JHEP reports : innovation in hepatology · 2026
Functional liver imaging score (FLIS): A prognostic biomarker for acute-on-chronic liver failure and liver-related mortality.
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Poetter-Lang Sarah, Balcar Lorenz, Ba-Ssalamah Ahmed, Bastati Nina, Ambros Raphael, Kristic Antonia, Krawanja Julia, Pomej Katharina, Simbrunner Benedikt, Semmler Georg, Schmidbauer Victor, Pochepnia Svitlana, Sobotka Daniel, Hodge Jacqueline C, Attenberger Ulrike, Trauner Michael, Reiberger Thomas, Beer Lucian, Mandorfer Mattias
Аннотация
BACKGROUND & AIMS: The functional liver imaging score (FLIS; range 0-6, with higher scores indicating better liver function), derived from gadoxetic acid-enhanced MRI, is a prognostic imaging biomarker in advanced chronic liver disease (ACLD). Our aim was to investigate whether semi-quantitative FLIS and quantitative imaging parameters, namely relative liver enhancement (RLE), relative enhancement ratio of the biliary system (REB), and liver-to-portal vein contrast ratio (LPC), predict acute-on-chronic liver failure (ACLF; a syndrome defined by extrahepatic organ failure and high short-term mortality) and liver-related mortality in acute decompensation (AD), the main at-risk population.
METHODS: We included 210 patients with ACLD who underwent GA-MRI-derived semi-quantitative FLIS assessment, in whom RLE, REB, and LPC were also computed by two independent, experienced radiologists. Patients were stratified into clinically stable ACLD (including compensated or non-acutely decompensated disease) and AD. The prognostic value of semi-quantitative FLIS and quantitative GA-MRI parameters for ACLF/liver-related death was evaluated using competing risk regression analyses, with liver transplantation considered a competing event.
RESULTS: FLIS was lower in AD (vs. clinically stable ACLD). Furthermore, low FLIS was an independent risk factor for ACLF development/liver-related death in AD (adjusted subdistribution hazard ratio [aSHR]: 2.37 [95% CI 1.08-5.17], p = 0.031; adjusted for MELD-Na, albumin, and etiological cure), but not in clinically stable ACLD (aSHR: 1.58 [95% CI 0.73-3.45], p = 0.250). Conversely, while RLE, REB, and LPC distinguished between AD and clinically stable ACLD (p <0.001), they did not predict ACLF/liver-related death.
CONCLUSIONS: The FLIS is a simple prognostic imaging biomarker in acute decompensation that predicts ACLF and liver-related mortality. FLIS-based risk stratification may help identify patients who could benefit from intensified monitoring or timely liver transplant evaluation.
IMPACT AND IMPLICATIONS: The visual, semi-quantitative functional liver imaging score (FLIS), derived from gadoxetic acid-enhanced MRI, assesses liver function. We found that FLIS predicts acute-on-chronic liver failure and liver-related mortality in patients with acutely decompensated cirrhosis, independent of established risk scores. Conversely, quantitative MRI parameters did not add prognostic value. Thus, FLIS-based risk stratification may help identify patients who could benefit from intensified monitoring or timely liver transplant evaluation.
METHODS: We included 210 patients with ACLD who underwent GA-MRI-derived semi-quantitative FLIS assessment, in whom RLE, REB, and LPC were also computed by two independent, experienced radiologists. Patients were stratified into clinically stable ACLD (including compensated or non-acutely decompensated disease) and AD. The prognostic value of semi-quantitative FLIS and quantitative GA-MRI parameters for ACLF/liver-related death was evaluated using competing risk regression analyses, with liver transplantation considered a competing event.
RESULTS: FLIS was lower in AD (vs. clinically stable ACLD). Furthermore, low FLIS was an independent risk factor for ACLF development/liver-related death in AD (adjusted subdistribution hazard ratio [aSHR]: 2.37 [95% CI 1.08-5.17], p = 0.031; adjusted for MELD-Na, albumin, and etiological cure), but not in clinically stable ACLD (aSHR: 1.58 [95% CI 0.73-3.45], p = 0.250). Conversely, while RLE, REB, and LPC distinguished between AD and clinically stable ACLD (p <0.001), they did not predict ACLF/liver-related death.
CONCLUSIONS: The FLIS is a simple prognostic imaging biomarker in acute decompensation that predicts ACLF and liver-related mortality. FLIS-based risk stratification may help identify patients who could benefit from intensified monitoring or timely liver transplant evaluation.
IMPACT AND IMPLICATIONS: The visual, semi-quantitative functional liver imaging score (FLIS), derived from gadoxetic acid-enhanced MRI, assesses liver function. We found that FLIS predicts acute-on-chronic liver failure and liver-related mortality in patients with acutely decompensated cirrhosis, independent of established risk scores. Conversely, quantitative MRI parameters did not add prognostic value. Thus, FLIS-based risk stratification may help identify patients who could benefit from intensified monitoring or timely liver transplant evaluation.