Elastography-based screening for esophageal varices in patients with advanced chronic liver disease

Elastography-based liver stiffness measurement(LSM) is a non-invasive tool for estimating liver fibrosis but also provides an estimate for the severity of portal hypertension in patients with advanced chronic liver disease(ACLD). The presence of varices and especially of varices needing treatment(VNT) indicates distinct prognostic stages in patients with compensated ACLD(cACLD). The Baveno VI guidelines suggested a simple algorithm based on LSM < 20 kPa(by transient elastography, TE) and platelet count > 150 G/L for ruling-out VNT in patients with cACLD. These(and other) TE-based LSM cut-offs have been evaluated for VNT screening in different liver disease etiologies. Novel point shear-wave elastography(pSWE) and two-dimensional shear wave elastography(2D-SWE) methodologies for LSM have also been evaluated for their ability to screen for "any" varices and for VNT. Finally, the measurement of spleen stiffness(SSM) by elastography(mainly by pSWE and 2D-SWE) may represent another valuable screening tool for varices. Here, we summarize the current literature on elastography-based prediction of "any" varices and VNT. Finally,we have summarized the published LSM and SSM cut-offs in clinically useful scale cards.

Renal dysfunction in cirrhosis: acute kidney injury and the hepatorenal syndrome

Renal dysfunction is a common complication of liver cirrhosis and of utmost clinical and prognostic relevance.Patients with cirrhosis are more prone to developing acute kidney injury(AKI)than the non-cirrhotic population.Pre-renal AKI,the hepatorenal syndrome type of AKI(HRS-AKI,formerly known as‘type 1’)and acute tubular necrosis represent the most common causes of AKI in cirrhosis.Correct differentiation is imperative,as treatment differs substantially.While pre-renal AKI usually responds well to plasma volume expansion,HRS-AKI and ATN require different specific approaches and are associated with substantial mortality.Several paradigms,such as the threshold of 2.5 mg/dL for diagnosis of HRS-AKI,have recently been abolished and novel urinary biomarkers are being investigated in order to facilitate early and correct diagnosis and treatment of HRS-AKI and other forms of AKI in patients with cirrhosis.This review summarizes the current diagnostic criteria,as well as pathophysiologic and therapeutic concepts for AKI and HRS-AKI in cirrhosis.