Prediction of Esophageal Varices by Liver Stiffness and Platelets in Persons With Human Immunodeficiency Virus Infection and Compensated Advanced Chronic Liver Disease

Abstract

Background People living with human immunodeficiency virus (PLWH) are at increased risk of cirrhosis and esophageal varices. Baveno VI criteria, based on liver stiffness measurement (LSM) and platelet count, have been proposed to avoid unnecessary esophagogastroduodenoscopy (EGD) screening for esophageal varices needing treatment (EVNT). This approach has not been validated in PLWH. Methods PLWH from 8 prospective cohorts were included if they fulfilled the following criteria: (1) compensated advanced chronic liver disease (LSM >10 kPa); (2) availability of EGD within 6 months of reliable LSM. Baveno VI (LSM <20 kPa and platelets >150 000/μL), expanded Baveno VI (LSM <25 kPa and platelets >110 000/μL), and Estudio de las Hepatitis Víricas (HEPAVIR) criteria (LSM <21 kPa) were applied to identify patients not requiring EGD screening. Criteria optimization was based on the percentage of EGDs spared, while keeping the risk of missing EVNT <5%. Results Five hundred seven PLWH were divided into a training (n = 318) and a validation set (n = 189). EVNT were found in 7.5%. In the training set, Baveno VI, expanded Baveno VI, and HEPAVIR criteria spared 10.1%, 25.5%, and 28% of EGDs, while missing 0%, 1.2%, and 2.2% of EVNT, respectively. The best thresholds to rule out EVNT were platelets >110 000/μL and LSM <30 kPa (HIV cirrhosis criteria), with 34.6% of EGDs spared and 0% EVNT missed. In the validation set, HEPAVIR and HIV cirrhosis criteria spared 54% and 48.7% of EGDs, while missing 4.9% and 2.2% EVNT, respectively. Conclusions Baveno VI criteria can be extended to HEPAVIR and HIV cirrhosis criteria while sparing a significant number of EGDs, thus improving resource utilization for PLWH with compensated advanced chronic liver disease.

EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis – 2021 update

“…17 This led to an expert recommendation to use these non-invasive criteria (defined "Baveno VI" criteria) to spare endoscopy in patients with cACLD. Since the publication of the criteria, several studies and 2 meta-analyses 280,281 confirmed the validity of this approach in all the major aetiologies of liver disease including HIV-HCV coinfection 282 and patients who achieved SVR after treatment of HCV, 283 showing rates of missed high-risk varices ranging from 0 to 2%; hence, these criteria can be considered validated. Since the Baveno VI criteria are conservative and enable no more than 10-25% of endoscopies to be spared, studies looking for expanded criteria have been published.…”

Refining the Baveno VI elastography criteria for the definition of compensated advanced chronic liver disease

“…The use of dual cut-offs may overcome both these limitations and introduce uniformity in the diagnosis of chronic liver disease. The Baveno VI criteria on screening for varices needing treatment including LS values <20 kPa and platelet count >150×10 9 cells/L(1) have already been validated in several small to medium independent J o u r n a l P r e -p r o o f cohorts (7)(8)(9)(10) and in a recent large meta-analysis of 30 studies (11). However, the criteria to rule in and out cACLD have not been externally validated in a real-world population until now.…”

Splenomegaly is a marker of advanced chronic liver disease and portal hypertension in HIV infection

“…Certain antiretroviral therapies, particularly didanosine, have been associated with non-cirrhotic portal hypertension [6]. Once ACLD and portal hypertension develop, PWH are at risk of variceal bleeding, ascites, hepatic encephalopathy and early death [4,7,8]. A finding of splenomegaly on ultrasound, a readily available tool in the practice of HIV medicine, does not suffice to refer for portal pressure measurements or endoscopy.…”

“…A finding of splenomegaly on ultrasound, a readily available tool in the practice of HIV medicine, does not suffice to refer for portal pressure measurements or endoscopy. Liver stiffness measurement (LSM) by transient elastography (TE) has allowed the noninvasive assessment of ACLD and identification of PWH with portal hypertension at risk for liver-related events [4,7,8]. However, TE is not a test routinely performed in PWH in clinical practice.…”