THE ROLE OF ELASTOGRAPHY IN CLINICALLY SIGNIFICANT PORTAL HYPERTENSION

• The Baveno VII presented the “rule of 5” for Vibration-Controlled Transient Elastography; liver stiffness measurement ≤15 kPa and platelets >150.000/mm3 exclude clinically significant portal hypertension (CSPH), while when ≥25 kPa is highly suggestive of CSPH.

• Spleen stiffness measurement has been proposed as a more specific technique to predict the presence of CSPH.

• Elastography has gained prestige in the non-invasive evaluation of patients with advanced chronic liver disease by allowing prophylactic measures to be taken when suggesting the presence of CSPH.

ABSTRACT

This is a narrative review that aims to discuss the importance of elastographic methods in the evaluation of clinically significant portal hypertension (CSPH) in cirrhotic patients, where the authors propose an algorithm for evaluating these patients. In compensated advanced chronic liver disease, the goal is to prevent the development of CSPH and, in those already with CSPH, prevent the appearance of gastroesophageal varices (GEV) and other complications of portal hypertension. In compensated cirrhosis, the prevalence of GEV is 30-40%, of which 10-20% are at risk of bleeding. Therefore, using non-invasive methods would exempt the patient from the need of an endoscopy. Hepatic Elastography is a non-invasive, safe, reproducible method, available through many techniques: Vibration-Controlled Transient Elastography (VCTE), Shear Wave Elastography (SWE) and Magnetic Resonance Elastography (MRE). The Baveno VII presented the “rule of 5” for VCTE: liver stiffness measurement (LSM) ≤15 kPa and platelets >150.000/mm³ exclude CSPH, while an LSM ≥25 kPa is highly suggestive of CSPH. Also, the “rule of 4” for SWE has been proposed: patients with ≥17 kPa could be considered as having CSPH. At last, spleen stiffness measurement (SSM) has been proposed as a more specific technique to predict the presence of CSPH. In conclusion, elastography has gained prestige in the non-invasive evaluation of patients with advanced chronic liver disease by allowing prophylactic measures to be taken when suggesting the presence of CSPH.

Keywords:
Portal hypertension; elastography; cirrhosis

Author	Design/N	Aim/primary endpoint	Results/conclusion
Groszmann RJ, et al.¹⁹19. Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. Portal Hypertension Collaborative Group. N Engl J Med. 2005;353:2254-61.	Prospective N=213 cirrhotic patients without varices receiving timolol (n=108) vs placebo (n=105)	Development of gastroesophageal varices or variceal hemorrhage	NSBB are ineffective in preventing varices/bleeding (39% treated vs 40% placebo; P=0.89) and are associated with adverse events
Villanueva C, et al.¹⁷17. Villanueva C, Albillos A, Genescà J, Abraldes JG, Calleja JL, Aracil C, et al. Development of hyperdynamic circulation and response to β-blockers in compensated cirrhosis with portal hypertension. Hepatology. 2016;63:197-206.	Prospective, multicentric, cross-sectional study N=273 cirrhotic with PH (194 with CSPH and 79 with subclinical PH)	To characterize the hemodynamic profile of each stage of PH in compensated cirrhosis and the response to NSBB according to stage	Patients with subclinical PH have less hyperdynamic circulation and lower portal pressure reduction using NSBB compared to those with CSPH, suggesting that NSBB are more suitable to prevent decompensation of cirrhosis in patients with CSPH than in earlier stages
Villanueva C, et al.¹⁸18. Villanueva C, Albillos A, Genescà J, Garcia-Pagan JC, Calleja JL, Aracil C, et al. β blockers to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension (PREDESCI): a randomised, double-blind, placebo-controlled, multicentre trial. Lancet. 2019;393:1597-1608.	Multicentric prospective, double-blind, RCT (PREDESCI). N=201 with compensated cirrhosis and CSPH without HRBV (100 received propranolol or carvedilol and 101 received placebo)	NSBB to prevent decompensation of cirrhosis with PH	Decompensation occurred in 16/100 (16%) patients in the NSBB group versus 27/101 (27%) patients in the placebo group (P=0.041). Long-term treatment with NSBB could increase decompensation-free survival in patients with compensated cirrhosis and CSPH
Albrades JC, et al.³3. Abraldes JC, Bureau C, Stefanescu H, Augustin S, Ney M, Blasco H, et al. Noninvasive tools and risk of clinically significant portal hypertension and varices in compensated cirrhosis: The “Anticipate” study. Hepatology. 2016;64:2173-84.	Prospective, multicentric N=518 patients with cACLD	To develop noninvasive tests-based risk prediction models to provide a point-of-care risk assessment of cACLD patients	Platelets ≥150.000 and a LSM value of 20 kPa would have a predictive probability for HRBV of 5%, and 30% of the patients showed a predictive probability of HRBV below 5%
Pons M, et al.⁴³43. Pons M, Augustin S, Scheiner B, Guillaume M, Rosselli M, Rodrigues SG, et al. Noninvasive Diagnosis of Portal Hypertension in Patients With Compensated Advanced Chronic Liver Disease. Am J Gastroenterol. 2021;116:723-32.	International cohort study N=836 compensated cirrhotic (358 HCV; 248 NASH; 203 alcohol abuse and 27 HBV)	To explore the prevalence of PH in the most common etiologies of patients with cACLD and develop classification rules based on LSM, that could be readily used to diagnose or exclude CSPH	LSM ≥25 kPa is sufficient to rule in CSPH in most etiologies, including non-obese with NASH, but not in obese patients with NASH. LSM ≤15 kPa plus platelets ≥150.000 ruled out CSPH in most etiologies
Rabiee A, et al.⁴⁵45. Rabiee A, Deng Y, Ciarleglio M, Chan JL, Pons M, Genesca J, Garcia-Tsao G. Noninvasive predictors of clinically significant portal hypertension in NASH cirrhosis: Validation of ANTICIPATE models and development of a lab-based model. Hepatol Commun. 2022;6:3324-34.	Validation study N=245 patients with compensated NASH cirrhosis	To validate the ANTICIPATE models using baseline data from a multicenter RCT; and to develop and validate a model using laboratory values (FIB4+)	The ANTICIPATE models performed well in predicting the presence of CSPH in NASH cirrhosis. A model using FIB-4 plus albumin (FIB4+) can be used to predict CSPH when VCTE is not available

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[1] Corresponding author: Cristiane Valle Tovo. E-mail: cristianev@ufcspa.edu.br