RPS 801 - Liver steatosis and fibrosis quantification

Author Block: V. Koch¹, L. D. Grünewald¹, J. Gotta¹, S. Mahmoudi¹, C. Booz¹, R. Hammerstingl¹, O. Darwish², T. Vogl¹, R. Sinkus³; ¹Frankfurt a. Main/DE, ²London/UK, ³Paris/FR
Purpose: Magnetic resonance elastography (MRE) can quantify tissue biomechanics non-invasively and represents a promising technique for assessing fibrosis in nonalcoholic fatty liver disease (NAFLD). This research presents the preliminary results of a prospective study designed to investigate the value of 2D/3D-MRE utilising the gravitational concept compared to the current product solution (2D-MRE Resoundant).
Methods or Background: Thirty-two participants with different stages of NAFLD were examined twice at 60Hz (Aera, 1.5T, Siemens Healthineers, Germany): firstly, using the Resoundant system (2D-MRE, SE-EPI sequence, 11secs BH) and secondly, using the gravitational transducer approach (2D-MRE and 3D-MRE, GRE sequence, TE=9.2ms (in-phase) and fractional motion encoding at 30mT/m, 14secs BH). While 2D-MRE provides solely the magnitude of the complex shear modulus |G*|, 3D-MRE allows for the additional quantification of both real and imaginary parts of G*. Data extraction and analysis was performed twice by two readers.
Results or Findings: We found a high level of correlation between the 2D-MRE acquisitions obtained using both the Resoundant MRE system and the gravitational transducer approach (r≥0.83 (95% CI, 0.69 to 0.92), p<0.001), although there was a clear bias with 2D-MRE overestimating stiffness values. For markers indicative of liver damage, GOT levels were below 30 for |G*|<4kPa, while for |G*|>4kPa, GOT levels were above 30 in a binary fashion. Interestingly, the 3D-MRE approach showed different correlations depending on the level of GOT expression: for GOT<30 wave attenuation showed a clear trend wrt GOT (r=-0.27, P=0.37), while for GOT>30 viscosity correlated very well to GOT (r=0.61, P=0.047). Viscosity for GOT<30 clustered at low values, similar to attenuation for GOT>30.
Conclusion: Gravitational MRE represents a novel method for the sensitive characterisation of patients with NAFLD, with 3D-MRE carrying the potential to provide imaging biomarkers for liver damage.
Limitations: This research is based on preliminary data.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study received approval from the relevant local Ethics Committee.

Author Block: N. Nakrour¹, E. Shumbayawonda², M. Pansini³, M. Harisinghani¹; ¹Boston, MA/US, ²Oxford/UK, ³Lugano/CH
Purpose: The objective of this study was to assess the comparative diagnostic value of multiparametric MRI (mpMRI) and magnetic resonance elastography (MRE) in real-world clinical practice for managing suspected chronic liver disease.
Methods or Background: A retrospective analysis of the prospective MR exams of 77 patients referred to tertiary chronic liver disease practices. Patients underwent MRE and mpMRI (LiverMultiScan) as a part of their routine clinical care. MRE measures liver fibrosis with liver stiffness (kPa). LiverMultiScan quantifies liver disease activity (iron-corrected T1, cT1), fat (proton density fat fraction, PDFF), and iron content (T2*). MRE≥3kPa indicates any level of fibrosis; cT1≥800ms and ≥875ms indicate active and high-risk disease, respectively.
Results or Findings: 55% (42) of patients were diagnosed with MASLD/MASH and 45% with mixed chronic liver diseases, including alcoholic liver disease, viral hepatitis, hemochromatosis, high ferritin, among others. The majority, 71% (55), had normal liver stiffness (≤3kPa); however, 29% (22) of these had active disease (cT1>800ms), with 14% (11) having elevated cT1 indicative of high-risk disease (cT1>875ms). There was a linear significant correlation between MRE and cT1 (r=0.411, p=0.0004), and those with elevated MRE (MRE>3kPa) had cT1 864±74ms. cT1 correlated with PDFF (r=0.5, p<0.001), but MRE was not (r=-0.055, p=0.65). cT1 was successful in 99% (76) of patients, while MRE was successful in 90% (69).
Conclusion: MRE and cT1 provide clinically complementary information on liver health state, with cT1 identifying patients with underlying liver disease activity who are at risk of worse outcomes but have normal liver stiffness. These patients would benefit from more intense clinical management or surveillance to prevent clinical outcomes. Caution should be taken in utilising MRE in patients with suspected high liver iron.
Limitations: MRE and cT1 had an unreliable result in one patient. MRE technical failures were in patients with elevated liver iron.
Funding for this study: This study was partially funded.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved with code: Protocol #2020P000706.

