Introduction
Physicians use portal pressure measurements in clinical practice and research but the methods are invasive, can cause complications, and are resource intensive1–3. Herein we describe preliminary findings of the minimally invasive HepQuant-SHUNT® test in the diagnosis of portal hypertension in pre-cirrhotic and compensated cirrhotic patients.
Methods.
The Institutional Review Boards of the University of Colorado Denver and NIDDK approved the studies. Wedged hepatic venous pressure (WHVP), hepatic venous pressure gradient (HVPG), liver histology, and HepQuant SHUNT were measured in 20 adults with clinically stable chronic liver disease. Direct portal pressure (dPP) via percutaneous transhepatic cannulation of the portal vein and HepQuant SHUNT were measured in 28 adults with clinically stable chronic hepatitis C (HCV). Transplant recipients and patients with prior TIPS or surgical portal-systemic shunts were excluded.
HepQuant SHUNT quantifies hepatic acinar function and effective sinusoidal perfusion by simultaneously measuring the flow-dependent clearance of cholate from both portal and systemic circulations. Test outputs include hepatic filtration rates, portal-systemic spillover of d4-CA (SHUNT%), [d4-CA] at 60 minutes (STAT), and a Disease Severity Index (DSI)4,7. Tolerability was determined by a 10 point Likert scale.
WHVP and dPP were considered equivalent, portal hypertension was defined as HVPG >5 mmHg or dPP >17 mmHg, and clinically significant portal hypertension was a HVPG >10 mmHg or dPP >22 mmHg. Relationships of the HepQuant-SHUNT test to portal pressure were evaluated by linear and logistic regression and ROC (c statistic) analyses.
Results
Subject Characteristics.
The mean age was 55 years; 26 were female, 40 were white, and 9 were Hispanic. BMI ranged from 21.1 to 40.6 kg m−2. Etiologies included HCV (n=32), nonalcoholic steatohepatitis (NASH, n=9), autoimmune hepatitis (AIH, n=3), and Wilsons disease, Budd-Chiari syndrome, primary sclerosing cholangitis, and cryptogenic liver disease. Twenty six had F0 to F2 (n=26), F3 (n=5), and F4 (n=17). Blood tests, MELD, and CTP scores indicated pre-cirrhotic or compensated liver disease. The Budd-Chiari# case, and patients with venovenous collaterals (n=5) were excluded leaving 42 study subjects.
HepQuant SHUNT results.
Half the subjects (n=21) had portal hypertension, 7 without cirrhosis, which was clinically significant in 13. The WHVP or dPP was 24.3 ± 4.4 mmHg in those with portal hypertension compared to 12.3 ± 3.9 mmHg in those without portal hypertension. Patients with portal hypertension had lower HFRs and greater SHUNT%, DSI and STAT (Supplemental Table 1). In univariate analysis, SHUNT%, Portal HFR, DSI, and STAT correlated significantly with portal pressure. In multivariate analysis, a model including SHUNT% (p=0.0028), LSM (p=0.0002), and platelet count (0.0106) (result for model, r=0.86, p<0.0001) correlated best with portal pressure.
Supplemental tables 2 and 3 show the ROC and univariate analyses in the diagnosis of portal hypertension and clinically significant portal hypertension. The most informative individual test for both was SHUNT% with c=0.922 (CI 0.796–0.982) and c=0.859 (CI 0.717–0.947). In the 28 subjects with both dPP and liver stiffness (LSM) measurements, diagnostic models of portal hypertension including LSM with either SHUNT%, DSI, or STAT had c statistics of 0.954, 0.959, and 0.938, respectively. A model with SHUNT%, LSM, and FIB-4 had nearly perfect diagnostic performance for portal hypertension (c=0.979), comparing favorably to the component tests (SHUNT c=0.931; LSM c=0.838; FIB-4 c=0.872) (Figure 1).
Figure 1:
Receiver-operator characteristic curves (ROCs) for diagnosis of portal hypertension are shown for the 28 patients that had direct portal pressure (dPP) and liver stiffness measurements (LSM). The left panel displays the individual ROCs for SHUNT%, quantifying portal-systemic shunting, LSM, a surrogate for liver fibrosis, and FIB-4, a surrogate for liver injury and fibrosis. The functional measurement, SHUNT%, had the highest c-statistic, c=0.931. The open circles are cutpoints based on Youden-J statistic. The right panel shows the ROC for the noninvasive model with near perfect diagnostic performance based on the combination of SHUNT%, LSM, and FIB-4. Abbreviations: AUROC, area under the receiver-operator characteristic curve; PH, portal hypertension; FIB-4, fibrosis-4 score; LSM, liver stiffness measurement; SHUNT, calculated from the ratio of clearances of 13C-cholate to d4-cholate.
