From the AGA Journals

MR elastography could predict cirrhosis in NAFLD

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Progress made on liver disease progression

NAFLD is rapidly becoming one of the most common causes of liver disease. While most patients have a benign course, approximately 20% of patients develop nonalcoholic steatohepatitis, the progressive form of the disease. Given the high prevalence (30% of the U.S. population), it is vital to determine which patients are at risk for progression, cirrhosis, and decompensation. Although liver biopsy is the preferred method, this procedure is invasive and carries substantial risks, including severe bleeding. Noninvasive tests that measure liver stiffness have emerged: Examples are controlled elastography (VCTE), such as Fibroscan, and magnetic resonance elastography (MRE). Data support the use of liver stiffness as a surrogate measure of fibrosis; MRE has demonstrated higher fidelity and accuracy, compared with VCTE, while being limited because of cost and availability. However, there is a paucity of data regarding the use of liver stiffness to predict progression to cirrhosis or liver-related events.

Dr. Yamini Natarajan

This study by Dr. Gidener and colleagues highlights the use of MRE to evaluate liver stiffness measurements as a predictor for cirrhosis and decompensation. Baseline measurements more than 4-5 kPa should alert clinicians regarding increased risk of progression to cirrhosis. Patients with cirrhosis and baseline measurements of 8 kPa or higher have a high risk of decompensation/death, suggesting that they should be followed more closely. Given the burgeoning number of patients with NAFLD and NASH, this study demonstrates the importance of identifying high-risk patients in order to optimize use of resources and improve clinical outcomes.

Yamini Natarajan, MD, is an investigator at the Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center, Houston, and an assistant professor, department of medicine, section of gastroenterology and hepatology, Baylor College of Medicine, Houston. She has no conflicts.



Liver stiffness measurement with magnetic resonance elastography (MRE) may prove predictive of future cirrhosis risk in patients with nonalcoholic fatty liver disease (NAFLD), according to researchers from the Mayo Clinic in Rochester, Minn.

“These data expand the role of MRE from an accurate diagnostic method to a prognostic noninvasive imaging biomarker that can risk-stratify patients with NAFLD and guide the timing of surveillance and further refine their clinical management,” wrote Tolga Gidener, MD, and colleagues. The study authors added that the research further expands “the role of MRE beyond liver fibrosis estimation by adding a predictive feature to improve individualized disease monitoring and patient counseling.” Their study was published in Clinical Gastroenterology and Hepatology.

Currently, there are no established noninvasive strategies that can effectively identify patients with NAFLD who are at high risk of progression to cirrhosis and liver-related complications. While fibrosis stage on histology may predict liver-associated outcomes in these patients, this approach is invasive, time consuming, and is generally not well tolerated by patients.

Although the technique has been noted for its high success rate and excellent levels of reliability and reproducibility, a possible limitation of MRE is its cost. That said, standalone MRE is reimbursed under Medicare Category I Current Procedural Terminology code 76391 with a cost of $240.02. However, there is also a lack of data on whether baseline liver stiffness measurement by MRE can predict progression of NAFLD to cirrhosis.

To gauge the role of baseline liver stiffness measurement by MRE, Dr. Gidener and colleagues performed a retrospective cohort study that evaluated hard liver–related outcomes in 829 adult patients with NAFLD with or without cirrhosis (median age, 58 years; 54% female) who underwent MRE during 2007-2019.

Patients in the study were followed from the first MRE until death, last clinical encounter, or the end of the study. Clinical outcomes assessed in individual chart review included cirrhosis, hepatic decompensation, and death.

At baseline, the median liver stiffness measurement was 2.8 kPa in 639 patients with NAFLD but without cirrhosis. Over a median 4-year follow-up period, a total of 20 patients developed cirrhosis, with an overall annual incidence rate of 1%.

Baseline liver stiffness measurement by MRE was significantly predictive of subsequent cirrhosis (hazard ratio, 2.93; 95% confidence interval, 1.86-4.62; P < .0001) per 1-kPa difference in liver stiffness measurement at baseline.

According to the researchers, the probability of future cirrhosis development can be ascertained using current liver stiffness measurement. As such, a greater than 1% probability threshold can be reached in 5 years in patients with a measurement of 2 kPa, 3 years in patients with a measurement of 3 kPA, and 1 year in patients with 4-5 kPa. “These time frames inform about estimated time to progression to hard outcomes and provide guidance for subsequent noninvasive monitoring for disease progression,” wrote the researchers.

The baseline liver stiffness measurement by MRE was also significantly predictive of future hepatic decompensation or death (HR, 1.32; 95% CI, 1.13-1.56; P = .0007) per 1-kPa increment in the liver stiffness measurement. Likewise, the 1-year probability of subsequent hepatic decompensation or death in patients with cirrhosis and baseline liver stiffness measurement of 5 kPa versus 8 kPa was 9% versus 20%, respectively. In terms of covariates, age was the only factor that increased the risk of hepatic decompensation or death.

While the current study offers a glimpse into the potential clinical implications of liver stiffness measurement by MRE in NAFLD, the researchers suggest the applicability of the findings are limited by the study’s small sample size, relatively short follow-up duration, and the small number of cirrhosis events.

The researchers received study funding from the National Institute of Diabetes and Digestive and Kidney Diseases, American College of Gastroenterology, National Institutes of Health, and the Department of Defense. The researchers disclosed no other relevant conflicts of interest.

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