From pressure to prognosis: establishing a common language for portal hypertension in advanced chronic liver disease.

Abstract

Risk stratification in compensated advanced chronic liver disease has traditionally been based on the identification of clinically significant portal hypertension (CSPH), defined as a hepatic venous pressure gradient (HVPG) of ≥10 mm Hg. CSPH is a well-established marker of poor prognosis, associated with a substantially higher risk of decompensation compared with the absence of CSPH (29% vs 10% at 4 years).Non-invasive tests (NITs) are increasingly used as surrogates for CSPH, yet their potential to directly predict clinical endpoints of decompensation or liver-related death remains underutilised. There is a clinical need to transition from static haemodynamic thresholds to the dynamic, individualised prediction of clinically meaningful outcomes using NIT-based direct risk assessment. Tools such as elastography, models such as ANTICIPATE and Non-Invasive CSPH Estimated Risk, and purely blood-based scores such as the Portal Hypertension Decompensation Score demonstrate prognostic accuracy comparable to HVPG measurement for the prediction of decompensation. The routine use of NITs also allows for continuous, longitudinal reassessment of a patient's risk and response to disease-modifying treatment.For these direct prediction models to be widely adopted in clinical practice, standardisation of clinical endpoints is essential, focusing on classical portal hypertension-related decompensation events rather than heterogeneous composite outcomes. Adopting an outcome-based terminology rather than relying on surrogate markers may also enhance public awareness, convey disease severity more effectively and foster earlier interventions for patients at risk.