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Noninvasive Prediction of Decompensation in Compensated Advanced Chronic Liver Disease and a Liver Stiffness From 15
Angus W Jeffrey1, Avik Majumdar2, Gary Jeffrey3
1Department of Medicine, The University of Western Australia, Perth, Western Australia, Australia; Department of Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Victorian Liver Transplant Unit, The Austin Hospital, Melbourne, Victoria, Australia.
Insights
The Portal Hypertension Decompensation Score (PDS) accurately predicts decompensation in compensated advanced chronic liver disease (cACLD) patients within the Baveno VII indeterminate zone. This score helps identify patients at high risk, improving clinical management and reclassifying many as low-risk.
Area of Science:
- Hepatology
- Gastroenterology
- Clinical Diagnostics
Background:
- Baveno VII criteria identify significant portal hypertension in compensated advanced chronic liver disease (cACLD).
- A substantial proportion of cACLD patients fall into an 'indeterminate zone' (LSM 15-25 kPa), requiring further risk assessment.
- Accurate prediction of decompensation in this indeterminate group is crucial for timely intervention.
Purpose of the Study:
- To evaluate the diagnostic accuracy of the Portal Hypertension Decompensation Score (PDS) for predicting first decompensation in cACLD patients with LSM between 15-25 kPa.
- To compare the PDS performance against other existing risk prediction models.
Main Methods:
- A multi-center Australian retrospective cohort study of 408 adults with cACLD in the indeterminate zone.
- The PDS was assessed for discrimination, calibration, and net clinical benefit.
- Comparison with ANTICIPATE-LRE, CHESS-ALARM, and ALBI scores for predicting decompensation events (variceal bleeding, ascites, hepatic encephalopathy).
Main Results:
- The PDS demonstrated excellent accuracy in predicting decompensation, with 3-year AUC of 0.96 and sensitivity, specificity, and negative predictive value exceeding 90%.
- The 3-year cumulative incidence of decompensation was 33% in the high-risk PDS group versus 1% in the low-risk group.
- PDS showed superior accuracy and net clinical benefit compared to other models, correctly reclassifying 64% of patients to a low-risk category.
Conclusions:
- The Portal Hypertension Decompensation Score (PDS) is a highly accurate tool for predicting decompensation in cACLD patients within the Baveno VII indeterminate zone (LSM 15-25 kPa).
- The PDS effectively identifies 74% of patients in the indeterminate zone, enabling better risk stratification and potentially avoiding unnecessary interventions.
- The score's ability to reclassify a significant proportion of patients as low-risk supports its utility in clinical decision-making for managing cACLD.
Background & Aims:
Baveno VII provides noninvasive criteria to rule in or out clinically significant portal hypertension and patients at high risk of decompensation in compensated advanced chronic liver disease. Around 50% of patients are unclassifiable, termed "the indeterminate zone." We aimed to evaluate the diagnostic accuracy of the Portal Hypertension Decompensation Score for prediction of first decompensation in patients with a liver stiffness measurement between 15 and 25 kPa.
Methods:
This study was a multicenter Australian retrospective cohort of adults with compensated advanced chronic liver disease in the indeterminate zone. The Portal Hypertension Decompensation Score was assessed for discrimination, calibration, and net clinical benefit with comparison to other existing models in prediction of decompensation (variceal bleeding, ascites, hepatic encephalopathy).
Results:
A total of 408 patients were followed for a median of 2.5 years with 21 (5%) experiencing decompensation. Baseline Portal Hypertension Decompensation Score had excellent accuracy predicting decompensation, with a time-dependent area under the curve at 1 year of 0.91 (95% confidence interval, 0.83-1.0), and 0.96 (95% confidence interval, 0.91-1.0) at 3 years with a sensitivity, specificity, and negative predictive value over 90% using previously validated cutoffs. The 3-year cumulative incidence of decompensation in the high-risk group was 33% and in the low-risk group was 1%. The Portal Hypertension Decompensation Score showed good calibration, was more accurate (P < .005), and displayed superior net clinical benefit on decision curve analysis than ANTICIPATE-LRE, CHESS-ALARM, and ALBI.
Conclusions:
The Portal Hypertension Decompensation Score is accurate in predicting decompensation in compensated advanced chronic liver disease falling within the Baveno VII indeterminate zone with a liver stiffness measurement between 15 and 25 kPa and can correctly identify 74% of patients in the indeterminate zone, with 64% of patients reclassified as low risk.
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