Baveno VII guidelines: shaping the future of portal hypertension management

Portal hypertension, a life-threatening complication of cirrhosis affecting millions globally, has seen paradigm shifts with the release of the Baveno VII consensus guidelines. A new review published online in Volume 138, Issue 18 of the Chinese Medical Journal on September 20 2025, dissects these guidelines, outlining critical advancements and unaddressed challenges in clinical practice.

Baveno VII redefines “first decompensation” as overt complications like variceal bleeding, ascites, or hepatic encephalopathy, emphasizing early intervention for clinically significant portal hypertension (CSPH). Noninvasive tools such as liver and spleen stiffness measurement now complement hepatic venous pressure gradient (HVPG) assessments, improving accessibility to CSPH diagnosis. For compensated patients, nonselective beta-blockers (NSBBs) like carvedilol are recommended to prevent decompensation, shifting focus from variceal bleeding alone to broader disease progression.

In decompensated patients, transjugular intrahepatic portosystemic shunt (TIPS) shows promise in preventing further complications, especially for refractory ascites. Etiological therapy remains foundational—antiviral treatments for hepatitis B/C and alcohol abstinence can slow disease progression, while non-etiological options like statins and SGLT2 inhibitors are under investigation for their disease-modifying potential.

Acute variceal bleeding (AVB) management has also evolved: preemptive TIPS is advised for high-risk patients, while antibiotic prophylaxis and vasoactive drugs improve outcomes. Endoscopic band ligation (EBL) remains first-line for esophageal varices, but proton pump inhibitors are now discouraged due to potential harms.

A groundbreaking Baveno VII concept is “recompensation,” defined as sustained etiological control, resolved decompensation, and improved liver function. Studies show that 60% of HBV-related decompensated cirrhosis patients achieve recompensation with antiviral therapy, though MASH-related cases face greater challenges due to limited etiological cures.

Despite progress, gaps persist: optimizing noninvasive diagnostics, personalizing NSBB use, and refining TIPS candidacy. Future research will focus on MASH therapies, liver regeneration, and long-term monitoring post-recompensation, including hepatocellular carcinoma surveillance.

About Professor Li Yang from Sichuan University

Prof. Li Yang

Affiliation: Division of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, Sichuan

Prof. Virginia Hernandez-Gea

Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain

Funding information

This work was supported by: FIS 23/00997 funded by “Instituto de Salud Carlos III” and co-funded by the European Union; “CIBEREHD” funded by “Instituto de Salud Carlos III” by the European Union’s Horizon 2020 research and innovation program under grant agreement N°825575 (RiTA); “CIBEREHD” funded by “Instituto de Salud Carlos III”; the “Commissioner for Universities and Research from the Department of Economy and Knowledge” of the “Generalitat de Catalunya” (AGAUR SGR2021 01115); the National Natural Science Foundation of China (No. 82470640); the 135 projects for disciplines of excellence, West China Hospital, Sichuan University (No. ZYGD23031); the National Key R&D Program of China (No. 2023YFC2507500); and the Provincial Natural Science Foundation of Shandong, China (Nos. ZR2022MH010 and ZR2023MH295).