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Baveno VII–VITRO algorithm for CSPH

Rule in or rule out clinically significant portal hypertension from liver stiffness, platelets and VITRO

Sources last checked: 2026-10-13

Baveno VII–VITRO algorithm for CSPH

Rule in or rule out clinically significant portal hypertension from liver stiffness, platelets and VITRO

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Derived and validated in patients with LSM ≥ 10 kPa undergoing HVPG measurement in Vienna. The Baveno VII rule-in (LSM ≥ 25 kPa) is validated for viral, alcohol-related and non-obese MASH/NASH cACLD; in obese MASH use the ANTICIPATE-NASH model instead. VWF is raised by infection and inflammation. Not for decompensated cirrhosis (CSPH is already present) or pre-hepatic portal hypertension.

Source: Jachs M, Hartl L, Simbrunner B et al. The sequential application of Baveno VII criteria and VITRO score improves diagnosis of clinically significant portal hypertension. Clin Gastroenterol Hepatol 2023;21(7):1854-1863.e10.Open

Interpretation

LSM < 10 kPa — cACLD ruled out; algorithm not applicableBillroth IV: LSM < 10 kPa rules out compensated advanced chronic liver disease.
CSPH ruled out — Baveno VII (LSM ≤ 15 kPa and platelets ≥ 150 G/L)Sensitivity and NPV > 90 %. Baveno VII: screening endoscopy can be avoided in this group, with repeat LSM (e.g. yearly).
CSPH ruled out — VITRO ≤ 1.5 (Baveno VII unclassified)Sequential algorithm (Jachs 2023): sensitivity 97.7 %, NPV 97.5 %; no patient in this group decompensated within 5 years.
Unclassified — CSPH neither ruled in nor outVITRO 1.5–2.5 after unclassified Baveno VII. Billroth IV names HVPG measurement and/or endoscopy for further evaluation (varices confirm CSPH).
CSPH ruled in — VITRO ≥ 2.5 (Baveno VII unclassified)Specificity 94.7 %, PPV 91.2 % (Jachs 2023). Baveno VII/Billroth IV consider NSBB therapy (carvedilol) for patients with CSPH.
CSPH ruled in — Baveno VII (LSM ≥ 25 kPa)Specificity and PPV > 90 % in viral, alcohol-related and non-obese MASH/NASH-related cACLD. Baveno VII considers NSBB therapy (carvedilol) for patients with CSPH.

What is the Baveno VII–VITRO algorithm for CSPH?

This algorithm applies the Baveno VII liver-stiffness and platelet criteria first and then the VITRO score for patients who remain unclassified. Jachs, Mandorfer, Reiberger and colleagues at the Vienna Hepatic Hemodynamic Lab developed it against HVPG measurements in 302 patients with compensated advanced chronic liver disease (Clin Gastroenterol Hepatol 2023), reducing the unclassified group to under 15 %. The Austrian Billroth IV consensus recommends this sequential use.

When to use it

  • Compensated advanced chronic liver disease (LSM ≥ 10 kPa) to decide whether CSPH is present.
  • Deciding on non-selective beta-blocker therapy and on the need for screening endoscopy.
  • When Baveno VII criteria alone leave the patient in the grey zone.

When not to use it

  • Decompensated cirrhosis (ascites, variceal bleeding, encephalopathy) — CSPH is already established.
  • Obese patients with MASH/NASH for the LSM ≥ 25 kPa rule-in (use ANTICIPATE-NASH).
  • Pre-hepatic or porto-sinusoidal vascular disease, where LSM does not reflect portal pressure.

How it is calculated

1. LSM < 10 kPa → cACLD ruled out 2. LSM ≤ 15 kPa and PLT ≥ 150 G/L → CSPH ruled out 3. LSM ≥ 25 kPa → CSPH ruled in 4. Otherwise VITRO ≤ 1.5 → ruled out; ≥ 2.5 → ruled in; between → unclassified

Clinical pearls and limitations

  • Derived and validated in patients with LSM ≥ 10 kPa undergoing HVPG measurement in Vienna. The Baveno VII rule-in (LSM ≥ 25 kPa) is validated for viral, alcohol-related and non-obese MASH/NASH cACLD; in obese MASH use the ANTICIPATE-NASH model instead. VWF is raised by infection and inflammation. Not for decompensated cirrhosis (CSPH is already present) or pre-hepatic portal hypertension.
  • Baveno VII describes liver stiffness measurement in the fasting state, with values ≥ 10 kPa confirmed by a repeat measurement.
  • In Jachs 2023, no patient ruled out by the algorithm decompensated within 5 years; 23.9 % of ruled-in patients did.
  • VWF increases with infection — postpone VITRO during intercurrent illness.
  • Unclassified patients need HVPG measurement and/or endoscopy (varices confirm CSPH).

Frequently asked questions

What are the Baveno VII criteria for CSPH?

LSM ≤ 15 kPa plus platelets ≥ 150 G/L rules out CSPH; LSM ≥ 25 kPa rules it in (viral, alcohol-related and non-obese MASH/NASH).

What do I do in the Baveno VII grey zone?

Calculate VITRO (VWF:Ag % ÷ platelets G/L): ≤ 1.5 rules out and ≥ 2.5 rules in CSPH; in between, Billroth IV names HVPG measurement or endoscopy for further evaluation.

Does a ruled-in result mean I should start carvedilol?

Baveno VII and Billroth IV recommend NSBB (preferably carvedilol) for patients with CSPH to prevent decompensation, provided there are no contraindications — the decision remains clinical.

Evidence and guidelines

  1. Primary source: Jachs M, Hartl L, Simbrunner B et al. The sequential application of Baveno VII criteria and VITRO score improves diagnosis of clinically significant portal hypertension. Clin Gastroenterol Hepatol 2023;21(7):1854-1863.e10.
  2. Reiberger T et al. Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV). Wien Klin Wochenschr 2023;135(Suppl 3):493-523.
  3. de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII — Renewing consensus in portal hypertension. J Hepatol 2022;76(4):959-974.
  4. Hametner S et al. The VITRO score as a new marker for clinically significant portal hypertension. PLoS One 2016;11(2):e0149230.

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