Abstract: Background and Aims Spleen stiffness measurement (SSM) by vibration-controlled transient elastography (VCTE) has been tested in a limited number of studies versus hepatic venous pressure gradient (HVPG), especially with the 100?Hz spleen-specific module. The current study aims to evaluate the diagnostic performance of this novel module for detecting clinically significant portal hypertension (CSPH) in a cohort of compensated patients with metabolic-associated fatty liver disease (MAFLD) as the main aetiology and to improve the performance of the Baveno VII criteria for CSPH diagnosis by including SSM. Methods This is a retrospective single-centre study including patients with available measurements of HVPG, Liver stiffness measurement (LSM) and SSM by VCTE with the 100?Hz module. Area under the receiver operating characteristic (AUROC) curve analysis was conducted to identify dual cut-offs (rule-out and rule-in) associated with the absence/presence of CSPH. The diagnostic algorithms were adequate if negative predictive value (NPV) and positive predictive values (PPV) were >90%. Results A total of 85 patients were included, 60 MAFLD and 25 non-MAFLD. SSM showed a good correlation with HVPG (MAFLD: r = .74; p?49.9 kPa, AUC 0.95). The addition of these cut-offs in a sequential or combined approach to the Baveno VII criteria significantly reduced the grey zone (60% vs. 15%?20%), while maintaining adequate NPV and PPV. Conclusions Our findings support the utility of SSM for diagnosing CSPH in MAFLD patients and demonstrate that the addition of SSM to the Baveno VII criteria increases accuracy.

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