Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Nov 27, 2020; 12(11): 1055-1066
Published online Nov 27, 2020. doi: 10.4254/wjh.v12.i11.1055
Non-invasive splenic parameters of portal hypertension: Assessment and utility
Ayesha Karim Ahmad, Sebastiana Atzori, James Maurice, Simon D Taylor-Robinson, Adrian KP Lim
Ayesha Karim Ahmad, Liver Unit, Department of Digestion, Metabolism & Reproduction, Faculty of Medicine, Imperial College London, London W2 1NY, United Kingdom
Sebastiana Atzori, James Maurice, Simon D Taylor-Robinson, Liver Unit, Department of Digestion, Metabolism & Reproduction, Imperial College London, London W2 1NY, United Kingdom
Adrian KP Lim, Liver Unit and Imaging, Department of Digestion, Metabolism & Reproduction, Imperial College London, London W2 1NY, United Kingdom
Author contributions: Ahmad AK collected data, performed statistical analyses, wrote the manuscript with support from other authors; Atzori S performed the experiments and statistical analyses; Maurice J critically appraised study design; Taylor-Robinson SD and Lim AKP designed, supervised and implemented the research; all authors discussed the results and contributed to the final manuscript.
Institutional review board statement: This study was performed in accordance with the 1975 Declaration of Helsinki, with approvals from the Research Ethics Committee and the Joint Research and Compliance Office of Imperial College London and Imperial College Healthcare NHS Trust.
Informed consent statement: Patients were required to give informed consent to the study in the form of written consent.
Conflict-of-interest statement: This work was supported by Philips Medical Systems (Seattle, Washington, United States); United Kingdom National Institute for Health Research Biomedical Facility at Imperial College London, London, United Kingdom.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Adrian KP Lim, MD FRCR, Doctor, Liver Unit and Imaging, Department of Digestion, Metabolism & Reproduction, Imperial College London, London W2 1NY, United Kingdom. a.lim@imperial.ac.uk
Received: July 16, 2020
Peer-review started: July 16, 2020
First decision: August 9, 2020
Revised: August 22, 2020
Accepted: October 9, 2020
Article in press: October 9, 2020
Published online: November 27, 2020
Processing time: 130 Days and 15.1 Hours
ARTICLE HIGHLIGHTS
Research background

Portal hypertension is a major complication of cirrhosis with a significant morbidity and mortality associated with it. Many of those with advanced chronic liver disease have esophageal varices and so, many patients undergo the gold-standard invasive procedures of performing an esophago-gastroduodenoscopy (EGD) or having the hepatic venous pressure gradient measurement taken through interventional radiology. However, both of these methods are invasive and carry a risk of complications.

Research motivation

Current guidelines propose that non-invasive methods can predict the incidence of clinically significant portal hypertension (CSPH). The latest guidelines suggest cirrhosis patients with a liver stiffness measurement < 20 kPa and a platelet count > 150000/μL can avoid screening endoscopy. Nevertheless, new algorithms are still required, as up to 40% of EGDs continue unnecessarily.

Research objectives

The aim of this study was to assess whether spleen stiffness measurement, spleen area and spleen diameter can independently predict CSPH, or in combination with other biochemical or elastography parameters. We also aimed to assess reproducibility of splenic area and diameter measurements.

Research methods

This was a single-centre prospective cohort study where a total of 50 patients were split into two groups and included in a retrospective analysis: 25 with evidence of CSPH (group 1) and 25 with no evidence of CSPH (group 2). The Philips EPIQ7 [elastography point quantification (ElastPQ)] (Philips Medical Systems, Seattle, United States) was used to record liver stiffness, spleen stiffness, spleen area and spleen diameter measurements for each patient. Univariate, multivariate and one-way random interclass correlation coefficient analyses were performed to assess the diagnostic accuracy of splenic parameters.

Research results

Body mass index, alanine aminotransferase, aspartate aminotransferase, γ-glutamyl transpeptidase, alkaline phosphatase, bilirubin, platelet count, albumin, prothrombin time, aspartate aminotransferase-to-platelet-ratio-index (APRI) score, liver stiffness, spleen stiffness, spleen area and spleen diameter were assessed in their ability to predict the presence of CSPH. A univariate analysis showed the best individual predictor of CSPH was platelet count [area under the receiver operating characteristic (AUROC) 0.846, P value < 0.001], followed by spleen area (AUROC 0.828, P value = 0.002) and APRI score (AUROC 0.827, P value < 0.001). A multiple logistic regression model revealed that two combinations independently predict CSPH. The combination with the greatest diagnostic accuracy included a combination of spleen area > 57.9 cm2 and platelet count < 126 × 109 which had 63.2% sensitivity, 100% specificity, 100% positive predictive value (PPV), 61.1% negative predictive value (NPV) (AUROC 0.876, P value < 0.001). An alternative combination of spleen stiffness >29.99 kPa and platelet count < 126 × 109 displayed a similar diagnostic accuracy with 88% sensitivity, 75% specificity, 78.6% PPV, 85.7% NPV (AUROC 0.855, P value < 0.001). Spleen area and spleen diameter demonstrated little inter-operator variability as measured by a one-way random interclass correlation coefficient (spleen area: 0.98, P value < 0.001; spleen diameter: 0.96, P value < 0.001).

Research conclusions

Combinations of spleen area and platelet count, or spleen stiffness and platelet count as measured by the ElastPQ may be safe and effective methods to diagnose CSPH. At present this cannot replace the gold standard.

Research perspectives

Performing large scale prospective studies with long-term follow-up and are needed to validate our findings.