5 Years Experience of the Vienna Hepatic Hemodynamic Laboratory

Introduction: The hepatic venous pressure gradient (HVPG) is the gold standard for diagnosis of portal hypertension (PHT). Transjugular liver biopsy (TJB) can be easily obtained during HVPG measurement. Together they constitute the optimal “one-stop shop“ for assessment of disease etiology and severity in clinical hepatology. Transient elastography (Fibroscan, FS) is a simple, rapid, and non-invasive method to measure liver stiffness (LS) that correlates with the amount of hepatic fibrosis. We present the Vienna database about our 5 years (2003–2008) experience in hepatic hemodynamic measurements.

Methods: A total of 591 patients had 850 HVPG measurements, 175 TJB and 323 FS examinations. Main indications were (1) evaluation of efficacy of beta-blocker (BB) or isosorbitmononitrate (ISMN) therapy for prevention of variceal bleeding, risk evaluation (2) before initiating antiviral therapy for chronic viral hepatitis or (3) before planned partial hepatectomy and (4) study protocols. Medical histories and complications during procedures were documented.

Results: 440 (74%) patients were male and median age was 52 (16–81) years. Etiologies of liver disease were 42% alcoholic (ALD), 40% viral (HBV, HCV, HIV-coinfections), 7% cryptogenic and 11% others (e.g. AIH, PBC, PSC). HVPG measurement was successful in 95% (559/591) of examinations, in other cases the catheter introducer could not be placed (15/591) or wedge position was insufficient (17/591). LS significantly correlated with HVPG (n=240, r=0.791, p<0.000001) and LS was higher in patients with PHT (47.2±22.4 kPa, n=142) than without (13.6±10.7 kPa, n=98). A significant difference in LS was also found between patients with normal HVPG (1–4mmHg, n=45), slightly elevated HVPG (5–9mmHg, n=53) and patients with PHT (n=142): 7.8±5.2 vs. 17.5±11.0 vs. 47.2±22.4 kPa (p<0.003). Patients with a history of variceal bleeding had significantly higher HVPG and LS (17.9±5.6mmHg, 48.8±27.2kPa) than those without (9.6±4.8mmHg, 20.6±13.7kPa). LS and HVPG were similar in METAVIR fibrosis stage (F) 0–2 (n=42, 4.4±2.6mmHg, 9.2±8.8kPa), but were significantly higher (p<0.007) compared to patients with F3 (n=18, 5.7±2.4mmHg, 12.8±6.9kPa) and F4 (n=32, 16.4±9.9mmHg, 40.1±22.9Kpa). Response rate of patients receiving BB for prophylaxis of variceal bleeding was 32% for BB monotherapy and 48% for BB-ISMN combination therapy in our patient series.

Conclusion: Evaluation of patients with chronic liver disease by measurements of HVPG, LS and TJB is safe and helps to guide further management, especially BB-ISMN therapy and treatment decisions for antiviral therapy of chronic viral hepatitis. FS can help to define the risk of severe fibrosis, PHT and variceal bleeding in patients not willing to undergo a liver biopsy or upper gastrointestinal endoscopy.