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BACKGROUND Advanced chronic liver disease is a progressive condition associated with high morbidity and mortality, leading to complications such as decompensation and hepatocellular carcinoma. Although prognostic scores such as the Child-Pugh score (which combines clinical assessment and laboratory parameters) and laboratory-based models, including Model for End-Stage Liver Disease (MELD) 3.0, albumin-bilirubin (ALBI) grade, and fibrosis-4 (FIB-4), are often used, their accuracy is limited by subjective assessments and variability in laboratory results. The Functional Liver Imaging Score (FLIS), a semi-quantitative magnetic resonance imaging (MRI) measure of liver function, may also be influenced by observer variability. This emphasizes the need for objective, reproducible tools to improve risk stratification and support treatment decision-making. AIM To evaluate the prognostic value of hepatic enhancement (HE) and signal intensity measured by gadoxetate disodium-enhanced MRI. METHODS In this retrospective cohort study, 100 patients with advanced chronic liver disease underwent gadoxetate-enhanced MRI. HE and signal intensity were measured quantitatively in liver segments III, VI, VIII, and the caudate lobe, and global values were calculated by averaging segmental measurements. Correlations were assessed with FLIS, Child-Pugh, MELD 3.0, ALBI, FIB-4, liver stiffness (FibroScan), and hepatic venous pressure gradient. Cox regression and receiver operating characteristic analysis were used to evaluate associations with hepatic decompensation, mortality, and hepatocellular carcinoma (HCC) occurrence during follow-up. RESULTS Global HE showed a significant correlation with FLIS (r = 0.797), Child-Pugh (r = -0.589), MELD 3.0 (r = -0.658), ALBI (r = -0.599), FIB-4 (r = -0.308), liver stiffness (r = -0.470), and hepatic venous pressure gradient (r = -0.340). Lower HE was significantly associated with a higher risk of decompensation and mortality in univariate Cox regression. After adjustment for MELD 3.0, etiology, and prior HCC, segment VI HE remained independently predictive of mortality. At 12 months, HE improved risk stratification for mortality and reduced unnecessary interventions by 11 per 100 patients at a 10% threshold in the decision curve analysis. HE had an area under the receiver operating characteristic curve of 0.74 for predicting decompensation and 0.74 for predicting mortality. HE was higher in patients who developed or experienced recurrence of HCC during follow-up, but this was not statistically significant (P = 0.1). CONCLUSION Lower HE in segment VI improved prognostic classification of high-risk patients. These patients align with Baveno VII criteria for intensified management, supporting the potential role of HE in risk-adapted surveillance.
Stanciu et al. (Fri,) studied this question.