The development and validation of magnetic resonance elastography for fibrosis staging in primary sclerosing cholangitis
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To develop and internally validate MR elastography (MRE) quantified liver stiffness (LS) cut-off values for distinguishing early/moderate fibrosis from cirrhosis in primary sclerosing cholangitis (PSC) against non-invasive fibrosis test of vibration-controlled transient elastography (VCTE).
Sixty-seven patients were enrolled prospectively at a tertiary care centre to undergo MRE and VCTE. MRE-quantified LS was calculated using three region-of-interest (ROI) methods: Trace, Average and Maximum. Each ROI method was compared with the reference standard of VCTE. Internal validation was performed with bootstrapping. Univariable and multivariable linear regression determined independent predictors for MRE-quantified LS and final Mayo Risk Score (MRS).
MRE-quantified LS by Trace ROI method had the highest sensitivity [87.5%; 95% confidence interval (CI), 66.0-96.8] and specificity (96.1%; 95%CI, 89.6-99.0) for distinguishing cirrhosis; and was the strongest predictor of final MRS (β, 0.44; 95% CI, 0.27-0.61). Alkaline phosphatase twice the normal upper limit (β, 1.55; 95% CI, 0.95-2.17), abnormal bilirubin (β, 1.27; 95% CI, 0.41-2.14) and thrombocytopaenia (β, 0.79; 95% CI, 0.12-1.46) were independent predictors of LS.
MRE has a higher correlation with MRS than VCTE; and though MRE is possibly influenced by severe cholestasis and portal hypertension, MRE-quantified LS is an independent predictor of worse MRS.
• MRE is valid and reliable in assessing cirrhosis in PSC, and MRE-quantified Liver stiffness (LS) score was the strongest predictor of final Mayo Risk Score (MRS).
• Trace ROI performs best for distinguishing moderate fibrosis from cirrhosis and has the highest correlation with Mayo Risk Score (MRS).
• Cholestasis, hyperbilirubinaemia and portal hypertension may influence MRE LS score.
KeywordsMagnetic resonance imaging Primary sclerosing cholangitis Elasticity imaging techniques Liver cirrhosis Bile ducts
Aspartate aminotransferase-to-platelet ratio
Area under the receiver operating characteristic
Body mass index
Inflammatory bowel disease
Gradient recalled echo
International normalised ratio
Magnetic resonance cholangiopancreaticogram
Magnetic resonance elastography
Mayo Risk score
Sodium-model for end-stage liver disease
Primary biliary cirrhosis
Primary sclerosing cholangitis
Upper limit of normal
Vibration-controlled transient elastography
This study has received peer-reviewed research grant funding by “The Physicians Services Incorporated Foundation, Toronto, Canada".
There has been no financial support for this work to the authors that could have influenced its outcome.
Compliance with ethical standards
The scientific guarantor of this publication is Dr. Kartik Jhaveri.
Conflict of interest
The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.
Statistics and biometry
Ravi Menezes kindly provided statistical advice for this manuscript. Dr. Angela Cheung, one of the co-authors, also has significant statistical expertise.
Written informed consent was obtained from all subjects (patients) in this study.
Institutional Review Board approval was obtained.
• diagnostic study
• performed at one institution