Hepatic venous pressure gradient, non-invasive tests, and prognosis across the subtypes of advanced steatotic liver disease

BACKGROUND & AIMS: Steatotic liver disease (SLD) encompasses metabolic dysfunction-associated liver disease (MASLD), alcohol-related liver disease (ALD), and a mixed type (MetALD). We investigated the course of compensated advanced chronic liver disease (cACLD) across SLD subtypes, the impact of clinically significant portal hypertension (CSPH), and the role of non-invasive tests (NITs). METHODS: This study included SLD patients with cACLD from 17 centers undergoing hepatic venous pressure gradient (HVPG) and NIT assessment through December 2023. Primary outcomes were first hepatic decompensation and liver-related mortality. RESULTS: Among 696 patients (ALD 22%, MetALD 20%, MASLD 58%), 94% had Child-Pugh A, and 60% had CSPH. Over a median follow-up of 3.8 years, 170 patients decompensated and 137 died (58% liver-related). The three-year cumulative decompensation incidence was highest in ALD (26%), followed by MetALD (21%) and MASLD (15%), yet differences were no longer significant after adjusting for age, sex, MELD, albumin, and HVPG. Similarly, liver-related mortality did not differ by SLD subtype in adjusted models. CSPH independently predicted decompensation across all subtypes. The ANTICIPATE-NASH model showed high and comparable diagnostic accuracy for CSPH across ALD, MetALD, and MASLD (AUROC 0.831-0.894). An ANTICIPATE-NASH probability ≥60% for ruling-in CSPH outperformed the original ANTICIPATE model in all subtypes and independently predicted decompensation with similar effect sizes (aSHR 2.57-2.71). CONCLUSIONS: Higher crude decompensation rates in ALD and MetALD reflect more severe liver disease at presentation, yet outcomes are comparable across the SLD spectrum after accounting for disease severity. ANTICIPATE-NASH accurately identifies CSPH across SLD subtypes, and both invasive and non-invasive measures of portal hypertension predict decompensation and liver-related death.