Prognostic performance of non-invasive tests for portal hypertension is comparable to that of hepatic venous pressure gradient

Abstract

Background and Aims

Non-invasive tests (NIT) for assessing the probability of clinically significant portal hypertension (CSPH) including the ANTICIPATE±NASH models based on liver stiffness measurement (LSM), platelet count (PLT)±body mass index (BMI), and the von Willebrand factor antigen (VWF) to PLT ratio (VITRO) have fundamentally changed the management of compensated advanced chronic liver disease (cACLD). However, their prognostic utility has not been compared head-to-head against the hepatic venous pressure gradient (HVPG) as the gold standard.

Methods

cACLD (LSM≥10 kPa) patients who underwent advanced characterization via same-day HVPG/NIT assessment from 2007-2022 were retrospectively included. Long-term follow-up data on hepatic decompensation was recorded.

Results

Four hundred twenty cACLD patients (51.9% viral hepatitis, 20.5% ALD, 18.6% MASLD/MetALD, 9.0% other) with a CSPH prevalence of 67.6% were included. The cumulative incidence of hepatic decompensation at 1 and 2 years were 4.7% and 8.0%, respectively. HVPG, VITRO, and ANTICIPATE±NASH-CSPH-probability showed similar time-dependent prognostic value (AUROC 0.683-0.811 at 1 and 0.699-0.801 at 2 years). In competing risk analyses adjusted for MELD and albumin, HVPG (adjusted subdistribution hazard ratio [aSHR]:1.099 [95%CI:1.054–1.150) per mmHg; p<0.001), or VITRO (aSHR:1.134 [1.062–1.211] per unit; p<0.001), or ANTICIPATE±NASH-CSPH-probability (aSHR:1.232 [1.094–1.387] per 10%; p<0.001) all predicted first decompensation during follow-up. Previously proposed cut-offs (HVPG≥10mmHg vs.<10mmHg, VITRO≥2.5 vs.<2.5, and ANTICIPATE-CSPH probability≥60% vs.<60%) all accurately discriminated between patients at negligible risk and those at substantial risk of hepatic decompensation.

Conclusions

The prognostic performance of ANTICIPATE±NASH-CSPH-probability and VITRO is comparable to that of HVPG, supporting their utility for identifying patients who may benefit from medical therapies for preventing first hepatic decompensation.

Impact and implications

Non-invasive tests (NIT) have revolutionized the diagnosis and management of clinically significant portal hypertension (CSPH) in compensated advanced chronic liver disease (cACLD) patients. However, limited data exists regarding the prognostic utility of NIT in direct comparison to the gold standard for prognostication in cACLD, i.e., the hepatic venous pressure gradient (HVPG). In our study including 420 cACLD patients, HVPG and NIT, i.e., most importantly, the ANTICIPATE±NASH model based on platelet count (PLT) and liver stiffness measurement (LSM), and the von Willebrand factor (VWF) to PLT ratio (VITRO), yielded similar AUROC for hepatic decompensation within one to two years. Thus, NIT should be applied and updated in yearly intervals in clinical routine to identify patients at short-term risk, thereby identifying patients who may benefit from treatment aiming at the prevention of hepatic decompensation.