Multiparametric MRI for Diagnosing Clinically Significant Portal Hypertension and Predicting Liver Decompensation

Background and Aims Clinically significant portal hypertension (CSPH; hepatic venous pressure gradient (HVPG) ≥ 10 mmHg) is a severe complication of chronic liver disease, with increased risk of variceal bleeding and liver decompensation (at HVPG ≥ 12 mmHg). This study evaluated the performance of multiparametric (mp)MRI for diagnosing CSPH and predicting liver decompensation, compared to ultrasound‐based shear wave elastography (SWE) and blood tests. Methods In this prospective single‐centre study (2018–2022), 59 patients (M 30, mean age 52.7 years) underwent mpMRI and HVPG measurement, with an average interval of 32 ± 31 days. The mpMRI protocol included 2D/3D MR elastography (MRE), T 1 /proprietary iron‐compensated T 1 (cT 1 )/T 1ρ mapping, gadoxetate‐enhanced dynamic contrast‐enhanced MRI (DCE‐MRI) of the liver and spleen, SWE and blood tests. Statistical analyses included Mann–Whitney U tests, ROC analysis, logistic regression and Cox proportional hazards models. Results CSPH was present in 13 patients (22%). Several MRI parameters showed high diagnostic performance for CSPH (AUC ≥ 0.8), with spleen stiffness‐2D MRE (AUC 0.88, 95% confidence interval (CI) 0.78–0.98) and liver uptake on DCE‐MRI (AUC 0.83, 95% CI 0.70–0.96) performing best, while SWE had AUCs of 0.63 (95% CI 0.45–0.81) for liver and 0.67 (95% CI 0.44–0.89) for spleen. Combining spleen stiffness‐2D MRE and liver uptake achieved an AUC of 0.93 (95% CI 0.86–1.00) for diagnosing CSPH. For predicting decompensation, spleen stiffness‐3D MRE and liver uptake rate had AUCs of 0.83 (95% CI 0.68–0.99) and 0.83 (95% CI 0.70–0.95), respectively, outperforming SWE. Conclusions Spleen stiffness measured with MRE combined with gadoxetate liver uptake (measured with DCE‐MRI) can diagnose CSPH and predict liver decompensation, with superior performance compared to SWE. Trial Registration ClinicalTrials.gov identifier: NCT03436550