ArticleLiver international : official journal of the International Association for the Study of the Liver2026
Prognostication of Liver Disease Patients via the WFUMB 'Rule-of-4' Algorithm Using SSI-2D-SWE-Based Liver Stiffness Measurement.
Article in Liver international : official journal of the International Association for the Study of the Liver, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.
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- Prognostication of Liver Disease Patients via the WFUMB 'Rule-of-4' Algorithm Using SSI-2D-SWE-Based Liver Stiffness Measurement.Liver international : official journal of the International Association for the Study of the Liver · 2026Article
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Abstract
backgroundThe World Federation for Ultrasound in Medicine and Biology (WFUMB) guidance update 2024 proposed a 'rule-of-4' using ARFI liver stiffness measurement (LSM) to stratify the risk of decompensation events. This rule identifies advanced chronic liver disease (ACLD) at a threshold of ≥ 13 kPa and indicates a high probability of clinically significant portal hypertension (CSPH) above 21 kPa.
methodsWe prospectively enrolled 187 patients undergoing same-day SSI-2D-LSM (Aixplorer SuperSonic Imagine) and hepatic venous pressure gradient (HVPG) measurement. Patients were stratified into three LSM groups < 13 kPa, 13-21 kPa and > 21 kPa and followed for decompensation events for 1 year (Y1).
resultsThe cohort comprised 31 (16.6%) patients with LSM < 13 kPa (non-ACLD); 33 (17.6%) LSM 13-21 kPa (ACLD) and 123 (65.8%) LSM > 21 kPa (high CSPH probability). The corresponding median HVPG values were 5 [IQR: 3-7] vs. 10 [7-14] vs. 17 [13-21] mmHg, respectively, and the corresponding CSPH prevalence was 6.5%, 54.5% and 91.9%. In ROC analysis to predict CSPH, SSI-2D-LSM demonstrated high accuracy (AUC: 0.83). Validating the new WFUMB extension of the 'rule-of-4', the recommended > 21 kPa threshold identified CSPH with a specificity of 80.0% and a PPV of 83.1%. In competing risk analysis, the Y1-decompensation rate was 0%, 10% and 24.7% of patients in the < 13 kPa, 13-21 kPa and > 21 kPa groups, respectively. For prediction of Y1-decompensation risk in the compensated ACLD (cACLD) subgroup, HVPG demonstrated the highest predictive accuracy (AUC: 0.92), while SSI-2D-LSM (AUC: 0.75) performed similarly to vibration-controlled transient elastography (VCTE: AUC: 0.77; AUC-comparison: p = 0.837).
conclusionsThe WFUMB 'rule-of-4' for ARFI-LSM allows for accurate and point-of-care non-invasive risk stratification of patients with liver disease. Specifically, the short-term risk of decompensation starts at SSI-2D-LSM ≥ 13 kPa and becomes considerable at SSI-2D-LSM > 21 kPa (indicating high CSPH probability). These findings support the broader implementation of ARFI-LSM for risk assessment in clinical routine.
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