Development and validation of an image biomarker to identify metabolic dysfunction associated steatohepatitis: MR-MASH score

David Marti-Aguado^{1

2}, Joud Arnouk³, Jia-Xu Liang^{4

5}, Carmen Lara-Romero^{4

5}, Jaideep Behari³, Alessandro Furlan⁶, Ana Jimenez-Pastor^{2

7}, Amadeo Ten-Esteve², Clara Alfaro-Cervello^{8

9}, Mónica Bauza¹⁰, Ana Gallen-Peris¹¹, Marta Gimeno-Torres¹², Víctor Merino-Murgui¹, Alexandre Perez-Girbes^{2

13}, Salvador Benlloch^{11

14}, Judith Pérez-Rojas¹⁰, Víctor Puglia¹⁵, Antonio Ferrández-Izquierdo^{8

9}, Victoria Aguilera^{14

16}, Bruno Giesteira¹⁷, Manuela França¹⁷, Cristina Monton¹, Desamparados Escudero-García^{1

9}, Ángel Alberich-Bayarri^{2

7}, Miguel A Serra^{1

9}, Ramon Bataller³, Manuel Romero-Gomez^{4

5

18}, Luis Marti-Bonmati^{2

13}

Affiliations

¹ Digestive Disease Department, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain.
² Biomedical Imaging Research Group (GIBI230), La Fe Health Research Institute, and Imaging La Fe node at Distributed Network for Biomedical Imaging (ReDIB) Unique Scientific and Technical Infrastructures (ICTS), Valencia, Spain.
³ Division of Gastroenterology, Hepatology and Nutrition, Center for Liver Diseases, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
⁴ Digestive Diseases Department, CIBERehd, Virgen del Rocio University Hospital, Seville, Spain.
⁵ Institute of Biomedicine of Seville (HUVR/CSIC/US), Department of Medicine, University of Seville, Seville, Spain.
⁶ Division of Abdominal Imaging, Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
⁷ Quantitative Imaging Biomarkers in Medicine, QUIBIM SL, Valencia, Spain.
⁸ Pathology Department, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain.
⁹ Faculty of Medicine, University of Valencia, Valencia, Spain.
¹⁰ Pathology Department, La Fe University and Polytechnic Hospital, Valencia, Spain.
¹¹ Digestive Disease Department, Hospital Arnau de Vilanova, Valencia, Spain.
¹² Digestive Disease Department, La Fe University and Polytechnic Hospital, Valencia, Spain.
¹³ Radiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain.
¹⁴ CIBERehd, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.
¹⁵ Pathology Department, Hospital Arnau de Vilanova, Valencia, Spain.
¹⁶ Hepatology and Liver Transplantation Unit, La Fe University and Polytechnic Hospital, Valencia, Spain.
¹⁷ Radiology Department, Centro Hospitalar Universitário do Porto, Instituto de Ciências Biomédicas de Abel Salazar, University of Porto, Porto, Portugal.
¹⁸ University of Seville, Seville, Spain.

PMID: 37904633
DOI: 10.1111/liv.15766

Multicenter Study

Development and validation of an image biomarker to identify metabolic dysfunction associated steatohepatitis: MR-MASH score

David Marti-Aguado et al. Liver Int. 2024 Jan.

. 2024 Jan;44(1):202-213.

doi: 10.1111/liv.15766. Epub 2023 Oct 30.