The self-reported patient survey (Supplemental Table 4) confirmed high tolerability of the SHUNT test and willingness to undergo repeat testing.
Discussion
This study demonstrates the HepQuant-SHUNT test detects portal hypertension and clinically significant portal hypertension with similar reliability to invasive pressure measurements. A key finding was the ability of the SHUNT test to detect hypertension early in the course of disease not only in clinically stable compensated cirrhosis by also in noncirrhotic patients. The clinical importance of this finding is reinforced by a recent report showing over 80% of patients with pre-cirrhotic primary biliary cholangitis had portal hypertension and of those over 30%had clinically significant portal hypertension5. The improved tolerability and acceptability of the SHUNT test, compared to strongly supports a role for the SHUNT test in the early detection of portal hypertension.
In contrast to current noninvasive tests which use surrogates for increased portal pressure 6, the SHUNT test directly measures the liver’s function, dual circulation and portal systemic shunting4,7,8. In comparison to HVPG, the SHUNT test is simple, minimally invasive, highly tolerated, and patients are readily willing to undergo repeat testing.
We conclude that the noninvasive HepQuant-SHUNT Test, either alone or in combination with other noninvasive tests, warrants further evaluation as an alternative to the existing invasive methods for assessing portal pressure and portal hypertension.
Supplementary Material
ACKNOWLEDGEMENT:
The authors wish to acknowledge both Jennifer DeSanto, RN and Andrea Herman RN for clinical coordination and Shannon Lauriski for laboratory analyses at the University of Colorado Denver. In addition, we thank M. Susan Mandell, M.D., Ph.D., for expert assistance in writing and editing the manuscript.
FINANCIAL SUPPORT:
Two cohorts comprised this study – an HVPG cohort and a dPP cohort. The HVPG cohort was studied under a Bioscience Discovery Evaluation Grant from the State of Colorado (POGG1 2015 0872). The dPP was studied at NIH-NIDDK and the study was supported in part by the Intramural Research Program of NIDDK, NCI, and the NIH Clinical Center. The Agilent LCMS system used in this study was owned by HepQuant LLC, and samples for this study were analyzed for cholate and cholate isotopes in the laboratory of G. T. Everson at the University of Colorado Denver via an Equipment Use Agreement between HepQuant LLC and the University.
LIST OF ABBREVIATIONS:
- BMI
Body mass index
- CSPH
clinically-significant portal hypertension
- CTP
Child-Turcotte-Pugh
- CTRC
Clinical Translational Research Center
- dPP
direct portal pressure
- DSI
disease severity index from the HepQuant SHUNT test
- FHVP
free hepatic venous pressure
- GGT
Gamma glutamyl-transferase
- HCV
hepatitis C virus
- HFR
Hepatic filtration rate
- HQ-SHUNT
the HepQuant SHUNT test
- HVPG
Hepatic venous pressure gradient
- IND
Investigational New Drug
- INR
International normalized ratio
- MELD
Model for end-stage liver disease
- NASH
nonalcoholic steatohepatitis
- PH
portal hypertension
- SD
Standard deviation
- SHUNT%
the percent of d4-cholate escaping first-pass hepatic extraction and shunting to the systemic circulation
- WHVP
wedged hepatic venous pressure
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
FINANCIAL DISCLOSURES: G. T. Everson, S. Helmke, and University of Colorado Denver have several issued and pending patents relevant to the analytical procedures used in this study. G. T. Everson is an equity owner/member and CEO CMO of HepQuant LLC and S. Helmke is an employee of HepQuant LLC. O. Etzion is a member of HepQuant LLC Scientific Advisory Board. Authors with no financial relationships to disclose are: A. Wieland, A. Rabab, E. Levy, D. Kleiner, J. DeSanto, S. Lauriski, and T. Heller.
CONFLICTS OF INTEREST: GT Everson and S Helmke have disclosed their interest in HepQuant LLC and patents related to the dual cholate test. O. Etzion has disclosed his participation in HepQuant’s Scientific Advisory Board.
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