Author Block: B. Masci, M. Zerunian, S. Nardacci, F. Pucciarelli, M. Polici, I. Nacci, D. Principessa, D. Caruso, A. Laghi; Rome/IT
Purpose: The purpose of this study was to evaluate the possible correlation between hepatic steatosis and sarcopenia assessed with skeletal muscle index (SMI) at unenhanced MRI of the abdomen in patients with multiple metabolic risk factors.
Methods or Background: 105 patients with metabolic syndrome were prospectively enrolled between October 2022 and June 2023. Each patient underwent 1.5T upper abdomen MRI examination, acquisition protocol included axial proton density fat fraction (PDFF), magnetic resonance elastography (MRE) and axial T1 weighted gradient-echo sequences targeted at the third lumbar vertebra (L3) level. A single radiologist performed quantitative image analysis on a dedicated workstation. Steatosis and myosteatosis estimation expressed as a percentage and liver stiffness (kPa) were collected and grading of steatosis and fibrosis was assigned. The presence of sarcopenia was assessed by segmenting the L3 dual-echo images with ImageJ pixel analysis software and calculating the SMI. Correlations among parameters were assessed using Spearman’s rank coefficient using a dedicated software and p<0.05 was considered significant.
Results or Findings: PDFF values of hepatic steatosis were found in 65% of patients (6.7±1.8%); liver stiffness resulted in higher compatibility with inflammation values in 35% of patients (2.6kPa±0.2kPa).
SMI average values were compatible with sarcopenia in 71% of patients (Males: 41.5±6.8cm^2/m^2; Females: 33.5±3.2cm^2/m^2).The statistical analysis showed significant correlation between hepatic steatosis and sarcopenia (P<0.03, rho 0.17). Moreover, by stratifying the cohort for sex, a significant correlation between the steatosis grade and sarcopenia in female patients (P<0.02, rho -0.38) emerges.
Conclusion: Patients with metabolic syndrome and hepatic steatosis are correlated with lower SMI values and sarcopenia, and the correlation is stronger in female patients. This method might be a non-invasive, radiation-free and repeatable method for a comprehensive metabolic assessment of the patients at diagnosis and at follow-up.
Limitations: We analysed a small population sample and performed a manual segmentation, which was often time consuming. A further limitation is the single vendor technology analysis approach taken.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the Institutional Review Board, and written informed consent was obtained for all patients.

Author Block: R. G. Barr¹, G. Ferraioli²; ¹Youngstown, OH/US, ²Pavia/IT
Purpose: The purpose of this study was to assess whether meal or water intake may affect the measurement of the ultrasound attenuation coefficient imaging, a parameter that is directly related to liver fat content.
Methods or Background: The study was performed in two centres (in Italy and in the USA). Attenuation coefficients were obtained using the ATI algorithm implemented in the Aplio i-series ultrasound systems (Canon Medical Systems, Japan) by one operator at each centre. Measurements were performed at baseline and 5, 15, 30, and 45 minutes after drinking 500ml of water (group1), or 30, 45, 60, 90, and 120 minutes after eating a meal of about 600 kilocalories (group2). Multilevel generalised estimating equations for repeated measures were used for the statistical analysis to consider the clustered nature of the data.
Results or Findings: Twenty-one individuals were enrolled: 11 (10 females; aged 43.7±12.5 years) in Italy and 10 (7 females; aged 59.7±7.1 years) in the USA. At the B-mode ultrasound, six (28.6%) had liver steatosis. The baseline attenuation coefficient values, in dB/cm/mHz were 0.62 (0.11) in group1 and 0.66 (0.12) in group2. There was not any significant difference in attenuation coefficient values at every timing either in group1 or group2. This result did not change even when controlling for sex, age, and skin-to-liver capsules.
Conclusion: The measurement of the attenuation coefficient, which is a biomarker of liver steatosis, does not require a fasting state and drinking water does not affect the result.
Limitations: Although the findings of this study were statistically significant, the number of participants was small.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the Western Reserve Health IRB, Youngstown, Ohio, USA, and the Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy.

