Expanding the Baveno VI criteria for the screening of varices in patients with compensated advanced chronic liver disease.

Patients with compensated advanced chronic liver disease (cACLD) can safely avoid screening endoscopy with a platelet count >150 × 109 cells/L and a liver stiffness measurement (LSM) <20 kPa (Baveno VI criteria). However, the total number of avoided endoscopies using this rule is relatively low. We aimed at expanding the Baveno VI criteria and validating them in additional cohorts. Patients from the Anticipate cohort (499 patients with cACLD of different etiologies) were used to study the performance of different thresholds of platelets and LSM for the identification of patients at very low risk (<5%) of having varices needing treatment (VNT). The new criteria (Expanded-Baveno VI) were validated in two additional cohorts from London (309 patients) and Barcelona (117 patients). The performance of the new criteria by etiology of cACLD was also assessed. The best new expanded classification rule was platelet count >110 × 109 cells/L and LSM <25 kPa. This was validated in the two additional cohorts. Overall, the Expanded-Baveno VI criteria would potentially spare 367 (40%) endoscopies (21% with Baveno VI criteria) with a risk of missing VNT of 1.6% (95% confidence interval, 0.7%-3.5%) in patients within the criteria and 0.6% (95% confidence interval, 0.3%-1.4%) in the overall population of 925 patients evaluated. The Expanded-Baveno VI criteria performed well in patients with cACLD with hepatitis C virus and alcoholic and nonalcoholic steatohepatitis. The new Expanded-Baveno VI criteria spare more endoscopies than the original criteria with a minimal risk of missing VNT in most of the main etiologies of cACLD. (Hepatology 2017;66:1980-1988).

Augustin S ，Pons M ，Maurice JB ，Bureau C ，Stefanescu H ，Ney M ，Blasco H ，Procopet B ，Tsochatzis E ，Westbrook RH ，Bosch J ，Berzigotti A ，Abraldes JG ，Genescà J ... -  《-》

Evaluation of three "beyond Baveno VI" criteria to safely spare endoscopies in compensated advanced chronic liver disease.

Liver stiffness measurement (LSM) <20 kPa and platelet count >150,000/mm3 exclude varices needing treatment (VNT) in viral compensated advanced chronic liver disease (cACLD), saving-up to 20-25% endoscopies (Baveno VI criteria). Refinements of such criteria to further reduce endoscopies and an approach without LSM (Platelet 150/MELD 6) were later proposed. To assess LSM 25/platelet 125, LSM 25/platelet 110 (Expanded-Baveno VI) and Platelet 150/MELD 6 accuracy versus Baveno VI criteria, and the impact of platelet count variability on criteria accuracy in all-etiologies cACLD. cACLD patients undergoing screening endoscopy with laboratory data within 6 months and LSM within one year. Of 442 patients, 31% had varices (7% with VNT). Baveno VI criteria had 100% sensitivity (Se) and negative predictive value (NPV) and spared 19.5% endoscopies. "LSM 25/platelet 125" and "Expanded-Baveno VI" criteria maintained such accuracy, sparing 15% and 24% more endoscopies, respectively (p < 0.001). Platelet 150/MELD 6 was less accurate, misclassifying 10% VNT. Platelet count variability exceeded 8% and one VNT patient was misclassified with both "Expanded-Baveno VI" and "LSM 25/platelet 125" criteria considering the previous platelet count. Both "Expanded-Baveno VI" and "LSM 25/platelet 125" criteria are accurate in cACLD, but the former are more advantageous. Platelet 150/MELD 6 proved inadequate.

Tosetti G ，Primignani M ，La Mura V ，D'Ambrosio R ，Degasperi E ，Mezzina N ，Viganò M ，Rumi M ，Fracanzani AL ，Lombardi R ，Fargion S ，Fraquelli M ，Aghemo A ，Lampertico P ... -  《-》

Non-invasive prediction of esophageal varices by stiffness and platelet in non-alcoholic fatty liver disease cirrhosis.

Baveno VI and expanded Baveno VI criteria can avoid the need for esophagogastroduodenoscopy (EGD) to screen for varices needing treatment (VNT) in a substantial proportion of compensated patients with viral and/or alcoholic cirrhosis. This multicenter, cross-sectional study aims to validate these criteria in patients with compensated cirrhosis due to non-alcoholic fatty liver disease (NAFLD), accounting for possible differences in liver stiffness measurement (LSM) values between M and XL probes. We assessed 790 patients with NAFLD-related compensated cirrhosis who had EGD within six months of a reliable LSM, measured by FibroScan® using M and/or XL probe. Baveno VI and expanded Baveno VI criteria were tested. The main variable used to optimize criteria was the percentage of endoscopies spared, keeping the risk of missing large VNT below a 5% threshold. LSM was measured by both M and XL probes (training set) in 314 patients, while only M or XL probe (validation sets) were used to measure LSM in 338 and 138 patients, respectively. In the training set, use of Baveno VI and expanded Baveno VI criteria reduced the number of EGD by 33.3% and by 58%, with 0.9% and 3.8% of large esophageal varices missed, respectively. The best thresholds to rule-out VNT were identified as platelet count >110,000/mm3 and LSM <30 kPa for M probe, and platelet count >110,000/mm3 and LSM <25 kPa for XL probe (NAFLD cirrhosis criteria). Thus, usage of NAFLD cirrhosis criteria would have led to an absolute reduction in the number of EGD screened patients of 34.7% and 10.5% with respect to Baveno VI and expanded Baveno VI criteria, respectively. The new NAFLD cirrhosis criteria, established for the FibroScan probe, can reduce the use of EGD for screening of VNT in NAFLD cirrhosis by more than half, with a chance of missing VNT below 5%. In non-alcoholic fatty liver disease-related compensated cirrhosis, the expanded Baveno VI criteria work better than the Baveno VI criteria for ruling out the presence of varices needing treatment, sparing unnecessary and invasive screening procedures. New diagnostic criteria for this patient group, based on liver stiffness measurement and platelet count, and optimized for the specific FibroScan® probe used, work better than both Baveno VI and expanded Baveno VI criteria. The accuracy of all non-invasive scoring criteria was lower in non-obese patients.

