Benedikt Simbrunner

Background and Aims: The applicability of non‐invasive tests (NITs) for clinically significant portal hypertension (CSPH) in patients with hepatocellular carcinoma (HCC) is controversial. We performed a head‐to‐head comparison of various NITs for CSPH and evaluated rule‐in/‐out criteria. Methods: We conducted a retrospective study including 283 patients with HCC undergoing hepatic venous pressure gradient (HVPG) measurement at the Vienna Hepatic Haemodynamic Lab with available, same‐day data on NITs (i.e., liver stiffness measurement [LSM], platelet count [PLT], von Willebrand factor antigen [VWF:Ag], and the ratio of VWF:Ag and PLT [VITRO]). For the subsequent analysis, we focused on patients with compensated advanced chronic liver disease (cACLD). Results: Among 164 patients with cACLD, most were BCLC 0/A (50.6%) and CSPH prevalence was 46.3%, the median LSM was 20.0 kPa (IQR: 13.3–37.9), and mean VWF:Ag/VITRO was 266 ± 119%/2.30 ± 1.81. The VITRO score yielded the highest discriminative ability to detect CSPH (AUROC: 0.834), followed by ANTICIPATE ± NASH (AUROC: 0.822), PLT (AUROC: 0.803), LSM (AUROC: 0.779), and VWF:Ag (AUROC: 0.707). The application of the Baveno VII criterium (LSM ≤ 15 kPa & PLT ≥ 150G/L) and the VITRO score (≤ 1.0) individually showed an excellent performance for ruling‐out CSPH (sensitivities: ≥ 95%, NPV: 100%/87.9%). For ruling‐in CSPH by individual criteria, the VITRO score provided the highest PPV (≥ 2.5, specificity/PPV: 89.8%/83.0%), followed by the Baveno VII criteria (specificity/PPV: 81.8%/74.6%). When sequentially applying Baveno VII criteria and VITRO, the grey zone could be significantly reduced to 16% (sensitivity/NPV: 94.7%/92.2%; specificity/PPV: 73.9%/84.4%). Conclusion: The discriminative ability in patients with cACLD and HCC was comparable to patients without HCC. However, PPVs of established criteria were < 90%, which may be explained by the comparatively low prevalence of CSPH in this context.

Introduction: The liver produces angiotensinogen (AGT), the key upstream precursor of the renin-angiotensin system (RAS). We measured AGT levels in patients across distinct advanced chronic liver disease (ACLD) stages and investigated the impact of AGT levels on clinical outcomes. Methods: We included clinically stable ACLD outpatients undergoing hepatic venous pressure gradient (HVPG) measurement between May 2018 and October 2023, as well as healthy controls (HCs) recruited in the prospective Vienna Cirrhosis Study (VICIS; NCT03267615). AGT was assessed by converting it to angiotensin I (Ang I) through incubation with excess recombinant human renin. RAS parameters were measured by liquid chromatography-tandem mass spectrometry. Patients were stratified as compensated (cACLD), single decompensated (sdACLD), or further decompensated ACLD (fdACLD). Results: Overall, 60 individuals (cACLD: n=16; sdACLD: n=22; fdACLD: n=12; HC: n=10) were included. AGT levels decreased significantly compared with HC and with increasing ACLD severity (HC: 943.2 vs. cACLD: 550.4 vs. sdACLD: 476.9 vs. fdACLD: 439.8 nmol/L; p p =0.002) and Ang 1-7 (cACLD: 3.0 vs. sdACLD: 3.2 vs. fdACLD: 8.5 pmol/L; p =0.022) increased significantly with ACLD severity. AGT did not correlate with Ang II (ρ=−0.23; p =0.101), but with Ang 1-7 (ρ=0.32; p =0.022) and MELD-Na (ρ=−0.29; p =0.042). Exploratory survival analyses, limited by the small sample size, showed that lower AGT was associated with all-cause mortality (adjusted for age and MELD-Na: asHR: 1.59; 95% CI: 1.09–2.27; p =0.012/adjusted for age and albumin: asHR: 1.52; 95% CI: 1.05–2.21; p =0.026). Conclusions: AGT levels decreased in ACLD, correlated with hepatic dysfunction, and were linked to all-cause mortality in exploratory survival analyses. Still, classical and alternative RAS parameters increased in parallel to ACLD severity.

