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

Abstract:

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.

Copyright © 2026 The Author(s). Published by Elsevier Inc. All rights reserved.

Keywords: MetALD, Metabolic dysfunction-associated steatotic liver disease, advanced chronic liver disease, alcohol-related liver-disease, cirrhosis, portal hypertension

References:

Authors

• Agustín Albillos |
• Edilmar Alvarado-Tapias |
• Angela Anton |
• Alba Ardevol |
• Dominik Bettinger |
• Anna Brujats |
• Federico Caceres |
• Petra Fischer |
• Sven Francque |
• Joan Genescà |
• Isabel Graupera |
• Daniel Gutmann |
• Virginia Hernández-Gea |
• Benedikt S Hofer |
• Jose Ignacio Fortea |
• Alba Jiménez-Masip |
• Wilhelmus Kwanten |
• Elba Llop |
• José Luis Calleja |
• Benjamin Maasoumy |
• Esther Maderuelo |
• Mattias Mandorfer |
• Helena Masnou |
• Lucile Moga |
• Raluca Pais |
• Grazia Pennisi |
• Juan M Pericas |
• Salvatore Petta |
• Bogdan Procopet |
• Ángela Puente |
• Vlad Ratziu |
• Pierre-Emmanuel Rautou |
• Thomas Reiberger |
• Dario Saltini |
• Lisa Sandmann |
• Filippo Schepis |
• Lotte Schoenmakers |
• Christian Sebesta |
• Georg Semmler |
• Sarah Shalaby |
• Luis Téllez |
• Michael Trauner |
• Emmanuel A Tsochatzis |
• Thomas Vanwolleghem |