Noninvasive predictors of variceal bleeding after clearance of the hepatitis C virus by direct antiviral drugs

Background The introduction of direct-acting antiviral drugs (DAAs) could safely eliminate the hepatitis C virus (HCV). Steatosis and fibrosis regression after HCV treatment could occur with subsequent improvement in the portal pressure. However, a subgroup of patients is still at risk of variceal bleeding from persistent clinically significant portal hypertension (CSPHT). Recognition of these patients, hence continuous screening, is clinically relevant. In resource-limited areas, the availability of noninvasive, simple markers to identify at-risk patients will help avoid gastroscopy. We aimed to investigate the utility of liver stiffness measurement (LSM) and the portal vein congestion index (PVCI) as noninvasive markers to identify subgroups of patients who need follow-up after HCV elimination. Patients and methods Retrospectively, we included 181 patients who received DAAs for HCV and achieved sustained virologic response. After 5 years of follow-up, we evaluated baseline parameters that could predict variceal bleeding. Baseline clinical and laboratory data, including baseline LSM and PVCI, were included. Patients were followed for 5 years for the occurrence of variceal bleeding. Results The ROC analysis revealed that at a cutoff level ≥ 0.563, PVCI could identify patients who experienced variceal bleeding with a 91.8% sensitivity, 90.9% specificity, and 79% PPV. Patients with PVCI ≥ 0.563 and LSM ≥ 21.2 kPa had a shorter interval before variceal bleeding. Cox regression analysis identified baseline CTP, PVCI, and LSM as the only significant independent predictors of variceal bleeding in the study population. Conclusions Although HCV treatment ameliorates liver pathology and may regress PHT, it may give “false assurance” to a subset of patients who are still at risk of variceal bleeding and require close follow-up to avoid devastating variceal rupture. Noninvasive identification and stratification of these patients can be achieved by integrating PVCI and LSM into the management strategy.