Author Block: I. Nacci, F. Pucciarelli, B. Masci, M. Zerunian, D. De Santis, D. Caruso, A. Laghi; Rome/IT
Purpose: The purpose of this study was to assess ultrasound attenuation coefficient (AC) for quantifying liver fat deposit and to evaluate two-dimensional shear wave elastography (2D-SWE) for quantifying liver fibrosis using MRI-proton density fat fraction (MRI-PDFF) and magnetic resonance elastography (MRE) as the references, respectively, in patients with risk factors for NAFLD.
Methods or Background: This prospective study included patients with risk factors for NAFLD (diabetes or metabolic syndrome). Patients with secondary causes of fat deposition were excluded. All participants underwent liver QUS and MRI on the same day, and laboratory tests within 30 days. Based on MRI-PDFF and MRE, we obtained normal liver, liver steatosis and liver fibrosis groups. We examined diagnostic performance of AC and 2D-SWE for detecting liver fat content and stiffness using area under receiver operating characteristic curve (AUC). We also analysed correlations of QUS biomarkers to MRI using Spearman correlation coefficient.
Results or Findings: A total of 54 participants were included. Of these participants, 21 (38.9%) had MRI-PDFF≥5%, and 10 (18.5%) had MRE≥2.9kPa. AUC of AC for determining greater than and equal mild steatotic livers was 0.80 (95% confidence interval [CI]: 0.67-0.94). AUC of 2D-SWE for determining greater than and equal F1 liver fibrosis was 0.59 (95% CI: 0.40-0.79). AC had a sensitivity of 71.4% and a specificity of 87.9%, 2D-SWE had a sensitivity of 60% and a specificity of 52.3%. AC did not correlate well with MRI-PDFF in assessing hepatic steatosis (r=0.43), and 2D-SWE did not correlate with MRE in evaluating liver fibrosis (r=0.39).
Conclusion: Our preliminary results show that QUS biomarkers are more accurate for screening mild hepatic steatosis than fibrosis in patients with risk factors for NAFLD, but do not accurately discriminate different degrees of steatosis and fibrosis.
Limitations: The sample size was small, and the study was single-centred.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study was approved by the relevant Institutional Review Board, and all patients gave informed consent.

Author Block: C. Hobeika¹, M. Ronot¹, D. Valla¹, J. M. Correas², V. Vilgrain¹, M. Dioguardi Burgio¹; ¹Clichy/FR, ²Paris/FR
Purpose: Non-invasive tools assessing steatosis, such as ultrasonography-based 2D-attenuation imaging (ATI), are needed to tackle the worldwide burden of NAFLD. This one-stage individual patient data (IPD) meta-analysis aimed to create an ATI-based steatosis grading system.
Methods or Background: A systematic review (EMBASE+MEDLINE, 2018-2022) identified studies, including patients with histologically or MRI-PDFF-verified ATI values for grading steatosis (S0 to S3). One-stage IPD meta-analyses were conducted using generalised mixed models with a random study-specific intercept. Created ATI-based steatosis grading system (aS0 to aS3) was externally validated on a prospective cohort of patients with type 2 diabetes and NAFLD (n=174, histologically and MRI-PDFF verified steatosis).
Results or Findings: Eleven enrolled studies included 1374 patients, classified into S0, S1, S2, and S3 in 45.4%, 35.0%, 9.3%, and 10.3% of the cases. ATI was correlated with histologically (r=0.60; 95%CI: 0.52,0.67; p<0.001), and MRI-PDFF (r=0.70; 95%CI: 0.66,0.73; p<0.001) quantified steatosis while uncorrelated with liver stiffness (r=0.03; 95%CI: -0.04,0.11, p=0.343). Steatosis grade (Coefficient: 0.27; 95%CI: 0.07,0.47; p=0.008) was the only independent factor associated with ATI, while age, sex, BMI, chronic hepatitis, and alcohol consumption were not. ATI marginal means within S0, S1, S2, and S3 subpopulations were 0.59 (95%CI: 0.56,0.61), 0.69 (95%CI: 0.65,0.72), 0.77 (95%CI: 0.73,0.81), and 0.84 (95%CI: 0.80, 0.89) dB/cm/MHz; all contrasts between grades were significant (p<0.0001). Three ATI thresholds were calibrated to create a new ATI-based steatosis grading system (aS0 to aS3, cut-offs: 0.66, 0.73, and 0.81dB/cm/MHz). Its external validation showed Obuchowski measures (to interpret as AUC values) of 0.84±0.01 and 0.82±0.02 with histologically- and MRI-PDFF-based references.
Conclusion: ATI is a reliable non-invasive marker of steatosis. This validated ATI-based steatosis grading system could be valuable in assessing NAFLD patients.
Limitations: There is a difference in steatosis prevalence among the included studies.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the local Institutional Research Board.

