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The Portal Hypertension Decompensation Score: A Validated Predictive Model of Liver Decompensation Related to Portal
Angus W Jeffrey1,2, Avik Majumdar3,4, Gary Jeffrey1,2
1Medical School, The University of Western Australia, Perth.
Insights
A new Portal Hypertension Decompensation Score (PDS) accurately predicts decompensation in compensated advanced chronic liver disease (cACLD) patients. This non-invasive score helps identify high-risk individuals needing further evaluation without liver stiffness measurement.
Area of Science:
- Hepatology
- Clinical Prediction Models
- Non-invasive Diagnostics
Background:
- Compensated advanced chronic liver disease (cACLD) requires non-invasive risk stratification for prognostication and management.
- Current methods may involve invasive procedures like liver stiffness measurement (LSM).
Purpose of the Study:
- To develop and validate a novel, non-invasive score to predict decompensation in cACLD patients.
- To create a tool that avoids the need for LSM in risk assessment.
Main Methods:
- Development of a predictive score using serum markers in a large training cohort (n=967) with competing risk analysis.
- Internal validation (n=417) and external validation (n=315) of the score.
- Comparison with existing scores in external validation cohorts.
Main Results:
- The Portal Hypertension Decompensation Score (PDS) was developed using bilirubin, ALT, ALP, albumin, and platelets.
- The PDS demonstrated good calibration and discrimination, with high accuracy (AUC 0.74-0.83) for predicting decompensation at 2 and 5 years.
- Low PDS scores showed high sensitivity (74-84%) for predicting no decompensation (NPV 91-95%), while high scores were specific (87-93%) for future decompensation (PPV 33-58%).
Conclusions:
- The PDS is an accurate and validated predictor of decompensation in cACLD.
- It effectively differentiates low-risk from high-risk patients, guiding further management decisions.
- The PDS offers a non-invasive alternative to LSM for risk stratification in cACLD.
Introduction:
There is a need for noninvasive risk stratification in people with compensated advanced chronic liver disease (cACLD) to prognosticate and guide management. We aimed to develop a score that predicts decompensation in people with cACLD without the need for a liver stiffness measurement.
Methods:
A multicenter state-wide cohort of patients with cACLD between 2004 and 2015 were followed until decompensation. A predictive score using serum markers was developed in a training cohort (n = 967) using competing risk analysis and internally validated (n = 417). Further external validation and comparison with other scores was undertaken in 315 patients between 2017 and 2024.
Results:
Decompensation occurred in 172 (17.8%), 64 (15.3%), and 51 patients (16.2%) in the training and 2 validation cohorts ( P = 0.60) after median follow-up of 3.2, 3.4, and 1.9 years, respectively. Bilirubin, alanine aminotransferase, alkaline phosphatase, albumin, and platelets predicted decompensation and combined into a final model-the Portal Hypertension Decompensation Score (PDS). The PDS was well calibrated with good discrimination for predicting decompensation. In the 2 validation cohorts, accuracy (time-dependent area under the curve) of the PDS for predicting decompensation was high at 2 years (0.75 and 0.82) and 5 years (0.74 and 0.83). A low score (< -3.348) had a sensitivity of 74%-84% in prediction of no decompensation with a negative predictive value of 91%-95%, whereas a high score (> -2.828) was 87%-93% specific for future decompensation with a positive predictive value of 33%-58%.
Discussion:
The PDS is an accurate predictor of decompensation in cACLD. It discriminates patients who are low risk from those who are high risk and who may benefit from further evaluation or treatment, without requiring the use of liver stiffness measurement.
