Background & Aims Liver fibrosis assessed by liver biopsy is predictive of clinical liver events in patients with nonalcoholic fatty liver disease (NAFLD). Magnetic resonance elastography (MRE) correlates with liver biopsy in assessing liver fibrosis. However, data assessing the relationship between MRE and clinical liver events are lacking. We investigated the association between MRE and clinical liver events/death and identified the cut‐off to predict clinical liver events in NAFLD patients. Methods We conducted a multicenter retrospective study of NAFLD patients who underwent MRE between 2016 and 2019. Clinical liver events were defined as decompensation events and death. We categorized patients into noncirrhosis, compensated cirrhosis and decompensated cirrhosis. Fisher's exact test was used to test association strength. Receiver operative curve methods were used to determine the optimal cut‐off of MRE liver stiffness and to maximize the accuracy for classifying noncirrhosis, compensated cirrhosis and decompensated cirrhosis. Logistic regression modelling was used to predict decompensation. Results The study included 320 NAFLD patients who underwent MRE. The best threshold for distinguishing cirrhosis from noncirrhosis was 4.39 kPa (AUROC 0.92) and from decompensated cirrhosis was 6.48 kPa (AUROC 0.71). Odds of decompensation increased as liver stiffness increased (OR 3.28) (P < .001). Increased liver stiffness was associated with ascites, hepatic encephalopathy, oesophageal variceal bleeding and mortality (median 7.10, 10.15 and 10.15 kPa respectively). Conclusion In NAFLD patients, liver stiffness measured by MRE with a cut‐off of ≥6.48 kPa is associated with decompensation and mortality, and specific MRE cut‐offs are predictive of individual clinical liver events.

INTRODUCTION: Estimating the severity of liver steatosis by controlled attenuation parameter (CAP) and liver fibrosis by transient elastography (TE) using the FibroscanTM machine provides a noninvasive method to establish the presence of nonalcoholic fatty liver disease (NAFLD) and assess its severity. The use of CAP/TE is becoming routine practice in adults yet limited data exists in children with suspected NAFLD. The aim of this study was to assess the feasibility and utility of measuring CAP/TE by FibroscanTM in a cohort of children with suspected NAFLD. METHODS: All children referred with a clinical suspicion of NAFLD (elevated alkaline phosphatase (ALT) or fatty infiltration on ultrasonography) who had CAP/TE measured were included. FibroscanTM testing was performed on a standardized machine with an experienced operator utilizing a medium (M) or extra-large (XL) probe. Standard criteria for having valid measurements were applied (IQR < 30% with >70% success rate). Severity of steatosis was evaluated based on the following cutoffs for CAP: <225 db/m (no steatosis), 225-250 db/m (mild steatosis), 250-300 db/m (moderate steatosis), >300 db/m (severe steatosis). Severity of liver stiffness was evaluated using the following TE cutoffs: <6 kPa (no fibrosis), 6-10 kPa (mild to moderate fibrosis), >10 kPa (advanced fibrosis). Baseline clinical and laboratory parameters were also collected. RESULTS: 119 children with suspected NAFLD were referred to the clinic between May 2017 and April 2019. The mean age at time of assessment was 13.0 (± 3.0) years. The majority were males (68%), obese (87%) and of Hispanic ethnicity (77%). The M probe was used to successfully complete 64% of scans whereas the XL probe was required for 36% of scans. 4/116 (3%) had a CAP < 225 indicating no steatosis. 15/116 (13%) of patients fell within the mild steatosis range (CAP 225-250), 31/116 (27%) with moderate steatosis (CAP 250-300) and the majority, 66/116 (57%), of patients having severe steatosis with CAP values > 300. On TE, 50% had no fibrosis, 45% with mild to moderate fibrosis and 7% with advanced fibrosis. Linear regression analysis demonstrated a weakly positive correlation between baseline ALT and TE measurements (correlation coefficient (r) was 0.24; P value < 0.05; Figure 1.1). CONCLUSION: CAP/TE provides a reliable way to confirm the diagnosis of NAFLD and assess its severity in children. Larger pediatric studies that assess the correlation with liver histology and disease progression are needed.

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