Author Block: G. Ferraioli¹, A. De Silvestri¹, R. G. Barr²; ¹Pavia/IT, ²Rootstown, OH/US
Purpose: It has been reported that the estimate of the ultrasound attenuation coefficient (AC) for liver fat quantification is affected by the depth of measurements, with a linear decrease of values with depth. The purpose of this paper was to determine whether the backscatter coefficient (BSC) has the same behavior.
Methods or Background: This retrospective study was performed with the Sequoia ultrasound system equipped with the ultrasound derived fat fraction (UDFF) algorithm (Siemens Healthineers, Germany) that combines BSC with AC. UDFF was obtained positioning the upper edge of the region of interest (3x3 cm) at 1.5, 2, 3, 4, 5 cm below liver capsule. BSC data were extracted from UDFF offline. The median value of five acquisitions was used for statistical analysis. A fractional polynomial regression, which selects the best model considering the polynomial development of the variables of interest, was used. The covariates included were age, sex, skin-to-liver-capsule distance, and stiffness. The distance was included as linear factor or with a power of -2;-1;-0.5;0;0.5;1;2;3 or each possible pair of them. Best fitting models was chosen according to partial F test. Body mass index (BMI) was not included because of collinearity with skin-to-liver capsule distance.
Results or Findings: Fifty-one individuals (25 females, mean age: 61±13 years; mean BMI: 27±6kg/m2; skin-to-liver-capsule distance: 2.0±0.5cm; liver stiffness: 8±6kiloPascal) were studied. Best fitting model included depth as square root (beta -40; 95% confidence intervals from -64 to -15) and linear factor (beta 11; 95% confidence intervals from 4 to 18). Skin-to-liver-capsule distance and stiffness also were independent predictors of BSC.
Conclusion: There is a depth dependence in liver BSC measurement that can substantially affect results. A standardised acquisition protocol is needed to compare results and to reliably assess changes in serial measurements.
Limitations: No limitations were identified.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: The study is retrospective.

