Possibilities of Using Magnetic Resonance Imaging with Proton Density Lipid Fraction Assessment for Diagnosing Steatosis Post-Liver Transplantation

Objective. To evaluate the effectiveness of steatosis detection in liver transplant patients using magnetic resonance imaging with proton density quantification of liver fat fraction (PDFF).

Materials and methods. А total of 113 liver transplant recipients (61 women and 52 men) aged 19 to 72 years were examined. All patients underwent magnetic resonance imaging (MRI) with proton density quantification of liver fat fraction. The obtained MRI (PDFF) data were compared with biopsy results. Calculation of the percentage of fatty infiltration of the liver based on right lobe liver biopsy data was used as a reference method.

Results. According to biopsy data, steatosis was absent in 81 patients (72 %), while steatosis of varying severity was detected in 32 patients (28 %). The comparison revealed significant differences in the PDFF (p ≤ 0.001) between patients with and without steatosis. The optimal cutoff value for distinguishing between normal and the presence of steatosis was 5.2 % (sensitivity 93 %, specificity 65 %). The correlation coefficient between PDFF methods and biopsy data was 0.66 (p ≤ 0.01).

Conclusions. Thus, magnetic resonance imaging with proton density lipid fraction (PDFF) assessment is a highly informative method for diagnosing fatty liver disease, including in patients after liver transplantation. Determining cutoff values for the severity of fatty liver disease requires further research.

1. Ivashkin V. T., Drapkina O. M., Maevskaya M. V., Raikhelson K. L., Okovityi S. V., Zharkova M. S., Grechishnikova V. R., Abdulganieva D. I., Alekseenko S. A., Ardatskaya M. D., Bakulin I. G., Baku­ lina N. V., Bogomolov P. O., Breder V. V., Vinnitskaya E. V., Geyvandova N. I., Golo­ vanova E. V., Grinevich V. B., Doshchitsin V. L., Dudinskaya E. N., Ershova E. V., Kodzoeva Kh. B., Kozlova I. V., Komshilova K. A., Konev Yu. V., Korochanskaya N. V., Kotovskaya Yu. V., Kravchuk Yu. A., Loranskaya I. D., Maev I. V., Martynov A. I., Mekhtiev S. N., Mishina E. E., Nadinskaia M. Yu., Nikitin I. G., Osipenko M. F., Ostroumova O. D., Pavlov Ch. S., Pogosova N. V., Radchenko V. G., Roytberg G. E., Saifutdinov R. G., Samsonov A. A., Seliverstov P. V., Sitkin S. I., Tarasova L. V., Tarzimanova A. I., Tkacheva O. N., Tkachenko E. I., Troshina E. A., Turkina S. V., Uspenskiy Yu. P., Fominykh Yu. A., Khlynova O. V., Tsyganova Yu. V., Sham­ khalova M. Sh., Sharkhun O. O., Shes­ takova M. V. Clinical Guidelines of the Russian Society for the Study of the Liver, Russian Gastroenterological Association, Russian Society for the Prevention of Non-Communicable Diseases, Russian Association of Endocrinologists, Russian Scientific Medical Society of Therapists, National Society of Preventive Cardiology, Russian Association of Gerontologists and Geriatricians on Non-Alcoholic Fatty Liver Disease. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2025;35(1): 94–152. (In Russ.). https://doi.org/10.22416/1382-4376-2025-35-1-94-152

2. Panina O. Yu., Akhmad E. S., Vasilev Yu. A., Petraikin A. V. Enhancing the Accuracy of Quantitative Liver Steatosis Assessment Using Magnetic Resonance Imaging in Can­ cer Patients. Vestnik of the Russian Scientific Center of Roentgenoradiology. 2025; 2025(1):53-67. (In Russ.). EDN: OHBZSX

3. Abdelhameed F., Kite C., Lagojda L., Dallaway A., Chatha K. K., Chaggar S. S., Dalamaga M., Kassi E., Kyrou I., Randeva H. S. Non-invasive Scores and Serum Bio­ markers for Fatty Liver in the Era of Meta­ bolic Dysfunction-associated Steatotic Li­ ver Disease (MASLD): A Comprehensive Review From NAFLD to MAFLD and MASLD. Curr Obes Rep. 2024;13(3):510- 531. https://doi.org/10.1007/s13679-024-00574-z.

