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The clinical use of HVPG measurements in chronic liver disease

Abstract

Portal hypertension is a severe, almost unavoidable complication of chronic liver diseases and is responsible for the main clinical consequences of cirrhosis. Measurement of the hepatic venous pressure gradient (HVPG) is currently the best available method to evaluate the presence and severity of portal hypertension. Clinically significant portal hypertension is defined as an increase in HVPG to ≥10 mmHg; above this threshold, the complications of portal hypertension might begin to appear. Measurement of HVPG is increasingly used in clinical hepatology, and numerous studies have demonstrated that the parameter is a robust surrogate marker for hard clinical end points. The main clinical applications for HVPG include diagnosis, risk stratification, identification of patients with hepatocellular carcinoma who are candidates for liver resection, monitoring of the efficacy of medical treatment, and assessment of progression of portal hypertension. Patients who experience a reduction in HVPG of ≥20% or to <12 mmHg in response to drug therapy are defined as 'responders'. Responders have a markedly decreased risk of bleeding (or rebleeding), ascites, and spontaneous bacterial peritonitis, which results in improved survival.

Key Points

  • Measurement of the hepatic venous pressure gradient (HVPG) is the gold standard technique for evaluation of portal hypertension in liver disease

  • In patients with cirrhosis, HVPG measurement provides independent prognostic information on survival and the risk of decompensation

  • The HVPG response to pharmacological therapy enables the identification of patients with portal hypertension who are most likely to benefit from treatment

  • Measurement of HVPG helps to assess the risk of liver failure and death after liver resection in patients with compensated chronic liver disease or hepatocarcinoma

  • No noninvasive alternatives to HVPG measurement are currently available

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Figure 1: Measuring the portal pressure in the normal and cirrhotic liver.
Figure 2: Venous access sites for hepatic vein catheterization.
Figure 3: Measurement of wedged hepatic venous pressure (WHVP).

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Acknowledgements

This work is supported in part by grants from Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación (FIS 06/0623, FIS 08/0193 and SAF 07/61298). CIBERehd is funded by Instituto de Salud Carlos III.

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Correspondence to Jaime Bosch.

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Bosch, J., Abraldes, J., Berzigotti, A. et al. The clinical use of HVPG measurements in chronic liver disease. Nat Rev Gastroenterol Hepatol 6, 573–582 (2009). https://doi.org/10.1038/nrgastro.2009.149

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