anticoagulation is to prevent thrombus extension to the superior mesenteric vein and/or favor recanalization if previously affected, allowing physiological anastomosis during liver transplantation and therefore improving outcome. Low-molecular-weight heparin and vitamin K antagonist have a similar safety profile without specific data in favor of any of them. Treatment with direct anticoagulants cannot be recommended yet because of limited experience in cirrhosis. Transjugular intrahepatic portosystemic shunt could be an alternative particularly if thrombosis progresses despite satisfactory anticoagulation and/or when PVT is associated with severe portal hypertension complications. However, careful consideration of potential risks and benefits of anticoagulation is recommended until further studies are conducted.

Screening and Surveillance of Varices in Patients With Cirrhosis

Gastro-esophageal varices (GEV) and variceal hemorrhage (VH) are clinical milestones in the natural history of cirrhosis, as they are closely related to the severity of portal hypertension and define specific stages in disease progression. Variceal hemorrhage is a life-threatening complication of cirrhosis and is one of the clinical complications that defines cirrhosis decompensation. The goal of screening and surveillance of varices is to identify patients with GEV at a high risk of bleeding, so that prevention strategies can be implemented. There have been significant updates in the management of GEV over the last years, particularly in the use of non-invasive methods to assess the degree of portal hypertension and the likelihood of having GEV. This paper is focused on esophageal varices with or without extension along the lesser curvature (type 1 or GOV1), as special considerations are required for the management of cardiofundal varices (GOV2 - esophageal varices extending into the fundus, or IGV1 - isolated gastric varices in the fundus) or isolated gastric varices type 2 (IGV2 – gastric varices elsewhere in the stomach, not in the fundus).

Long-term outcome of transjugular intrahepatic portosystemic shunt for portal hypertension in autosomal recessive polycystic kidney disease

BackgroundAutosomal recessive polycystic kidney disease (ARPKD) with congenital hepatic fibrosis (CHF) causes portal hypertension and its complications. A transjugular intrahepatic portosystemic shunt (TIPSS) could serve as a symptomatic treatment for portal hypertension-related symptoms in these children. AimsTo study the effect of TIPSS on portal hypertension, liver and kidney function and the long term complications. Materials and methodsWe report on 5 children with CHF treated with a TIPSS to manage severe portal hypertension related symptoms. ResultsMean follow-up time was 7 years and 2 months. At the end of follow-up there was a reduction of spleen size (p = 0.715) and hypersplenism with a rise in platelet count (p = 0.465). Esophageal varices and ascites disappeared in all patients. Liver and kidney function remained stable. In two patients endotipsitis was suspected and two patients developed an in-stent stenosis. There was no sign of encephalopathy in our patients. ConclusionTIPSS using ePTFE-covered stent is a feasible and effective alternative for surgical portosystemic shunting in children with CHF, also on the long term. It can postpone the need of a liver transplantation but close monitoring remains important for early diagnosis of endotipsitis or stent dysfunction related to stenosis.

Modification of splenic stiffness on acoustic radiation force impulse parallels the variation of portal pressure induced by transjugular intrahepatic portosystemic shunt.

Spleen and liver stiffness (LS) measured by acoustic radiation force impulse (ARFI) imaging has been shown to be useful in identifying patients with portal hypertension. The study aims to establish if the modification of portal pressure induced by a transjugular intrahepatic portosystemic shunt (TIPS) parallels the modification of spleen or LS measured by ARFI in order to understand if ARFI may be used to monitor the modification of portal pressure in patients with cirrhosis. Thirty-eight patients with severe portal hypertension underwent LS and spleen stiffness (SS) before TIPS and 1week after TIPS. Portal atrial gradient (PAG) was measured before and after the shunt opening. Portal atrial gradient decreased significantly from 19.5 to 6mmHg (P<0.001). SS decreased significantly after TIPS (pre-TIPS 3.7m/s vs post-TIPS 3. 1m/s; P<0.001), and LS was also significantly modified by TIPS (pre-TIPS 2.8m/s vs post-TIPS 2.4m/s; P=0.003). PAG and SS values measured before and after TIPS were significantly correlated (r=0.56; P<0.001); on the other hand, PAG and LS were not (r=0.19; P=0.27). Two patients developed a persistent hepatic encephalopathy refractory to medical treatment and were submitted to the reduction of the stent diameter. The modification of SS was parallel to the modification of PAG. Spleen stiffness is superior to LS in detecting the modification of portal pressure induced by TIPS. This makes SS a potential non-invasive method to monitor the modification of portal hypertension. Further investigations are needed to establish applicability and clinical utility of this promising tool in the treatment of portal hypertension.

Clinical characteristics and treatment of pyrrolizidine alkaloid-related hepatic vein occlusive disease.