Author Block: Z. Zsombor, A. D. Rónaszéki, B. Csongrády, R. Stollmayer, B. K. Budai, V. Bérczi, P. Maurovich-Horvat, K. Hagymási, P. N. Kaposi-Novák; Budapest/HU
Purpose: The goal of our study was to evaluate artificial intelligence-calculated hepatorenal index (AI-HRI) as a diagnostic method for hepatic steatosis.
Methods or Background: We prospectively enrolled 103 patients with clinically suspected metabolic dysfunction-associated steatotic liver disease (MASLD). All patients had a quantitative ultrasound (QUS), including AI-HRI, ultrasound attenuation coefficient (AC), and ultrasound backscatter-distribution coefficient (SC) measurements. The ultrasonographic fatty liver indicator (US-FLI) score was also calculated. The magnetic resonance imaging fat fraction (MRI-PDFF) was the reference to classify patients into four grades of steatosis: none <5%, mild 5-10%, moderate 10-20%, and severe ≥20%. We determined the agreement between AI-HRI by two examiners using the intraclass correlation coefficient (ICC) of 68 cases.
Results or Findings: The AI-HRI was significantly different between groups without (1.480 ±0.607, p<0.003) and with mild steatosis (2.155 ±0.776), as well as between mild and moderate steatosis (2.777 ±0.923, p<0.018). AI-HRI showed a moderate correlation with AC (Spearman's r=0.597), SC (rs=0.473), US-FLI (r=0.5), and MRI-PDFF (r=0.528). The agreement in AI-HRI was good between the two examiners (ICC=0.635, 95% confidence interval (CI)=0.411–0.774, p<0.001). The AI-HRI could detect mild steatosis (AUC=0.758, 95% CI=0.621–0.894) with fair and moderate/severe steatosis (AUC=0.803, 95% CI=0.721–0.885) with good accuracy. However, the performance of AI-HRI was not significantly different (p<0.578) between the two diagnostic tasks.
Conclusion: AI-HRI is an efficient, reproducible, and accurate QUS method to diagnose mild and moderate hepatic steatosis.
Limitations: This is a single-centre study with a limited number of patients.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the Regional and Institutional Science and Research Ethics Committee at Semmelweis University (Protocol number: SE RKEB 140/2020, 16-07-2020).

Author Block: C. Solito, C. Di Bella, P. Pacini, G. T. Lucarelli, M. Renda, V. Dolcetti, G. Del Gaudio, V. Cantisani; Rome/IT
Purpose: Metabolic dysfunction-associated fatty liver disease (MAFLD) is the most frequent chronic liver disease in the adult population and liver biopsy diagnosis is the gold standard. The purpose of this study is to evaluate the diagnostic accuracy of the new Hepato-Renal Index with Automated ROI Recommendation (EzHRI™), Tissue Attenuation Imaging (TAI™), and Tissue Scatter distribution Imaging (TSI™) ultrasound software for hepatic steatosis quantification, comparing with MRI.
Methods or Background: 92 patients underwent multiparametric ultrasound evaluation and 3T MRI evaluation with two different techniques- 3D T2* with Dixon pulse multiple-echo sequence (IDEAL IQ; MR-PDFF- and MR spectroscopy). The best QUS cut-offs have been identified and the QUS results are compared with MRI proton density fat fraction for diagnosis and quantification of liver fat content. Inter-observational variability was also tested between two operators.
Results or Findings: The best cut-off values for MAFLD diagnosis are EzHRI>1.21; TAI>0.63 and TSI>92 with a sensitivity of 97.5%, 88.8% and 98.8% respectively and a specificity of 83.3%, 100% and 66.7% respectively. Comparing QUS with MRI in detection of liver steatosis, sensitivity and specificity were 88.8% and 100% for TAI, 98.8% and 66.7% for TSI and 97.5% and 83.3% for EzHRI. In the quantification of liver fat content, TAI sensitivity and specificity were 80%-100%, 100%-100% and 100%-100% for mild, moderate and severe steatosis respectively; TSI sensitivity and specificity were 97.8%-66.7%, 100%-66.7% and 100%-66.7% for mild, moderate and severe steatosis respectively; EzHRI sensitivity and specificity were 95.6%-83.3%, 100%-83.3% and 100%-83.3% for mild, moderate and severe steatosis respectively.
Conclusion: QUS is a useful tool for screening and monitoring patients with MAFLD and can assist in avoiding unnecessary biopsies.
Limitations: This study is limited by interoperator variability, which diminishes its reproducibility. Furthermore, there is reduced accuracy in patients with obesity or renal disease.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by Sapienza-Roma. No additional information was provided by the submitter.

