Prognostic power of dynamic enhancement in advanced chronic liver disease: Moving beyond static liver structure

Abstract

The recent study by Stanciu et al, published in World Journal of Hepatology, highlights an important transition in hepatology, shifting from structural assessment toward functional evaluation in advanced chronic liver disease. Their work demonstrates that quantitative hepatic enhancement on gadoxetate-enhanced magnetic resonance imaging (MRI), specifically within Segment VI, provides clinically relevant prognostic information for mortality and decompensation. This editorial evaluates the clinical utility of hepatic enhancement and the semi-quantitative Functional Liver Imaging Score, which integrates hepatocyte uptake via organic anion-transporting polypeptides, biliary excretion mediated by multidrug resistance associated protein 2, and portal hemodynamics. While MRI-derived metrics offer powerful risk stratification, their widespread implementation is often hindered by high costs, inter-scanner variability, and renal contraindications. Conversely, dynamic contrast-enhanced ultrasound provides a cost-effective alternative for real-time hemodynamic profiling, specifically through metrics like hepatic vein arrival time. We propose a tiered diagnostic hierarchy where simpler non-invasive tests and contrast-enhanced ultrasound serve as broad screening tools, reserving advanced functional MRI for high-risk patients. Such a stratified approach facilitates broader access to precision medicine approaches by bridging the gap between sophisticated scientific metrics and scalable clinical practice. Integrating artificial intelligence-driven quantification and rapid protocols will be essential to achieving a truly function-guided management strategy in patients suffering from advanced chronic liver disease.

Keywords: Advanced chronic liver disease; Functional liver imaging score; Hepatic enhancement; Gadoxetate-enhanced magnetic resonance imaging; Contrast-enhanced ultrasound; Hepatic vein arrival time; Portal hypertension; Risk stratification; Prognosis

Core Tip: Current approaches in hepatology increasingly emphasize functional assessment in addition to structural evaluation. While magnetic resonance imaging-derived scores, such as the functional liver imaging score, offer relevant prognostic information, their practical limitations, including cost and technical variability, may restrict widespread use. In contrast, contrast-enhanced ultrasound offers a widely accessible technique for dynamic hemodynamic assessment. The future of clinical practice lies in a stepwise diagnostic approach – utilizing simpler bedside tests for broad screening while reserving advanced magnetic resonance imaging for high-risk cases to support broader implementation of personalized liver care.