Hematopoietic stem cell transplantation related hepatic vein occlusive disease (HSCT-HVOD) has been researched extensively; however, little is known about the clinical features and treatment of pyrrolizidine alkaloid-induced HVOD (PA-HVOD). This retrospective single centre study examined the clinical and laboratory characteristics of 108 patients with acute PA-HVOD and explored the efficacy of anticoagulation and TIPS therapy. The study included 108 consecutive patients with PA-HVOD between July 2008 and June 2016. The clinical manifestations and the results of laboratory and imaging tests were evaluated. The survival rates of patients treated with different approaches were recorded. Serum total bilirubin was <34.2μmol/L (2mg/dL) in approximately 40% of patients. More than 90% of patients were presented with hepatomegaly, uneven liver perfusion in the balance phase, compressive stenosis of the hepatic segmental inferior vena cava and decreased peak velocity of portal vein blood flow. Severe portal hypertension was observed in all patients undergoing HVPG examination or TIPS operation. Anticoagulation therapy with low molecular weight heparin combined with warfarin was significantly more effective than liver protection and supportive therapy, and TIPS further improved the prognosis of patients who did not respond to anticoagulation therapy. The total effective rate of the anticoagulation-TIPS ladder therapeutic strategy was 91%. Patients with PA-HVOD had different characteristics than those with HSCT-HVOD. Anticoagulation and TIPS treatment may be effective for patients with PA-HVOD.

Non-invasive measurement of HVPG using graph analysis based on dynamic contrast-enhanced ultrasound with ESAOTE MyLab: The CLEVER Study

Background and aims: Non-invasive methods accurately estimating hepatic venous pressure gradient (HVPG) are un unmet clinical need. Preliminary data suggested that graph analysis of dynamic contrast enhanced ultrasonography (DCE-US) of the liver using a “connectome” approach allows assessment of the liver microcirculatory derangement and mirrors the severity of portal hypertension (Amat-Roldan et al. Radiology 2015). The EC-funded prospective CLEVER study (FP7-IAPP-GA-2013-612273-CLEVER) is aimed at developing a novel automatized software based on DCE-US able to improve prognostication in cirrhosis. First extended results were developed with a Siemens Acuson Sequoia in Barcelona, showing optimal correlation with HVPG. Here we report the adaptation of this CLEVER software to DCE-US videos acquired with ESAOTE MyLab equipments in Bologna to predict HVPG in a population of patients with F≥3 hepatopathy.

Use of a new type of controlled expansion stent in the creation of Transjugular Intrahepastic Portosystemic Shunt for the treatment of severe portal hypertension. A single center experience with 1 year follow-up

Background and aims: Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a valid option for the treatment of complications in liver cirrhosis. Portosystemic encephalopathy (PSE) is a side effect and studies showed that it could be prevented by using underdilated stents. With the present study we want to bring our personal experience in the use of a controlled expansion stent in TIPS creation (GORE® VIATORR® VTX).

Von Willebrand factor indicates bacterial translocation, inflammation, and procoagulant imbalance and predicts complications independently of portal hypertension severity.

Elevated plasma von Willebrand factor antigen (vWF) has been shown to indicate the presence of clinically significant portal hypertension, and thus, predicts the development of clinical events in patients with cirrhosis. To investigate the impact of bacterial translocation and inflammation on vWF, as well as the association between vWF and procoagulant imbalance. Moreover, we assessed whether vWF predicts complications of cirrhosis, independent of the severity of portal hypertension. Our study population comprised 225 patients with hepatic venous pressure gradient (HVPG)≥10mm Hg without active bacterial infections or hepatocellular carcinoma. vWF correlated with markers of bacterial translocation (lipopolysaccharide-binding protein [LBP; ρ=0.201; P=0.021]), inflammation (interleukin 6 [IL-6; ρ=0.426; P<0.001] and C-reactive protein [CRP; ρ=0.249; P<0.001]), and procoagulant imbalance (factor VIII/protein C ratio; ρ=0.507; P<0.001). Importantly, the associations between vWF and these parameters were independent of HVPG. Moreover, vWF (per 10%) independently predicted variceal bleeding (hazard ratio [HR]: 1.08 [95% confidence interval (95% CI): 1.01-1.16]; P=0.023), requirement of paracentesis (HR: 1.05 [95% CI: 1.01-1.1]; P=0.023) and bacterial infections (HR: 1.04 [95% CI: 1-1.09]; P=0.04) including spontaneous bacterial peritonitis (HR: 1.09 [95% CI: 0.999-1.18]; P=0.053) on a trend-wise level. After backward elimination, vWF (HR: 1.05 [95% CI: 1.02-1.08]; P=0.003) and CRP (per 10mg/L; HR: 1.53 [95% CI: 1.14-2.05]; P=0.005) remained in the final model for transplant-free mortality. Finally, the independent prognostic value of vWF/CRP groups for mortality was confirmed by competing risk analysis. Our results demonstrate that vWF is not only a marker of portal hypertension but also independently linked to bacterial translocation, inflammation and procoagulant imbalance, which might explain its HVPG-independent association with most clinical events. Prognostic groups based on vWF/CRP efficiently discriminate between patients with a poor 5-year survival and patients with a favourable prognosis.