Characterization of toxin-induced mouse models of regressive liver disease, focusing on the detecting of a suitable therapeutic window during fibrosis and portal hypertension (PH) regression. C57BL/6JRj mice were studied when exposed to thioacetamide (TAA) or carbon tetrachloride (CCl₄) for 8 or 12 weeks (8w/12w) and after one/two (+R1/+R2) week(s) of TAA/CCl₄-free regression. Healthy controls received NaCl or olive oil (OO). Primary readouts included liver fibrosis (collagen proportionate area, CPA), portal pressure (PP), serum transaminases and hepatic fibrosis-related gene expression. The diseased models (8wTAA/12wTAA/8wCCl₄/12wCCl₄) showed significant fibrosis (CPA: 3.03/3.87/8.53/16.90%; vs. NaCl/OO: 0.87/1.15%) and PH (PP: 6.8/7.7/8.5/10.0 mmHg; vs. NaCl/OO: 5.5/5.1 mmHg). CPA significantly regressed in 8wTAA+R1 (2.60%; p = 0.01) and 12wCCl₄+R1 (10.9%; p = 0.01), but not in 12wTAA+R1/8wCCl₄+R1. CPA regression was significant in all +R2-groups (p < 0.001) but not in 8wCCl₄+R2 (p = 0.30). Significant PP regression was found at 8wCCl₄+R1 (5.8 mmHg; p = 0.004) and 12wCCl₄+R1 (8.4 mmHg; p = 0.01), but not in the 8w/12w TAA models. All +R2-groups showed significant PP regression: 8wTAA+R2 (6.0 mmHg; p ≤ 0.001), 12wTAA+R2 (6.0 mmHg), 8wCCl₄+R2 (6.0 mmHg, p = 0.004) and 12wCCl₄+R2 (7.9 mmHg, p = 0.008). Serum AST/ALT levels at +R1/+R2 returned to levels of healthy controls. Hepatic Col1a1 and Timp1 gene expression peaked in 12w-groups and showed a gradual decrease at +R1/+R2: Col1a1 (12wTAA+R1/+R2: -14%/-29%, p = 0.002; 12wCCl₄+R1/R2: -28%/-23%, p = 0.05) and Timp1 (12wTAA+R1/+R2: -41%/-61%, p ≤ 0.001; 12wCCl₄+R1/R2: -43%/-40%, p ≤ 0.001). While liver disease regressed in all models/timepoints, both liver fibrosis (CPA) and PP remained increased in the 12wCCl₄+R1/R2 settings - qualifying this model as suitable for pre-clinical testing of therapeutic strategies aimed at promoting liver fibrosis and PH regression.

Background and Aims: Portal‐hypertensive gastropathy (PHG) is considered a potential cause of chronic bleeding and anaemia in patients with advanced chronic liver disease (ACLD) and might represent an endoscopic reflection of an impaired gut‐liver axis associated with portal hypertension. The clinical significance of PHG in patients with ACLD undergoing routine endoscopies remains understudied. Methods: PHG was classified as absent, mild, or severe in prospectively recruited ACLD patients undergoing routine endoscopy (i.e., variceal screening) in the absence of acute bleeding between Q2/2017‐Q3/2023. PHG severity was correlated with liver disease severity, systemic inflammation, anaemia, and development of non‐variceal bleeding, decompensation or liver‐related death during follow‐up. Results: Among 324 patients included in the study, 68 (21%) had no PHG, 190 (58.6%) mild, and 66 (20.4%) severe PHG. Increasing PHG severity was associated with higher MELD ( p < 0.001), hepatic venous pressure gradient (HVPG, p < 0.001), presence of varices ( p = 0.001), and elevated IL‐6 levels ( p < 0.001). Iron deficiency anaemia occurred at similar frequencies in patients with mild (24.2%) and severe PHG (31.8%). PHG evaluation was not confounded by the presence of histological gastritis or proton pump inhibitor use. During a median follow‐up of 17.6 months, severe PHG was not associated with an increased risk of non‐variceal gastrointestinal bleeding, transfusion‐dependent anaemia, or bacterial infections. Severe PHG was associated with a higher incidence of hepatic decompensation and liver‐related mortality (HR = 1.64; p = 0.015). However, severe PHG was not an independent risk factor for hepatic decompensation and liver‐related death (aHR: 1.12; p = 0.727) when adjusted for portal hypertension (HVPG; aHR: 1.07; p = 0.007) and liver dysfunction (MELD; aHR: 1.05; p = 0.123). Conclusion: In stable patients with ACLD undergoing routine endoscopy, the presence and severity of PHG reflect portal hypertension, liver disease severity, and systemic inflammation. However, PHG does not represent an independent risk factor for liver disease progression when adjusted for established markers of portal hypertension and hepatic dysfunction. Trial Registration: NCT03267615

