Application of Noninvasive Tools to Decide the Need for Beta-Blockers for Variceal Bleeding Prophylaxis in Compensated Advanced Liver Disease: A Decision Curve Analysis

Samagra Agarwal; Sanchit Sharma; Ankur Jindal; Sushrut Singh; Rakesh Jagdish; Deepak Gunjan; Shiv K Sarin; Anoop Saraya

doi:10.1016/j.jceh.2021.09.016

Application of Noninvasive Tools to Decide the Need for Beta-Blockers for Variceal Bleeding Prophylaxis in Compensated Advanced Liver Disease: A Decision Curve Analysis

J Clin Exp Hepatol. 2022 May-Jun;12(3):917-926. doi: 10.1016/j.jceh.2021.09.016. Epub 2021 Sep 25.

Authors

Samagra Agarwal¹, Sanchit Sharma¹, Ankur Jindal², Sushrut Singh², Rakesh Jagdish², Deepak Gunjan¹, Shiv K Sarin², Anoop Saraya¹

Affiliations

¹ Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110026, India.
² Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.

Abstract

Background and aims: Noninvasive tools (NITs) reliably categorise patients with compensated advanced chronic liver disease (cACLD) into high-risk and low-risk group for harbouring varices needing treatment. Here, we assess the ability of these NITs to predict the need for nonselective beta-blockers at baseline based on risk of variceal bleeding (VB) on follow-up.

Methods: This was a retrospective multicentre analysis of patients with cACLD categorised at baseline into different risk groups by NITs (Baveno-VI, expanded Baveno-VI, platelet-albumin, platelet-model for end-stage liver disease (MELD) and anticipate study platelet criteria) and by endoscopy (high risk vs low risk/no varices). VB event rates on follow-up were estimated in different risk strata. Decision curve analysis (DCA) was used to estimate the benefit of administering nonselective beta-blockers (NSBB) using NITs over endoscopic classification at different threshold probabilities of VB event rates and estimating the number needed to treat (NNT) to identify one additional bleeder over endoscopy.

Results: A total of 1284 patients (mean age: 44.7 ± 13.5 years, 72.4% males) of hepatitis B (29.2%), nonalcoholic fatty liver disease (24.9%), hepatitis C (20.1%), and alcohol (17.5%)-related cACLD were included with 323 (25.2%) having high-risk varices. Ninety-eight (7.6%) patients developed VB over a median follow-up of 20 (9-35) months. The 1-year and 3-year rate of VB with all NITs was 5.7-7.4% and 13.2-16.4% among high-risk and 0-2.3% and 0-5% among low-risk subgroups, respectively (P < 0.001) in both viral and nonviral aetiologies. Among patients classified as low risk on Baveno-VI criteria, none developed VB on follow-up. At thresholds of <3% event rate of VB, Baveno-VI (NNT-176), platelet-albumin (NNT-576) and anticipate platelet (NNT-233) criteria were superior, whereas endoscopic stratification was superior above this event rate on DCA.

Conclusions: The use of both elastography and blood-based NITs at baseline can accurately identify the need for NSBB for VB prophylaxis in patients of cACLD on follow-up.

Keywords: Baveno-VI; DCA, Decision curve analysis; EBL, Endoscopic band ligation; HCC, Hepatocellular carcinoma; HE, Hepatic encephalopathy; HRVs, High risk varices; LRVs, Low risk varices; LSM, Liver stiffness measurement; NITs, Non-invasive tools; NNT, Number needed to treat; NSBB, Non-selective beta blockers; PVT, Portal venous thrombosis; VB, Variceal bleeding; VNT, Varices needing treatment; cACLD, Compensated advanced chronic liver disease; decision thresholds; noninvasive tools; variceal bleeding; varices needing treatment.