5 th AISF Post-Meeting Course Diagnostic and Therapeutic Invasive Procedures in Hepatology Rome, February 25 th Diagnostic Procedures Measurement of Hepatic venous pressure in management of cirrhosis Clinician s opinion Wilma Debernardi Venon Az. Osp. Univ. San Giovanni Battista di Torino
Wilma Debernardi Venon Azienda Ospedaliero Universitaria S. Giovanni Battista, Torino La sottoscritta dichiara di non aver avuto negli ultimi dodici mesi conflitto d interesse in relazione a questa presentazione e che la presentazione non contiene discussione di farmaci in studio o ad uso off-label
Portal hypertension and hepatic venous pressure gradient N 400 350 300 250 200 150 100 50 0 1972-82 1982-92 1992-2002 2002-12 Published articles pathophysiology and treatment of portal hypertension syndrome
Hepatic venous pressure gradient and clinical practice TIPSS Gastroenterology 2003 Risk of variceal bleeding Response to NSBB and rebleeding Hepatology 1985 Lancet 1995
Portal hypertension in chronic liver disease HCC HVPG (mmhg) 12 10 6 0
Should measurement of HVPG be used in clinical practice? If Yes,..HVPG is the goal standard technique to diagnosis of portal hypertension and its severity Safe Accurate Reproducible Well accepted Specific training Cost-effective Invasive Hepatology 2004 Hepatology 2006 J Clin Gastroent 2007 Gastroenterol Clin Bio 2008
Should measurement of HVPG be used in clinical practice?. Non invasive methods.. INR, albumin and ALT predicts CSPH but not esophageal varices CSPH Varices Platelet count /spleen diameter: 100% NPV for detection EV Am J Gastroenterol 2008 Gut 2003
Should measurement of HVPG be used in clinical practice? FIBROSCAN is not accurate to detect CSPH in cirrhosis Any size EV: cut off 21.1 kpa CSPH: cut off 13.6 kpa Hepatology 2007 J Hepatology 2012
Should measurement of HVPG be used in clinical practice? US Doppler Spleen length >13 cm Portal vein diameter >13 mm Portal vein velocity < 20 cm /sec Intraparenchymal renal artery impedance Presence of abdominal collaterals.. can be useful to select the patients requiring invasive evaluation but not for monitoring the response to therapy or for preventing the complications Am J Gastroenterol 2008 J Gastroenterol 2011
Hepatic venous portal gradient in clinical practice: When? Differential diagnosis of portal hypertension Ischemic cardiomyopathy Valvular heart disease Restrictive lung disease Cardiac surgery Acute myocardical infarction BM transplant Leukemia Myelofibrosis Myelodisplasia Lymphoma Polycytemia Budd Chiari Acute and chronic renal failure Dialysis Amyloidosis Renal transplantation Abnormal liver function test Ascites Esophageal varices W J Gastroenterol 2008
Differential diagnosis of portal hypertension Hemodynamic pattern Posthepatic: Intrahepatic : postsinusoidal sinusoidal Intrahepatic presinusoidal Prehepatic WHVP FHVP= HVPG N WHVP FHVP N= HVPG WHVP N FHVP N= HVPG N
Differential diagnosis of portal hypertension Vascular pattern Cirrhosis CHF CO 2 venography NCPH Cirrhosis Right cardiac catheterization Transjugular hepatic biopsy Gut 2000 DLD 2011
Hepatic venous portal gradient in clinical practice: When? Prediction of Clinical Events and Survival Baseline HVPG 10 mmhg predicts the development of varices Prediction of decompensation HVPG (HR 1.16) > MELD (HR1.12) single HVPG > change HVPG J Hepatology 2006 N Eng J Med 2005 Scand J Gastr 2012
Hepatic venous portal gradient in clinical practice: When? Prediction of Clinical Events and Survival HVPG and outcome in compensated cirrhosis Prognosis after acute decompensation Prediction of first decompensation 1 survival 0,8 0,6 0,4 0,2 0 >16 mmhg >16 mmhg 0 12 24 36 48 60 months 16 mmhg HVPG < 10 mmhg 90% free clinical decompensation at 4 yrs Gastroenterology 1992 Gastroenterology 2007 J Gastroenterology 2011 Scand J Gastroent 2012
Hepatic venous portal gradient in clinical practice: When? Prediction of Clinical Events and Survival B Blockers did not prevent varices in compensated cirrhosis Response to antiviral therapy reduces PP Effect of AT1 receptor blocker on PP % change HVPG 25 15 5-5 -15 Hepatitis C -25 Candesartan Placebo Hepatitis B Am J Gastr 2006 Hepatology 2007 J Hepatology 2007 J Hepatology 2009
Hepatic venous portal gradient in clinical practice: When? Hepatitis C recurrence after LT Diagnostic value of liver fibrosis and HVPG to predict clinical decompensation Hepatology 2006
Hepatic venous portal gradient in clinical practice: When? Prediction of Clinical Events and Survival Esophageal varices and risk of bleeding Variceal size Variceal wall tension Hepatic function No bleeding
Hepatic venous portal gradient in clinical practice: When? Prediction of Clinical Events and Survival Primary prophylaxis of variceal bleeding Responders to BB: 35-40% 50% of non responders: no bleeding Worsening HVPG response worsening hepatic function Adverse events: EBL > BB Stop BB increase risk of bleeding Hepatology 2002 Gut 2004 Hepatology 2004
HVPG measurement in primary prophylaxis is not recommended
Hepatic venous portal gradient in clinical practice: When? Prediction of Clinical Events and Survival Acute variceal bleeding % pts 60 40 < 20 mmhg > 20 mmhg 20 entro 72 h 0 Failure control rebleeding mortality bleeding MELD 18 + > 4 Blood Units < 24 h Rebleeding mortality (HR 7.4) Hepatology 2008 Gut 2008
Hepatic venous portal gradient in clinical practice: When? Prediction of Clinical Events and Survival Early TIPS reduces failure to control bleeding and mortality in patients with AVB at high risk for treatment failure NEJM 2010 Baveno 2010
HVPG measurement is recommended in selecting patients with high risk of early rebleeding
Hepatic venous portal gradient in clinical practice: When? Prediction of Clinical Events and Survival Prevention of variceal rebleeding Haemodynamic response to NSBB reduces the risk of rebleeding Combination treatment is efficacy for the prevention of rebleeding Hepatology 2003 Hepatology 2000 Baveno 2010
Hepatic venous portal gradient in clinical practice: When? Prediction of Clinical Events and Survival Prevention of variceal rebleeding Repeated HVPG Banding legation + drug therapy treatment used % alcoholic disease time of follow up % Child C patients timing HVPG overlap 20% and < 12mmHg 5 TC RC: recruitement time adverse events in drug treated efficacy EVL alone Combined therapy is effective treatment for the prevention of rebleeding Primary prophylaxis Secondary prophylaxis Acute response to propranolol to identify non responders?
Repeated HVPG measurement in not recommended in identifying NSBB non-responders
Hepatic venous portal gradient in clinical practice: When? HVPG and surgical resection of hepatocellular carcinoma HVPG predicts the risk of hepatic decompensation and survival in Child A cirrhotic patients Gastroenterology 1996 Hepatology 1999
HVPG should be used to select Child A cirrhotic patients with HCC for hepatic resection