Author Block: T. Zheng¹, Y. Zhu², Y. Chen¹, Y. Qu¹, Y. Chen², B. Song¹; ¹Chengdu/CN, ²Shanghai/CN
Purpose: This study aimed to develop a fully automated diagnostic convolutional neural network (CNN) model for cirrhosis based on liver MRI and serum biomarkers.
Methods or Background: This single-centre retrospective study enrolled consecutive patients receiving pathological evaluation of liver fibrosis stage and contrast-enhanced liver MRI between March 2010 and May 2021. On the training set, an MRI-based CNN model was constructed for cirrhosis against pathology, and then a combined model was developed integrating the CNN model and serum biomarkers. On the testing set, the area under the receiver operating characteristic curve (AUC) was computed to compare the diagnostic performance of the combined model with that of aminotransferase-to-platelet ratio index (APRI), fibrosis-4 index (FIB-4), and radiologists. The influence of potential confounders on the diagnostic performance was evaluated by subgroup analyses.
Results or Findings: A total of 934 patients (median age, 53 years; 762 men; training, n=840) were enrolled, 601 (64%) with pathological cirrhosis. The CNN model was constructed on pre-contrast T1- and T2-weighted imaging, and the combined model was developed integrating the CNN model, age, and eight serum biomarkers. On the testing dataset, the combined model achieved an AUC of 0.89, which outperformed FIB-4, APRI and two radiologists (AUC: 0.71 to 0.78, all p<0.05). Subgroup analyses revealed comparable diagnostic performances of the combined model in patients with different sizes of focal liver lesions.
Conclusion: Based on pre-contrast T1- and T2-weighted imaging, age, and serum biomarkers, the combined model allowed accurate diagnosis of cirrhosis, independent of size of focal liver lesions.
Limitations: The limitations of the study are that it is a single-centre retrospective study, lack of a head-to-head comparison with elastography techniques, and unknown model performance compared with a combination of radiologists and serum biomarkers .
Funding for this study: Funding was received from the National Natural Science Foundation of China (Grant No. U22A20343, 82101997), National Health Commission Capacity Building and Continuing Education Center (Grant No. YXFSC2022JJSJ007), the 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University (Grant No. ZYJC21012), Med-X Center for Informatics, Sichuan University (NO.YGJC007), and the Science and Technology Department of Sichuan Province (No. 2022YFS0071).
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the Ethics Committee on Biomedical Research, West China Hospital of Sichuan University (2021-1370).

Author Block: D. Catucci, J. Hrycyk, N. F. Lange, V. Obmann, A. Berzigotti, L. Ebner, A. Christe, J. T. Heverhagen, A. T. Huber; Berne/CH
Purpose: This study aimed to analyse the performance of caudate to right lobe ratio (CRL-R), liver segmental volume ratio (LSVR) and liver segmental volume and attenuation ratio (LSVAR) to screen for chronic liver disease (CLD) on routine abdominal CT scans and to predict the 5-year probability of transplant-free survival and first hepatic decompensation.
Methods or Background: This retrospective study included 108 patients without CLD (noCLD-group; n=108), as well as 98 patients with CLD and liver biopsy. All patients underwent abdominal CT scans between 03/2015 and 08/2017. Patients with CLD were further divided into three groups based on their liver fibrosis degree: early CLD (F0-F2; eCLD-group; n=40), advanced CLD (F3-F4; aCLD-group; n=20), and aCLD with clinically significant portal hypertension according to the BAVENO VII consensus (aCLDPH-group; n=38). CRL-R, LSVR, and LSVAR were measured in all patients. The study analysed the 5-year outcomes of each patient, including death or liver transplantation and first hepatic decompensation. Statistical analysis included the Kruskal-Wallis test, ROC curve analysis, and the Kaplan-Meier curve.
Results or Findings: CRL-R, LSVR and LSVAR differed significantly between all groups (p<0.001). A CRL-R cutoff-value of > 0.93 proofed best to detect patients with CLD (sensitivity of 69%, specificity of 78%). Patients with both CRL-R >0.99 and LSVR >0.37 had the lowest probability of 5-year transplant-free survival (46%) and the lowest probability of a decompensation-free 5-year course (75%).
Conclusion: CRL-R, LSVR and LSVAR allow screening for CLD and prognostication of 5-year transplant-free survival and occurrence of first hepatic decompensation.
Limitations: The limitations of this study were its retrospective design and the lack of invasive measurement of the hepatovenous pressure gradient, which was not available due to ethical concerns.
Funding for this study: This study received funding by the Swiss National Science Foundation (SNF), Grant number 188591.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This retrospective study was approved by the Institutional Review Board.