INTRODUCTION: Clinically significant portal hypertension (CSPH) denotes the hemodynamic threshold for hepatic decompensation in advanced chronic liver disease and is increasingly diagnosed by noninvasive tests (NITs). Although liver stiffness measurement by vibration-controlled transient elastography is affected by body composition, intriguingly, no data on sex differences of its diagnostic or prognostic performance are available. We aimed to address this knowledge gap. METHODS: A total of 420 stable outpatients who underwent hepatic venous pressure gradient measurement from 2007 to 2022 at the Vienna Hepatic Hemodynamic Lab were included. The sex-specific diagnostic performance of prevailing NITs was evaluated. Moreover, the sex-specific cumulative incidences of first hepatic decompensation were analyzed using competing risk models stratified by the Baveno VII criteria and the sequential Baveno VII-VITRO algorithm. RESULTS: Two-hundred eighty-one (66.9%) patients were men, whereas 139 (33.1%) were women. Liver stiffness measurement performed better in male patients (area under the receiver operating characteristic curve [AUROC] = 0.845) than in female patients (AUROC = 0.811; P = 0.447), whereas for VITRO, the AUROC in female patients (0.854) was higher, as compared with male (0.814) subjects ( P = 0.370). The ANTICIPATE ± metabolic dysfunction-associated steatohepatitis model exhibited the highest AUROC in both sexes (male = 0.885; female = 0.872; P = 0.755). Finally, Baveno VII criteria and the sequential Baveno VII-VITRO algorithms were similarly effective in ruling-in/out CSPH in men and women. Thus, we observed a comparable diagnostic performance of NITs between the sexes, with no statistically significant differences. Interestingly, female patients classified as ruled-in by Baveno VII as well as by sequential Baveno VII-VITRO algorithm showed a trend toward higher decompensation rates, as compared with males. DISCUSSION: Individual NITs and Baveno VII-based algorithms show a similar accuracy for the diagnosis of CSPH and prognostication in men and women.

Background: The World Federation for Ultrasound in Medicine and Biology (WFUMB) guidance update 2024 proposed a ‘rule‐of‐4’ using ARFI liver stiffness measurement (LSM) to stratify the risk of decompensation events. This rule identifies advanced chronic liver disease (ACLD) at a threshold of ≥ 13 kPa and indicates a high probability of clinically significant portal hypertension (CSPH) above 21 kPa. Methods: We prospectively enrolled 187 patients undergoing same‐day SSI‐2D‐LSM (Aixplorer SuperSonic Imagine) and hepatic venous pressure gradient (HVPG) measurement. Patients were stratified into three LSM groups < 13 kPa, 13–21 kPa and > 21 kPa and followed for decompensation events for 1 year (Y1). Results: The cohort comprised 31 (16.6%) patients with LSM < 13 kPa (non‐ACLD); 33 (17.6%) LSM 13–21 kPa (ACLD) and 123 (65.8%) LSM > 21 kPa (high CSPH probability). The corresponding median HVPG values were 5 [IQR: 3–7] vs. 10 [7–14] vs. 17 [13–21] mmHg, respectively, and the corresponding CSPH prevalence was 6.5%, 54.5% and 91.9%. In ROC analysis to predict CSPH, SSI‐2D‐LSM demonstrated high accuracy (AUC: 0.83). Validating the new WFUMB extension of the ‘rule‐of‐4’, the recommended > 21 kPa threshold identified CSPH with a specificity of 80.0% and a PPV of 83.1%. In competing risk analysis, the Y1‐decompensation rate was 0%, 10% and 24.7% of patients in the < 13 kPa, 13–21 kPa and > 21 kPa groups, respectively. For prediction of Y1‐decompensation risk in the compensated ACLD (cACLD) subgroup, HVPG demonstrated the highest predictive accuracy (AUC: 0.92), while SSI‐2D‐LSM (AUC: 0.75) performed similarly to vibration‐controlled transient elastography (VCTE: AUC: 0.77; AUC‐comparison: p = 0.837). Conclusions: The WFUMB ‘rule‐of‐4’ for ARFI‐LSM allows for accurate and point‐of‐care non‐invasive risk stratification of patients with liver disease. Specifically, the short‐term risk of decompensation starts at SSI‐2D‐LSM ≥ 13 kPa and becomes considerable at SSI‐2D‐LSM > 21 kPa (indicating high CSPH probability). These findings support the broader implementation of ARFI‐LSM for risk assessment in clinical routine.