4. Ahn J., Choi H. J., Park S. E., Seo C. H., Hong T. H., You Y. K. Noninvasive Eva­ luations to Estimate Graft Steatosis in Living Donor Liver Transplant for Donor Safety and Successful Outcome. Transplant Proc. 2022;54(2):374-379. https://doi.org/10.1016/j.transproceed.2021.12.017

5. Alsaqa M., Sierra L., Marenco-Flores A., Parraga X., Barba R., Goyes D., Ozturk N. B., Curry M. P., Bonder A., Saberi B. Metabolic Dysfunction-Associated Steatotic Liver Disease Correlates With Higher Lower Graft Survival in Liver Transplant Recipients with Hepatocellular Carcinoma. Eur. J. Gastroenterol. Hepatol. 2025;37(4):497-504. https://doi.org/10.1097/MEG.0000000000002914

6. Azizi N., Naghibi H., Shakiba M., Morsali M., Zarei D., Abbastabar H., Ghanaati H. Curr Obes. Evaluation of MRI Proton Density Fat Fraction in Hepatic Steatosis: A Systematic Review and Meta-Analysis. Eur. Radiol. 2025;35(4):1794-1807. https://doi.org/10.1007/s00330-024-11001-1

7. Bae J. S., Lee D. H., Suh K. S., Kim H., Lee K. B., Lee J. Y., Han J. K. Noninvasive Assessment of Hepatic Steatosis Using A Pathologic Reference Standard: Comparison of CT, MRI, and USbased Techniques. Ultrasonography. 2022;41(2):344-354. doi: 10.1007/s10238-022-00799-z. https://doi.org/10.14366/usg.21150.

8. Bannas P., Kramer H., Hernando D., Agni R., Cunningham A. M., Mandal R., Moto­ sugi U., Sharma S. D., Munoz del Rio A., Fernandez L., Reeder S. B. Quantitative Magnetic Resonance Imaging of Hepatic Steatosis: Validation in ex vivo Human Li­ vers. Hepatology. 2015;62(5):1444-1455. https://doi.org/10.1002/hep.28012

9. Bydder M., Shiehmorteza M., Yokoo T., Su­ gay S., Middleton M. S., Girard O., Schroe­ der M. E., Wolfson T., Gamst A., Sirlin C. Assessment of Liver fat Quantification in the Presence of Iron. Magn. Reson. Imaging. 2010;28:767-776. https://doi.org/10.1016/j.mri.2010.03.017

10. Caussy C., Johansson L. Magnetic Resonan­ ce-Based Biomarkers in Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohe­ patitis. Endocrinol Diabetes Metab. 2020; 3(4):e00134.https://doi.org/10.1002/edm2.134

11. Chowdhury A. B., Mehta K. J. Liver Biopsy for Assessment of Chronic Liver Diseases: a Synopsis. Clin. Exp. Med. 2023;23(2):273- 285. https://doi.org/10.1007/s10238-022-00799-z

12. Dumortier J., Giostra E., Belbouab S., Mo­ rard I., Guillaud O., Spahr L., Boillot O., Rubbia-Brandt L., Scoazec J., Hadengue A. Non-alcoholic Fatty Liver Disease in Li­ ver Transplant Recipients: Another Story of «seed and soil». Am. J. Gastroenterol. 2010; 105(3):613–620. https://doi.org/10.1038/ajg.2009.717

13. Hu F., Yang R., Huang Z., Wang M., Yuan F., Xia C., Wei Y., Song B. 3D Multi-Echo Dixon Technique for Simultaneous As­ sessment of Liver Steatosis and Iron Over­ load in Patients with Chronic Liver Diseases: a Feasibility Study. Quant Imaging Med. Surg. 2019;9(6):1014-1024. https://doi.org/10.21037/qims.2019.05.20

14. Jichitu A., Bungau S., Stanescu A. M. A., Vesca C. M., Toma M. M., Bustea C., Iur­ ciuc S., Rus M., Bacalbasa N., Diaconu C. C. Non-Alcoholic Fatty Liver Disease and Car­ diovascular Comorbidities: Pathophysio­ logical Links, Diagnosis, and Therapeutic Management. Diagnostics (Basel). 2021;11 (4):689. https://doi.org/10.3390/diagnostics11040689.

15. Kleiner D. E., Brunt E. M., Van Natta M., Beh­ ling C., Contos M. J., Cummings O. W., Ferrell L. D., Liu Y. C., Torbenson M. S., UnalpArida A., Yeh M., McCullough A. J., Sanyal A. J. Design and Validation of a Histological Scoring System for Nonalcoholic Fatty Liver Disease. Nonalcoholic Steatohepatitis Cli­ nical Research Network. Hepatology. 2005; 41(6):1313-21. https://doi.org/10.1002/hep.20701

16. Malik S. M., Devera M. E., Fontes P., Shaikh O., Sasatomi E., Ahmad J. Recurrent Disease Following Liver Transplantation for Nonalcoholic Steatohepatitis Cirrhosis. Liver Transpl. 2009;15(12):1843-1851. https://doi.org/10.1002/lt.21943

17. Middleton M. S., Heba E. R., Hooker C. A., Bashir M. R., Fowler K. J., Sandrase­ garan K., Brunt E. M., Kleiner D. E., Doo E., Van Natta M. L., Lavine J. E. Agree­ ment Between Magnetic Resonance Ima­ ging Proton Density Fat Fraction Measure­ ments and Pathologist-Assigned Steatosis Grades of Liver Biopsies from Adults with Nonalcoholic Steatohepatitis. Gastroenterology. 2017;153(3):753-761. https://doi.org/10.1053/j.gastro.2017.06.005

