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Multicenter Study
. 2025 Dec;35(12):7927-7939.
doi: 10.1007/s00330-025-11774-z. Epub 2025 Jun 25.

Ultrasound hepatorenal index for the diagnosis of steatosis in patients with type 2 diabetes: a prospective validation study

Macil Hamadouche  1   2 , Valérie Vilgrain  1   2 , Christian Hobeika  3   4   5 , Laurent Castera  1   6 , Dominique Valla  6 , Pierre-Emmanuel Rautou  1   7 , Francesco Matteini  2 , Philippe Garteiser  1 , Bernard Van Beers  1   2 , Jean-Michel Correas  8   9   10 , Maxime Ronot  1   2 , Marco Dioguardi Burgio  11   12
Affiliations
Multicenter Study

Ultrasound hepatorenal index for the diagnosis of steatosis in patients with type 2 diabetes: a prospective validation study

Macil Hamadouche et al. Eur Radiol. 2025 Dec.

Abstract

Objectives: To evaluate the performance of the ultrasound hepatorenal index (US-HRI) for the diagnosis of hepatic steatosis in patients with type 2 diabetes and metabolic dysfunction-associated steatotic liver disease (MASLD), using MRI proton density fat fraction (MRI-PDFF) as reference.

Materials and methods: This two-center prospective study included 129 and 263 patients in the training and validation cohorts, respectively, between 2019 and 2022. Hepatic steatosis was classified according to MRI-PDFF as S0 (≤ 6.5%), S1 (6.5-16.5%), S2 (16.5-22%), and S3 (> 22%). Obuchowski measurement (OB) was performed to assess the diagnostic performance of US-HRI in the whole cohort. Optimal cut-offs of US-HRI for diagnosing ≥ S1 and ≥ S2 were identified in the training cohort by maximizing the Youden index and were applied in the validation cohort.

Results: Overall, 392 patients were included (mean age, 59 years ± 9.5; 235 men). The OB (four class problem S0 to S3) was 0.79 ± 0.01. Pairwise accuracy was good for S0 vs S1, S2 or S3 (0.78 to 0.89) but decreased for distinguishing among higher grades (0.54 to 0.62). Optimal US-HRI threshold for diagnosing ≥ S1 was 1.16, with a sensitivity of 82.7% (95% CI: 77.4-87.3), specificity of 80.0% (95% CI: 56.3-94.3), and AUC of 0.81 (95% CI: 0.76-0.86). The threshold for diagnosing ≥ S2 was 1.47, with a sensitivity of 49.0% (95% CI: 39.1-59.0), specificity of 73.0% (95% CI: 65.3-79.7), and AUC of 0.61 (95% CI: 0.55-0.67).

Conclusion: US-HRI was a reliable tool for diagnosing steatosis in type 2 diabetic patients with MASLD. However, its performance in assessing more severe grades of steatosis was inadequate.

Key points: Question Ultrasound hepatorenal index (US-HRI) performance for the diagnosis of steatosis in type 2 diabetic patients with metabolic dysfunction-associated steatotic liver disease (MASLD) is not well defined. Findings US-HRI demonstrated good diagnostic performance for steatosis (S0 vs S1-S3), but this decreased for diagnosing S2-S3. Clinical relevance US-HRI provides a quantitative approach for detecting hepatic steatosis in patients with MASLD and type 2 diabetes, but has shown limited effectiveness in grading higher grades.

Keywords: Diagnostic techniques and procedures; Non-alcoholic fatty liver disease; Severity of illness index; Ultrasonography, Fatty liver.

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Conflict of interest statement

Compliance with ethical standards. Guarantor: The scientific guarantor of this publication is Marco Dioguardi Burgio. Conflict of interest: M.R. is a member of the Scientific Editorial Board for European Radiology (section: Magnetic Resonance). As such, they have not participated in the selection or review processes for this article. The remaining 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: One of the authors has significant statistical expertise; moreover, no complex statistical methods were necessary for this paper. Informed consent: Written informed consent was obtained from all subjects (patients) in this study. Ethical approval: Institutional Review Board approval was obtained. Study subjects or cohorts overlap: Some study subjects or cohorts have been previously reported in the following publications: Dioguardi Burgio et al [41], Castera et al [23], and Castera et al [42]. Methodology: Prospective Diagnostic study Multicenter study

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