Authors

Affiliations

¹ Digestive Disease Department, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain.
² Biomedical Imaging Research Group (GIBI230), La Fe Health Research Institute, and Imaging La Fe node at Distributed Network for Biomedical Imaging (ReDIB) Unique Scientific and Technical Infrastructures (ICTS), Valencia, Spain.
³ Division of Gastroenterology, Hepatology and Nutrition, Center for Liver Diseases, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
⁴ Digestive Diseases Department, CIBERehd, Virgen del Rocio University Hospital, Seville, Spain.
⁵ Institute of Biomedicine of Seville (HUVR/CSIC/US), Department of Medicine, University of Seville, Seville, Spain.
⁶ Division of Abdominal Imaging, Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
⁷ Quantitative Imaging Biomarkers in Medicine, QUIBIM SL, Valencia, Spain.
⁸ Pathology Department, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain.
⁹ Faculty of Medicine, University of Valencia, Valencia, Spain.
¹⁰ Pathology Department, La Fe University and Polytechnic Hospital, Valencia, Spain.
¹¹ Digestive Disease Department, Hospital Arnau de Vilanova, Valencia, Spain.
¹² Digestive Disease Department, La Fe University and Polytechnic Hospital, Valencia, Spain.
¹³ Radiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain.
¹⁴ CIBERehd, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.
¹⁵ Pathology Department, Hospital Arnau de Vilanova, Valencia, Spain.
¹⁶ Hepatology and Liver Transplantation Unit, La Fe University and Polytechnic Hospital, Valencia, Spain.
¹⁷ Radiology Department, Centro Hospitalar Universitário do Porto, Instituto de Ciências Biomédicas de Abel Salazar, University of Porto, Porto, Portugal.
¹⁸ University of Seville, Seville, Spain.

PMID: 37904633
DOI: 10.1111/liv.15766

Erratum in

Correction to 'Development and Validation of an Image Biomarker to Identify Metabolic Dysfunction Associated Steatohepatitis: MR-MASH Score'.
[No authors listed] [No authors listed] Liver Int. 2025 Apr;45(4):e16190. doi: 10.1111/liv.16190. Epub 2024 Nov 26. Liver Int. 2025. PMID: 39588872

Abstract

Background and aims: Diagnosis of metabolic dysfunction-associated steatohepatitis (MASH) requires histology. In this study, a magnetic resonance imaging (MRI) score was developed and validated to identify MASH in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). Secondarily, a screening strategy for MASH diagnosis was investigated.

Methods: This prospective multicentre study included 317 patients with biopsy-proven MASLD and contemporaneous MRI. The discovery cohort (Spain, Portugal) included 194 patients. NAFLD activity score (NAS) and fibrosis were assessed with the NASH-CRN histologic system. MASH was defined by the presence of steatosis, lobular inflammation, and ballooning, with NAS ≥4 with or without fibrosis. An MRI-based composite biomarker of Proton Density Fat Fraction and waist circumference (MR-MASH score) was developed. Findings were afterwards validated in an independent cohort (United States, Spain) with different MRI protocols.

Results: In the derivation cohort, 51% (n = 99) had MASH. The MR-MASH score identified MASH with an AUC = .88 (95% CI .83-.93) and strongly correlated with NAS (r = .69). The MRI score lower cut-off corresponded to 88% sensitivity with 86% NPV, while the upper cut-off corresponded to 92% specificity with 87% PPV. MR-MASH was validated with an AUC = .86 (95% CI .77-.92), 91% sensitivity (lower cut-off) and 87% specificity (upper cut-off). A two-step screening strategy with sequential MR-MASH examination performed in patients with indeterminate-high FIB-4 or transient elastography showed an 83-84% PPV to identify MASH. The AUC of MR-MASH was significantly higher than that of the FAST score (p < .001).

Conclusions: The MR-MASH score has clinical utility in the identification and management of patients with MASH at risk of progression.

Keywords: magnetic resonance; metabolic dysfunction-associated steatohepatitis; proton density fat fraction; waist circumference.

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References

REFERENCES

1. Younossi ZM, Golabi P, de Avila L, et al. The global epidemiology of NAFLD and NASH in patients with type 2 diabetes: a systematic review and meta-analysis. J Hepatol. 2019;71(4):793-801.
1. Simon TG, Roelstraete B, Khalili H, Hagström H, Ludvigsson JF. Mortality in biopsy-confirmed nonalcoholic fatty liver disease: results from a nationwide cohort. Gut. 2021;70(7):1375-1382.
1. Rinella ME, Lazarus JV, Ratziu V, et al. A multi-society Delphi consensus statement on new fatty liver disease nomenclature. Hepatology. 2023. doi:10.1097/HEP.0000000000000520
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Development and validation of an image biomarker to identify metabolic dysfunction associated steatohepatitis: MR-MASH score

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Development and validation of an image biomarker to identify metabolic dysfunction associated steatohepatitis: MR-MASH score

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