18. Nath P. Effect of Exercise on NAFLD and Its Risk Factors: Comparison of Moderate versus Low Intensity Exercise P. Nath. Journal of Clinical and Translational Hepatology. 2020;28;8(2):120-126. https://doi.org/10.14218/JCTH.2019.00012

19. Qayyum A., Nystrom M., Noworolski S. M., Chu P., Mohanty A., Merriman R. MRI Steatosis Grading: Development and Initi­ al Validation of a Color Mapping System. AJR Am. J. Roentgenol. 2012;198(3):582- 588. https://doi.org/10.2214/AJR.11.6729

20. Qi Q., Weinstock A. K., Chupetlovska K., Borhani A. A., Jorgensen D. R., Furlan A., Behari J., Molinari M., Ganesh S., Humar A., Duarte-Rojo A. Magnetic Resonance Imaging-Derived Proton Density Fat Frac­ tion (MRI-PDFF) is a Viable Alternative to Liver Biopsy for Steatosis Quantification in Living Liver Donor Transplantation. Clin. Transplant. 2021;35(7):e14339. https://doi.org/10.1111/ctr.14339

21. Rozani S., Dalamaga M., Weber G., Grtz­ mann R. Liver Transplantation in the Era of Obesity: A Metabolic Public Health Crisis Meets A Surgical Frontier. Metabol Open. 2025;27;28:100410. https://doi.org/10.1016/j.metop.2025.100410

22. Savino A., Loglio A., Neri F., Camagni S., Pasulo L., Lucа M. G., Trevisan R., Fagiuoli S., Vigant M. Metabolic-Dysfunction-Asso­ ciated Steatotic Liver Disease (MASLD) after Liver Transplantation: A Narrative Re­ view of an Emerging Issue. J. Clin. Med. 2024 ;13(13):3871. https://doi.org/10.3390/jcm13133871

23. Stine J. G., Munaganuru N., Barnard A., Wang J. L., Kaulback K., Argo C. K., Singh S., Fowler K. J., Sirlin C. B., Loomba R. Change in MRI-PDFF and Histologic Res­ ponse in Patients with Nonalcoholic Steato­ hepatitis: A Systematic Review and MetaAnalysis. Clin. Gastroenterol. Hepatol. 2021; 19(11):2274-2283.e5. https://doi.org/10.1016/j.cgh.2020.08.061

24. Tang A., Desai A., Hamilton G., Wolfson T., Gamst A., Lam J., Clark L., Hooker J., Chavez T., Ang B. D., Middleton M. S., Peterson M., Loomba R., Sirlin C. B. Accuracy of MR Imaging-Estimated Proton Density Fat Fraction for Classification of Dichotomized Histologic Steatosis Grades In Nonalcoholic Fatty Liver Disease. Radiology. 2015;274(2):416-425. https://doi.org/10.1148/radiol.14140754

25. Tejedor-Tejada J., Valenzuela E. F., Muñoz R. N., Gómez L. H., García-Pajares F., Ál­ varez C. A., Sánchez-Martín F., AlonsoMartín C., Sánchez-Antolín G. De-novo Nonalcoholic Fatty Liver Disease at 5 Years After Liver Transplantation: Prevalence And Predictive Factors. Eur. J. Gastroenterol Hepatol. 2021;33(3):399-406. https://doi.org/10.1097/MEG.0000000000001736

26. Wibulpolprasert P., Subpinyo B., Chirnak­ sorn S., Shantavasinkul P. C., Putade­ chakum S., Phongkitkarun S., Sritara C., Angkathunyakul N., Sumritpradit P. Correla­ tion Between Magnetic Resonance Imaging Proton Density Fat Fraction (MRI-PDFF) and Liver Biopsy to Assess Hepatic Steatosis in Obesity. Sci. Rep. 2024; 22;14(1):6895. https://doi.org/10.1038/s41598-024-57324-3

27. Wu S., Pan J., Song M., Zhao Y., Chen W., Huang H., Zhu Y. Chen F. Performance of Magnetic Resonance Imaging and Ul­ trasound for Identifying the Different Deg­ rees of Hepatic Steatosis: A Systematic Review and Meta-Analysis. Acad Radiol. 2025;32(11):6528-6540. https://doi.org/10.1016/j.acra.2025.03.008

28. Xian Y. X., Weng J. P., Xu F. MAFLD vs. NAFLD: Shared Features and Potential Changes in Epidemiology, Pathophysiology, Diagnosis, and Pharmacotherapy. Chin. Med. J. 2020;134(1):8–19. https://doi.org/10.1097/CM9.0000000000001263

29. Zhang Y. X., Feng Y. P., You C. L., Zhang L. Y. The Diagnostic Value of MRI-PDFF in Hepatic Steatosis of Patients with Meta­ bolic Dysfunction-Associated Steatotic Liver Disease: A Systematic Review and Meta-Analysis. BMC Gastroenterology, Gastroenterol. 2025;1;25(1):451. https://doi.org/10.1186/s12876-025-04017-4