Gadoxetic acid-enhanced MRI-derived functional liver imaging score (FLIS) and spleen diameter predict outcomes in ACLD

Background & Aims: Functional liver imaging score (FLIS) - derived from gadoxetic acid-enhanced MRI - correlates with liver function and independently predicts liver-related mortality in patients with chronic liver disease (CLD), while splenic cra-niocaudal diameter (SCCD) is a marker of portal hypertension. The aim of this study was to investigate the accuracy of a com-bination of FLIS and SCCD for predicting hepatic decompensa-tion, acute-on-chronic liver failure (ACLF), and mortality in patients with advanced CLD (ACLD). Methods: We included 397 patients with CLD who underwent gadoxetic acid-enhanced liver MRI. The FLIS was calculated by summing the points (0-2) of 3 hepatobiliary-phase features: hepatic enhancement, biliary excretion, and portal vein signal intensity. Patients were stratified into 3 groups according to liver fibrosis severity and presence/history of hepatic decompensa-tion: non-ACLD, compensated ACLD (cACLD), and decom-pensated ACLD (dACLD).Results: SCCD showed excellent intra-and inter-reader agree-ment. Importantly, SCCD was an independent risk factor for hepatic decompensation in patients with cACLD (per cm; adjusted hazard ratio [aHR] 1.13; 95% CI 1.04-1.23; p = 0.004). Patients with cACLD and a FLIS of 0-3 points and/or a SCCD of >13 cm were at increased risk of hepatic decompensation (aHR 3.07; 95% CI 1.43-6.59; p = 0.004). In patients with dACLD, a FLIS of 0-3 was independently associated with an increased risk of ACLF (aHR 2.81; 95% CI 1.16-6.84; p = 0.02), even after adjusting for other prognostic factors. Finally, a FLIS and SCCD-based al-gorithm was independently predictive of transplant-free mor-tality and stratified the probability of transplant-free survival (TFS) in ACLD (p <0.001): FLIS 4-6 and SCCD <-13 cm (5-year TFS of 84%) vs. FLIS 4-6 and SCCD >13 cm (5-year TFS of 70%) vs. FLIS 0-3 (5-year TFS of 24%).Conclusion: The FLIS and SCCD are simple imaging markers that provide complementary information for risk stratification in patients with compensated and decompensated ACLD.Lay summary: Magnetic resonance imaging (MRI) can be used to assess the state of the liver. Previously the functional liver im-aging score, which is based on MRI criteria, was developed as a measure of liver function and to predict the risk of liver-related complications or death. By combining this score with a mea-surement of spleen diameter, also using MRI, we generated an algorithm that could predict the risk of adverse liver-related outcomes in patients with advanced chronic liver disease.(c) 2022 The Author(s). Published by Elsevier B.V. on behalf of Euro-pean Association for the Study of the Liver. This is an open access article under the CC BY license (http://creativecommons.org/licenses/ by/4.0/).