Predicting hepatic decompensation using non-invasive tests in a contemporary multicentre cohort of patients with cACLD.

Background & Aims The NICER (liver and spleen stiffness by vibration-controlled transient elastography (VCTE), platelet count, and body mass index) and the ANTICIPATE±NASH models predict clinically significant portal hypertension (CSPH) in compensated advanced chronic liver disease (cACLD). This study reports follow-up data of the NICER cohort, comparing the prognostic utility of non-invasive tests for CSPH (CSPH-NITs) and hepatic venous pressure gradient (HVPG).Methods Child-Turcotte-Pugh A cACLD (liver stiffness ≥10kPa and/or F3/4) patients from 16 European centres undergoing paired HVPG and CSPH-NITs assessment from 2020-2023 were included and followed until incident hepatic decompensation, hepatocellular carcinoma, death, or last visit.Results Three hundred and fifty-eight cACLD patients (MASLD: 40.7%/MetALD/ALD: 32.1%/viral: 16.2%; CSPH prevalence: 62.0%) were included. The cumulative 1-year and 2-year incidences of decompensation were 7.3 (95% CI: 5.9-8.7%) and 12.6 (10.3-14.9%). Albumin levels were a key predictor of decompensation (subdistribution hazard ratio [sHR]: 0.836 [95% CI: 0.779-0.897]) besides either HVPG (albumin-adjusted SHR: 1.126 [1.059-1.198]) or NICER (albumin-adjusted SHR: 1.207 [1.043-1.397]) or ANTICIPATE±NASH (albumin-adjusted SHR: 1.174 [1.003-1.374]). Models comprising albumin alongside HVPG or CSPH-NIT yielded high C-index for decompensation (0.772-0.806). Stratifying patients by a predicted 1-year decompensation-free survival probability of ≥95% or <95% identified ≈60% of patients as being at negligible 1-year risk (1.4-2.1%), while the remaining patients were at high risk of decompensation (14.3-16.0%).Conclusion In our multicentre study of contemporary European cACLD patients, non-invasively estimated CSPH risk was as predictive for decompensation as HVPG. Models comprising indicators of portal hypertension and albumin discriminated between patients at negligible decompensation risk and those with a 1-year risk of ≈15%, i.e., the potential target population for preventive strategies.Impact And Implications Non-invasive tests (NITs) facilitate the early diagnosis and management of clinically significant portal hypertension (CSPH) in patients with compensated advanced chronic liver disease (cACLD) patients. In our contemporary cohort of cACLD patients with mainly steatotic liver disease recruited at 16 European expert centres, the hepatic venous pressure gradient (HVPG) and NITs were similarly predictive of decompensation within one to two years of follow-up. Serum albumin levels were identified as the second main predictor of decompensation besides the HVPG or NITs for CSPH. Novel models were developed that could accurately predict the risk for decompensation, thereby refining point-of-care risk stratification and clinical trial design in CTP-A cACLD patients.