A combined model based on spleen stiffness measurement and Baveno VI criteria to rule out high-risk varices in advanced chronic liver disease

Abstract

Background & Aims: Recently, Baveno VI guidelines suggested that esophagogastroduodenoscopy (EGD) can be avoided in patients with cACLD who have a liver stiffness measurement (LSM) < 20 kPa and platelet count >150,000/mm 3. We aimed to: assess the performance of spleen stiffness measurement (SSM) in ruling out patients with high-risk varices (HRV); validate Baveno VI criteria in a large population and assess how the sequential use of Baveno VI criteria and SSM could safely avoid the need for endoscopy. Methods: We retrospectively analysed 498 cACLD patients who had undergone LSM/SSM by transient elastography (TE) (Fibroscan®), platelet count and EGDs from 2012 to 2016 referred to our tertiary centre. The new combined model was validated internally by a split-validation method, and externally in a prospective multicentre cohort of 115 patients. Results: SSM, LSM, platelet count and Child-Pugh-B were independent predictors of HRV. Applying the newly identified SSM cutoff (≤46 kPa) or Baveno VI criteria, 35.8% and 21.7% of patients in the internal validation cohort could have avoided EGD, with HRV being missed in only 2 % in both cases. The combination of SSM with Baveno VI criteria would have led to additionally avoiding 22.5% of EGDs, reaching a final value of 43.8% spared EGDs, with <5% missed HRV. Results were confirmed in the prospective external validation cohort, as the combined Baveno VI/SSM≤46 Model would have safely spared (0 HRV missed) 37.4% of EGDs, compared to 16.5% avoiding Baveno VI Criteria only. Conclusions: A non-invasive prediction model combining SSM with Baveno VI criteria may be useful to rule out HRV and could make it possible to avoid a significantly larger number of unnecessary EGDs compared to Baveno VI criteria only. Lay summary: Spleen stiffness measurement (SSM) assessed by TE, the most widely used electrographic technique, is a non-invasive technique that can help the physician to better stratify the degree of portal hypertension and the risk of oesophageal varices in patients with cACLD. Performing SSM together with LSM during the same examination is simple and fast and this sequential model can identify a greater number of patients that can safely avoid EGD, which is an invasive and expensive examination.

Sound Conclusions: How Splenic Elastography May Decrease the Need for Endoscopic Variceal Surveillance

“…In this issue of Digestive Diseases and Sciences, Karagiannakis and colleagues [4] report for the first time how SSM measured using ultrasonic two-dimensional shear wave elastography (2D-SWE) improves the ability of the Baveno VI criteria to risk-stratify cirrhotic patients for the presence of VNT, safely reducing the number of unnecessary EGDs. The authors not only confirmed our findings [3] but also showed that the measurement of SSM alone can reduce, in a cohort of cirrhotic patients, the number of unnecessary EGDs performed. Identifying new specific SSM cutoffs for 2D-SWE, they were able to spare more than 40% of EGDs in a cirrhotic cohort of 71 patients, achieving a missed VNT rate < 5%, an arbitrary threshold included in the Baveno recommendations [1].…”

“…For the first time last year, the authors combined the measurement of spleen stiffness (SSM), as assessed by TE, with the Baveno VI criteria in a diagnostic algorithm aiming to improve its performance. The algorithm was tested in a cohort of > 500 patients with advanced chronic liver disease (ACLD), demonstrating that is possible to correctly identify VNT while decreasing the number of EGDs needed to identify VNT [3].…”

How to clarify the Baveno VI criteria for ruling out varices needing treatment by noninvasive tests

“…Thus, the papers aiming to validate these criteria have used three different methods to calculate missed VNT. In all of them, the numerator was the number of missed VNT, but the denominator was either: the number of spared endoscopies, as done by Bae et al in a recent issue of this journal; the number of VNT, as we did recently also in this journal and elsewhere; or the whole patient population, as done by Augustin et al Therefore, our aim with the present work was to perform a literature review and analyse the calculation methods to clarify their diagnostic meaning.…”

Assessing spleen stiffness by point shear‐wave elastography: Is it feasible and reproducible in patients with chronic liver disease? Is it useful to predict portal hypertension?

“…Thus, the spleen stiffness (SS) measurement is potentially an alternative test to assess the presence and severity of PH in a non‐invasive way. TE is currently the most commonly used technique to assess SS, but measuring SS by ARFI methods and pSWE too has been evaluated for predicting the presence and degree of PH, and has given promising data, whereas the role of these techniques in detecting any presence of OVs is still sub‐optimal …”

“…8,9 Thus, the spleen stiffness (SS) measurement is potentially an alternative test to assess the presence and severity of PH [10][11][12][13][14][15][16] in a non-invasive way. TE is currently the most commonly used technique to assess SS, 14,17,18 but measuring SS by ARFI methods and pSWE too has been evaluated for predicting the presence and degree of PH, [18][19][20] and has given promising data, whereas the role of these techniques in detecting any presence of OVs is still sub-optimal. [21][22][23] We performed a prospective single-centre cohort study in order to investigate the feasibility and reproducibility of the SS measurement by using pSWE in a cohort of consecutive patients with CLDs of different aetiology who underwent liver biopsy.…”