Petta S ，Sebastiani G ，Bugianesi E ，Viganò M ，Wong VW ，Berzigotti A ，Fracanzani AL ，Anstee QM ，Marra F ，Barbara M ，Calvaruso V ，Cammà C ，Di Marco V ，Craxì A ，de Ledinghen V ... -  《-》

Validation of original, expanded Baveno VI, and stepwise & platelet-MELD criteria to rule out varices needing treatment in compensated cirrhosis from various etiologies.

The Baveno VI criteria to rule out varices needing treatment (VNT) was introduced in 2015. Soon after, the expanded Baveno VI and stepwise platelet-MELD criteria were proposed to be equal/more accurate in ruling out VNT; however, neither has been widely validated. We aimed to validate all 3 criteria in compensated cirrhosis from assorted causes. We conducted a cross-sectional study including all adult compensated cirrhotic patients who underwent endoscopic surveillance at our center from 2014 to 2018 and had transient elastography (TE), and laboratory data for criteria calculation within 6 months of endoscopies. Exclusion criteria were previous decompensation, unreliable/invalid TE results, and liver cancer. The diagnostic performances of all criteria were evaluated. A total of 128 patients were included. The major cirrhosis etiologies were hepatitis C and B (37.5% and 32.8%, respectively). VNT was observed in 7.8%. All criteria yielded high negative predictive values (NPVs)>95%, missed VNT was observed in 2%, 2.7%, and 2.8% in the original, expanded Baveno VI, and platelet-MELD criteria, respectively. The expanded Baveno VI and the platelet-MELD criteria yielded significantly better specificities and could spare more endoscopies than the original Baveno VI criteria. All 3 criteria showed satisfactorily high NPVs in ruling out VNT in compensated cirrhosis from various causes. The expanded Baveno VI and the platelet-MELD criteria could spare more endoscopies than the original Baveno VI criteria. From a public health standpoint, the platelet-MELD criteria might be useful in a resource-limited setting where TE is not widely available.

Nawalerspanya S ，Sripongpun P ，Chamroonkul N ，Kongkamol C ，Piratvisuth T ... -  《Annals of Hepatology》

Validation of the Baveno VI and the expanded Baveno VI criteria to identify patients who could avoid screening endoscopy.

The Baveno VI and the expanded Baveno VI criteria were proposed to help identify patients who could safely avoid screening endoscopies for clinically significant varices among patients with compensated advanced chronic liver disease. However, these criteria require cross-validation, especially in Asian populations where the aetiologies of liver disease are different. A total of 1035 patients, including 282 patients with compensated advanced chronic liver disease of different aetiology, were analysed. The compensated advanced chronic liver disease was defined by liver stiffness measurement ≥10 kPa, Child-Pugh class A and absence of prior liver decompensation. High-risk varix was defined as a grade ≥2 oesophageal varix, any varix with a red colour sign or gastric varices. High-risk varixs were present in 19.5% (55/282 patients) with compensated advanced chronic liver disease. Among compensated advanced chronic liver disease patients, the expanded criteria could spare more endoscopies (51.7%) than the original criteria (27.6%). However, the expanded criteria missed a greater number of high-risk varixs (6.8%) than the original criteria (3.8%). When stratified according to liver disease aetiology, the negative predictive values for the original Baveno VI criteria were 0.92, 1.00, 1.00 and 1.00, and the negative predictive values for the expanded criteria were 0.92, 0.96, 0.92 and 0.93 for hepatitis B, hepatitis C, alcohol and non-alcoholic fatty liver disease, respectively. High-risk varixs were rarely detected in patients without compensated advanced chronic liver disease (1.1%, 8/753 patients). In this Asian cohort study, the Baveno VI criteria were able to identify who could safely avoid screening endoscopy. The expanded Baveno VI criteria could spare more endoscopies but also could increase the odds of missing a high-risk varix.

Bae J ，Sinn DH ，Kang W ，Gwak GY ，Choi MS ，Paik YH ，Lee JH ，Koh KC ，Paik SW ... -  《-》