Decision support only — not a substitute for Baveno VII, EASL/AASLD guidance, GESA, eTG, or your liver team. The whole job here is to stop the first decompensation: treat the aetiology, stratify portal-hypertension risk non-invasively, and start carvedilol when CSPH is present. Once ascites, variceal bleeding, jaundice or encephalopathy appear, the patient moves to the decompensated pathway. Verify all doses.
1 Baveno VII "Rule of Five" — stratify with liver stiffness + platelets
<10kPa+ plt >150
cACLD excluded. CSPH excluded if LSM <15 + platelets >150 ×10⁹/L.
No portal-hypertension intervention. Focus entirely on treating the cause; routine follow-up.
10–15kPaprobable cACLD
Advanced chronic liver disease likely; CSPH not yet established.
Confirm with additional non-invasive tests (platelets, spleen stiffness). Treat the cause.
15–20kPacertain cACLD
cACLD confirmed. CSPH unconfirmed unless platelets low.
Baveno VI: LSM <20 + plt >150 → low varices risk, spare screening endoscopy. Grey zone if plt low.
20–25kPagrey zone / probable CSPH
LSM 20–25 + plt <150 (or 15–20 + plt <110) → ≥60% CSPH risk. ~40% of cACLD sit here.
Screen endoscopy; weigh carvedilol. Substantial decompensation risk — don't dismiss as "compensated and fine."
≥25kPacertain CSPH
CSPH ruled in. ≥50 kPa = "critical" — highest decompensation/death risk.
Carvedilol to prevent first decompensation (PREDESCI). No endoscopy needed to start it.
The paradigm shift: treat CSPH with carvedilol on diagnosis, rather than waiting to find high-risk varices on endoscopy. Carvedilol 6.25 mg/day → up to 12.5 mg/day, titrating to tolerance (don't drop SBP <90 or HR <50). LSM is by vibration-controlled transient elastography; values can be falsely high with food, congestion, or active inflammation — measure fasting.
2 Treat the cause — this is the disease-modifier
Remove the driver
- AlcoholAbstinence — the single biggest lever. Offer pharmacotherapy + support.
- HBVAntiviral suppression (entecavir/tenofovir) — can regress fibrosis.
- HCVDirect-acting antivirals — cure; portal pressure falls after SVR.
Metabolic & autoimmune
- MASLDWeight loss, metabolic control. GLP-1 RA / SGLT2i increasingly used for the drivers.
- AIH/PBCImmunosuppression / ursodeoxycholic acid as indicated.
Why it matters
- RegressionEtiological control can regress fibrosis and even achieve recompensation (Baveno VII). The portal hypertension follows the cause.
3 Prevent decompensation & protect the liver
Pharmacological prevention
- CarvedilolFor CSPH — prevents first decompensation, improves survival. Preferred NSBB (greater portal-pressure effect than propranolol/nadolol).
- VaricesIf not on NSBB and not endoscopy-spared → screen; high-risk varices → EBL or NSBB.
- StatinsEmerging: may lower portal pressure and decompensation/mortality — safe in compensated disease, not yet a formal recommendation.
Avoid harm
- NSAIDsAvoid — precipitate ascites, AKI, bleeding.
- ParacetamolStill the preferred analgesic, but cap at ≤2 g/day in cirrhosis.
- SedativesMinimise — they can unmask encephalopathy.
- PPIsDeprescribe unnecessary PPIs — associated with SBP and infection risk.
4 Surveillance & supportive care
HCC surveillance
- How6-monthly ultrasound ± AFP in all cirrhosis (and high-risk HBV without cirrhosis).
- CaveatUS sensitivity drops in obesity/MASLD — use CT or MRI when US is inadequate.
Protect & prevent
- VaccinateHepatitis A & B, pneumococcal, influenza, COVID.
- BonesHepatic osteodystrophy — DXA, vitamin D/calcium.
- ScreenDiabetes, renal function, comorbidities.
Nutrition
- ProteinDon't protein-restrict — sarcopenia worsens outcomes. Adequate protein intake.
- FastingAvoid prolonged fasts; a late-evening snack reduces overnight catabolism.
- FrailtyAddress muscle wasting and physical activity.
5 Track the trajectory & know when it changes
Monitor
- ScoresTrack Child-Pugh & MELD over time; repeat LSM to gauge response to etiological treatment.
- RecompensationSustained etiological control + no decompensation + improved function → a real, achievable endpoint.
When it tips over
- First eventAscites, variceal bleed, jaundice, or encephalopathy = decompensation → switch to the decompensated pathway.
- TransplantRefer with decompensation, HCC within criteria, or a rising MELD — don't wait for crisis.
Sources.
Baveno VII — de Franchis et al, J Hepatol 2022 (Rule of Five, cACLD/CSPH non-invasive criteria, carvedilol to prevent first decompensation, Baveno VI endoscopy-sparing, recompensation). EASL & AASLD portal-hypertension and HCC-surveillance guidance (Rule-of-Five adopted). GESA; eTG for Australian practice.
Key trials/evidence: PREDESCI (NSBB prevents decompensation in CSPH); transient-elastography validation cohorts (Rule-of-Five vs decompensation/death/HCC); statin observational/RCT signals in cirrhosis.
Caveats: LSM thresholds assume vibration-controlled transient elastography and a fasting, non-congested, non-inflamed liver — interpret cautiously otherwise. The grey zone (LSM 15–25 with low platelets) is genuinely uncertain and actively researched. HCC-surveillance modality and transplant-referral criteria vary locally — confirm against your unit. Companion to the decompensated cirrhosis sheet.