Algorithms which integrate Baveno VII criteria with spleen stiffness measurement (SSM) demonstrate improved performance by reducing the diagnostic gray zone for clinically significant portal hypertension, compared to using Baveno VII criteria alone, according to study results published in The Lancet Gastroenterology & Hepatology.

A comprehensive search was conducted in PubMed, Embase, Scopus, Web of Science, and the Cochrane Library. The eligible studies included cross-sectional studies that reported hepatic venous pressure gradient and SSM, utilizing transient elastography; 2-dimensional shear-wave elastography (2D-SWE); and point shear-wave elastography (p-SWE) in adults with compensated advanced chronic liver disease (ACLD).

The primary outcome was the performance of 2 SSM-based algorithms. These algorithms were evaluated based on their sensitivity, specificity, and summary negative predictive values (NPV) and positive predictive values (PPV) in comparison to the Baveno VII model.

A total of 1,245 patients were included across 17 studies that met the inclusion criteria. Of these, 11 studies were available in full-text format, while the remaining 6 studies were abstracts.

The main cohort for transient elastography included 600 patients (mean [SD] age, 58[12] years; men, 69%) with viral etiology. The median rate of SSM failure was 16% (95% CI, 7-24), and 27% of patients had large varices.

The Baveno VII algorithm was validated to effectively identify both the presence and absence of clinically significant portal hypertension.  It demonstrated a 100% sensitivity and NPV for ruling out this condition, while also achieving a 95% PPV and specificity for ruling it in. However, 48% (95% CI, 44-52) of patients had indeterminate results in the gray zone, while 57% (95% CI, 52-62) of patients with clinically significant portal hypertension fell within the rule-in zone.

The single cutoff model of Baveno VII-SSM demonstrated a high sensitivity of 93% (95% CI, 85-97) and a NPV of 85% (95% CI, 60-96) in effectively ruling out clinically significant portal hypertension. Furthermore, it exhibited a specificity of 86% (95% CI, 80-91) and a PPV of 92% (95% CI, 83-95) in accurately identifying cases of clinically significant portal hypertension. Notably, 88% (95% CI, 84-91) of patients with clinically significant portal hypertension fell within the rule-in zone, while 9% (95% CI, 7-12) of patients were categorized in the gray zone.

The dual cutoff model of Baveno VII-SSM exhibited favorable results in terms of NPV at 98% (95% CI, 58-100) and sensitivity at 100% (95% CI, 91-100). Additionally, it displayed a PPV of 93% (95% CI, 84-97) and specificity of 89% (95% CI, 84-93). The gray zone accounted for approximately 32% (95% CI 28-36) of patients, while the rule-in zone included 76% (95% CI 72-80) of patients with clinically significant portal hypertension.

Within the 2D-SWE cohort (n=225), all 3 algorithms identified clinically significant portal hypertension (PPV ≥90%). However, despite their effectiveness, these algorithms fell short in ruling out clinically significant portal hypertension, as their NPV was inadequate. Moreover, the available data were insufficient to evaluate the performance of SSM using p-SWE.

The study was limited due to the absence of individual patient data from four study groups, leading to the exclusion of certain eligible patients from the meta-analysis.

Researchers concluded, “Further studies are needed to assess if SSM-based diagnosis can identify patients who would benefit from non-selective β-blocker treatment.” 

References:

Dajti E, Ravaioli F, Zykus R, et al. Accuracy of spleen stiffness measurement for the diagnosis of clinically significant portal hypertension in patients with compensated advanced chronic liver disease: a systematic review and individual patient data meta-analysis. Lancet Gastroenterol Hepatol. Published online July 18, 2023. doi:10.1016/S2468-1253(23)00150-4