Ten cohorts were included (n=595 patients) with hepatic venous pressure gradient measures at baseline and follow-up who were included in analyses). These cohorts came from two RCTs, five prospective non-randomised studies, and three cohorts representing some patients who were originally part of RCTs. Quality scores were between 4 and 8, with eight studies scoring between 6 and 8.
Primary and secondary prophylaxis:
The risk of variceal bleeding was significantly lower in patients with a hepatic venous pressure gradient (HVPG) reduction (classified as overall, complete or partial) compared with patients without a HVPG response.
For overall HVPG response patients, the relative risk of bleeding was 0.27 (95% CI: 0.14 to 0.52) with significant heterogeneity (p=0.011) and the number needed to treat was 3 (95% CI: 2 to 5). In complete HVPG response patients, the relative risk of bleeding was 0.48 (95% CI: 0.28 to 0.81) without heterogeneity. In partial HVPG response patients the relative risk of bleeding was 0.41 (95% CI: 0.20 to 0.81) with heterogeneity (p=0.007).
Exclusion of an outlying study that reported the longest interval to re-measurement, and had the lowest quality score, yielded a significantly lower risk of bleeding, without heterogeneity. The recalculated relative risk of bleeding was 0.23 (95% CI: 0.15 to 0.36) for overall HVPG response patients, 0.27 (95% CI: 0.13 to 0.56) for complete HVPG response patients, and 0.33 (95% CI: 0.21 to 0.51) for partial HVPG response patients.
The relative risk of liver-related mortality was significantly lower in overall HVPG response patients (12% versus 26%, relative risk 0.58, 95% CI: 0.37, 0.91) compared to HVPG non-response patients, without heterogeneity. The number needed to treat was 6 (95% CI: 4 to 11). The relative risk of any death or liver transplantation was significantly lower for overall HVPG response patients compared to HVPG non-response patients at 0.71 (95% CI: 0.49 to 1.0), without heterogeneity.
Primary prophylaxis (four cohorts, n=185 patients):
The relative risk of variceal bleeding was significantly lower in overall (0.24, 95% CI: 0.10 to 0.56) and partial (0.30, 95% CI 0.12 to 0.77) HVGP response patients compared with HVPG non-response patients, without heterogeneity. The number needed to treat for both overall and partial HVPG response patients was 4 (95% CI: 2 to 8).
Secondary prophylaxis (six studies, n=363 patients)
Overall HVPG response patients showed a significantly lower variceal bleeding risk than HVPG non-response patients (16% versus 46%, relative risk 0.35, 95% CI 0.16 to 0.80), with significant heterogeneity (p=0.006). The relative risk of bleeding was non-significantly lower in partial HVPG response patients (0.52, 95% CI 0.22 to 1.22), with significant heterogeneity (p=0.003). Exclusion of the study reporting the longest interval to re-measurement yielded a relative risk of bleeding of 0.38 (95% CI: 0.23 to 0.62). The number needed to treat was 3 (95% CI: 2 to 4).