Results of portosystemic shunting in patients with hepatic cirrhosis and ascites syndrome

Purpose. Assess the results of portal systemic shunting (PSSh) in patients with liver cirrhosis (LC) with ascitic syndrome.&#x0D; Materials and methods. Analyse the results of PSSh in 556 patients operated a year from 2000 to 2015. The basis of the analysis taken all the features related to the development and progression of ascitic syndrome. Depending on the shunt type, research conducted with most frequently performed shunts groups.&#x0D; Results. Initial decompensated cirrhosis by edema-ascites syndrome significantly increases the risk of specific complications such as hepatic insufficiency from 6.9% to 13.5%, hepatic encephalopathy from 12.1% to 16.2% and increase in ascites from 7.2% to 16.2%, and the mortality rate from 2.1% to 3.8%. The main cause of early mortality after PSSh is a risk of thrombosis of the anastomosis with recurrent bleeding, whereas other specific complications, conservative measures allow neutralizing the difference in the index of satisfactory results of the operation (96.2% — in the group with ascites before PSSh against; 97.9% — in the group without ascites). Quantitative and qualitative analysis of ascites showed that in the coming period after the shunt (3-5 days) the development of this complication depends on the type of bypass surgery, so when the distal splenorenal shunts (DSRS) production of ascites significantly increased (P &lt;0,01), while total protein component fluid significantly (P &lt;0,02) higher than in patients in ascites with central bypass type. This fact is due to the formation of the selective type of bypass on the background of DSRS, and the growth of ascites does not depend on the presence of complications before surgery, indicating that the impact factor of the severity of portal hypertension and therefore the adequacy of decompression of the portal vein system, against which a decrease in blood albumin fraction and increase it in ascites (R2 = 0,57) may be indicative of a high residual portal pressure.&#x0D; Conclusion. In patients with cirrhosis after PSSh in 70.2% of cases of decompensation of ascites syndrome is caused directly with cirrhotic process and the growth of functional impairment of hepatocytes, the remaining 29.8% of cases, the formation of the complications associated with the progression of PH syndrome on the background of anastomotic thrombosis.

Performance of spleen stiffness measurement in prediction of clinical significant portal hypertension: A meta-analysis

Our purpose was to evaluate the correlation between spleen stiffness (SS) measured by ultrasound-based elastography and hepatic venous pressure gradient (HVPG) and assess the accuracy of SS in detecting clinical significant portal hypertension (CSPH) and severe portal hypertension. Nine studies were included from thorough literature research and selection processes. A random model was used to analyze the correlation between HVPG and SS. We adopted the bivariate mixed effects model to assess the diagnostic performance. Regarding to correlation between SS and HVPG, the summary correlation coefficient was 0.72 (95% confidence interval [CI], 0.63-0.80). In detection of CSPH, the sensitivity, specificity, AUC and DOR were: 0.88 (0.70-0.96), 0.84 (0.72-0.92), 0.92 (0.89-0.94) and 38 (17-84) for CSPH, respectively; and 0.92 (0.82-0.96), 0.79 (0.72-0.85), 0.87 (0.84-0.90) and 41 (17-100) for severe portal hypertension, respectively. Correlation between SS and HVPG was good. Although SS showed good sensitivity and specificity, the different cut-off values and techniques among studies might limit the impact of our results on clinical practice. Therefore, more high-quality prospective studies are required to evaluate the role of SS in predicting portal hypertension.

Measurement of Portal Pressure and its Application in the Clinical Setting

AbstractPortal hypertension is a severe, yet common sequela of patients with chronic liver disease and is responsible for many of the complications seen in this population. Measurement of the hepatic venous pressure gradient (HVPG) is the current gold standard technique for identifying and evaluating the severity of portal hypertension. Any increase in HVPG to ≥10 mm Hg is considered clinically significant portal hypertension. Above this threshold, complications of portal hypertension begin to manifest. In addition to assessing portal hypertension, various HVPG thresholds have been shown to have strong prognostic value for risk of complications and therapeutic failure, as well as survival in patients with chronic liver disease. These clinical applications include quantification of disease progression and regression in chronic viral hepatitis, acute alcoholic hepatitis, and hepatocellular carcinoma. Other applications include preoperative evaluation of liver resection and transplantation in patients with cirrhosis and hepatocellular carcinoma, assessment of response to therapy for portal hypertension, and identification of the need for transjugular intrahepatic portosystemic shunt (TIPS) revision.