Background and Aims: Homozygosity for the SERPINA1 Pi * Z deficiency allele is the culprit of alpha‐1 antitrypsin deficiency‐related liver disease, while harbouring a single Z ‐allele (e.g., the common Pi * MZ genotype) is the strongest genetic risk factor for advanced chronic liver disease (ACLD) and its progression. However, the impact of the Pi * MZ genotype on hepatocellular carcinoma (HCC) development in patients who have already progressed to ACLD has yet to be established. Thus, we investigated the impact of the Pi * MZ genotype on the development of HCC among longitudinally followed ACLD patients. Methods: Patients undergoing hepatic venous pressure gradient (HVPG) measurement and genotyping at the Vienna Hepatic Haemodynamic Lab were included, excluding those with HCC. Competing risk analyses with HCC as the outcome of interest and death/liver transplantation as competing events were performed. Results: We included 815 patients (mean age: 54 ± 11 years; viral hepatitis: 53%, alcohol‐related liver disease: 37% and metabolic dysfunction‐associated steatotic liver disease: 10%). Overall, 30 patients (4%) harboured the Pi * MZ genotype. During a median follow‐up of 47.3 months, 68 patients developed an HCC (8/30 with Pi * MZ ). The Pi * MZ genotype was associated with increased risks of HCC development in univariable as well as in multivariable analyses, accounting for other important factors (i.e., age, sex, removal of the primary aetiological factor, aspartate‐aminotransferase, albumin and HVPG) identified in our study (adjusted subdistribution hazard ratio [aSHR]: 3.31 [95% confidence interval (CI): 1.26–8.65]; p = 0.015). The impact of the Pi * MZ genotype was confirmed adjusting for the aMAP score (aSHR: 2.94 [95% CI: 1.45–5.97]; p = 0.003). Conclusion: The SERPINA1 Pi * MZ genotype is associated with an increased risk of HCC development in patients with ACLD, independently of other HCC risk factors.

Background &Aims: Growth differentiation factor‐15 (GDF‐15), a cell stress‐induced cytokine, is implicated in liver disease pathophysiology. We investigated GDF‐15 in cirrhosis, focusing on its association with disease‐driving pathomechanisms, platelet function, hepatic decompensation, and mortality. Methods: We included patients with cirrhosis undergoing hepatic venous pressure gradient (HVPG) measurement at the Vienna General Hospital. Platelet surface P‐selectin and glycoprotein IIb/IIIa (GPIIb/IIIa) expression after agonist stimulation were assessed by flow cytometry as platelet activation markers. GDF‐15 serum levels were quantified by electrochemiluminescence immunoassay. Results: Among 106 patients (median age 55.1 years; 70.8% male), median GDF‐15 was 2880 (1850–4770) pg/mL. GDF‐15 correlated with hepatic dysfunction (MELD Spearman's ρ : 0.50; albumin ρ : −0.57), HVPG ( ρ : 0.47), systemic inflammation (C‐reactive protein ρ : 0.45; interleukin 6 [IL‐6] ρ : 0.55; procalcitonin ρ : 0.58), liver stiffness ( ρ : 0.67) and enhanced liver fibrosis test ( ρ : 0.64) (all p < 0.001). GDF‐15 was higher in patients with detectable bacterial DNA in blood (3520 vs. 2250 pg/mL; p < 0.001) and correlated with lipopolysaccharide ( ρ : 0.34; p = 0.010) and lipoteichoic acid ( ρ : 0.37; p = 0.004). Platelet activation was not linked to GDF‐15 after adjusting for liver disease severity, yet patients with undetectable GPIIb/IIIa activation after stimulation showed significantly higher GDF‐15. Over a median follow‐up of 51.5 (26.0–58.2) months, 38 patients decompensated and 21 died (61.9% liver‐related). GDF‐15 (aHR per 100 pg/mL: 1.015; 95% CI: 1.004–1.026; p = 0.007) predicted decompensation risk independently of HVPG, MELD, albumin and IL‐6. Similarly, GDF‐15 was associated with higher risk of all‐cause (HR: 1.019; 95% CI: 1.009–1.029; p < 0.001) and liver‐related mortality (HR: 1.019; 95% CI: 1.007–1.032; p = 0.002). Conclusions: GDF‐15 is a promising biomarker in cirrhosis that reflects disease‐driving pathomechanisms and independently predicts decompensation and mortality.