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IVC unnecessary in estimating transplant-free survival in patients with cirrhosis

Researchers found hepatic venous pressure gradient to be best measured as a gradient between wedged hepatic vein pressure and free hepatic vein pressure for determining orthotopic liver transplant-free survival among patients with cirrhosis. Measurements using the inferior vena cava were less accurate in their estimation, they found.

Researchers retrospectively analyzed data of 1,282 patients with cirrhosis followed at the Liver Unit in Hospital Clinic de Barcelona, Spain, from January 2006 to December 2012. Their aim was to establish which gradient, wedged hepatic vein pressure (WHVP)-free hepatic vein pressure (FHVP) or WHVP- inferior vena cava (IVC), better correlates with orthotopic liver transplantation (OLT)-free survival.

All clinical and biochemical data of each patient, along with hepatic venous pressure gradient (HVPG) measurements, were collected. For the final analysis, 380 patients were included and followed for a mean of 43 months.

Of the 380 patients, 40% either underwent OLT ( n = 40) or died over the course of the study period (n = 111). Three patients were lost to follow-up. The overall OLT-free survival rate was 86.5% at 1 year, 70% at 3 years and 59.5% at 5 years.

Overall, HVPG-free was lower compared with HVPG-IVC among the patients (16 ± 5 mm Hg vs. 17 ± 5.5 mm Hg; P < .001). Seventy-five percent of patients did not show FHVP-IVC discrepancy (within ± 2 mm Hg; n = 285) compared with 25% of patients who showed a discrepancy of less than – 2 mm Hg or greater than 2 mm Hg (n = 95).

Multivariate analysis showed ascites to be the only independent factor for predicting a discrepancy between FHVP and IVC (HR = 3.49; 95% CI, 2.15-5.66).

The HVPG-free area under the receiver operating curve was 0.68 for predicting OLT-free survival (95% CI, 0.62-0.73). In patients without discrepancy, 16 mm Hg was the best cutoff value for predicting survival, independent of being calculated as HVPG-free or HVPG-IVC, according to the research. In patients with discrepancy, 16 mm Hg remained the best cutoff value for HVPG-free, but not for HVPG-IVC. Of these patients, 26% were misclassified regarding their risk for OLT or death (n = 25).

The OLT-free survival rates were 96% at 1 year, 85% at 3 years and 75.5% at 5 years in patients with HVPG-free less than 16 mm HG compared with 78% at 1 year, 57% at 3 years and 45.5% at 5 years for patients with HVPG-free greater than 16 mm (P < .001). 

“The results of the present study, together with [other] considerations, strongly support not to use IVC pressure to calculate HVPG in any circumstance,” the researchers wrote. “The results of our study suggest that in patients with cirrhosis, HVPG should be calculated as the difference between WHVP and FHVP, even in the presence of differences between IVC and FHV pressures over 2 mm Hg.” – by Melinda Stevens

Disclosures: Silva-Junior reports no relevant financial disclosures. Please see the study for a full list of all other authors’ relevant financial disclosures.