Abstract

Background: Baveno VII was proposed for non-invasive identification of clinically significant portal hypertension. However, a substantial proportion of patients is classified in the grey zone (i.e., liver stiffness 15-24.9 kPa and/or platelet count <150 ×10⁹/L). We aimed to evaluate the risk and predictors of hepatic decompensation in grey zone patients and determine the prognostic role of spleen stiffness measurement (SSM).

Methods: Prospective cohorts (from Hong Kong, Korea and France) of patients who had undergone transient elastography examination for chronic liver disease were included. The risk of hepatic decompensation was estimated using competing risk regression with hepatocellular carcinoma and non-liver related death as competing events.

Results: We identified 2763 compensated advanced chronic liver disease (cACLD) patients. There were 1243 (44.9%) and 536 (19.4%) patients in the Baveno VII grey zone and high-risk groups, respectively. The cumulative incidence of decompensation at 5 years was significantly different among the low-risk (0.6% [95% CI, 0.2-1.3%]), grey zone 4.2% (95% CI, 3.1-5.4%) and the high-risk groups (11.4% [95% CI, 8.7-14.6%]). By competing risk analysis, aetiology of liver disease (non-viral hepatitis), albumin-bilirubin score and alkaline phosphatase level were independently associated with decompensation in grey zone patients (Figure). The combination of Baveno-VII and spleen stiffness significantly reduced patients classified into the grey zone (12.8% in cACLD patients), while maintaining high discrimination of decompensation in the low- and high-risk groups.

Conclusion: Patients in the grey zone of the Baveno VII criteria remain at high risk of hepatic decompensation. Clinical risk factors and spleen stiffness can further stratify the risk in such patients.