Clinical significance of worsening portal hypertension during long-term medical treatment in patients with cirrhosis who had been classified as early good-responders on haemodynamic criteria

Background & Aims: it is established that cirrhotic patients who respond to beta-blockers by lowering their hepatic venous pressure gradient (HVPG) to <= 12 mmHg or by >= 20% of the baseline values are protected from bleeding. However, it is not known whether the effect remains unchanged over the treatment period. Methods: A group of 24 patients with cirrhosis and oesophageal varices, treated with beta-blockers nitrates, good-responders on haemodynamic criteria, were followed for up to 76 months with sequential HVPG measurements. Another group of 16 patients was used for validation. Results: HVPG worsened in 10 of the 24 patients during follow-up. Changes in HVPG correlated to concomitant changes in liver function parameters. Variceal bleeding occurred in four of the 10 patients whose HVPG had worsened (bleed: 3-21 months after the measured increase in HVPG) and in none of those with stable HVPG (p = 0.02). Patients with increased HVPG also had shorter survival (p = 0.05). Worsening of HVPG was an independent predictor of death, additive to Child-Pugh or MELD scores, in a time-dependent Cox's regression analysis. This relationship was confirmed in the validation group. Conclusions: Worsening HVPG during follow-up in patients who had initially been good-responders to medical treatment is related to worsening in hepatic function. The maintenance of a good haemodynamic response to medical treatment of portal hypertension is an excellent predictor of outcome in these patients. (C) 2009 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.