IN A LARGE international cohort of nearly 1,800 patients with primary biliary cholangitis (PBC), researchers have shown that the most recent liver stiffness measurement (LSMc) is the single strongest predictor of first hepatic decompensation, trumping both biochemical response and earlier elastography trends. The findings were drawn from 24 tertiary centres across 13 countries.
Discordant Signals Are Common, But Stiffness Wins
Both biochemical response (typically alkaline phosphatase–based criteria such as Paris-II) and liver stiffness measurement (LSM) are known prognostic tools in PBC. However, up to 55% of patients showed discordance between LSM and biochemical response over a median 22-month follow-up. Patients could, for example, normalise ALP yet show increasing stiffness, or vice versa, creating real-world uncertainty.
Despite this complexity, the study found that LSMc >10 kPa was a powerful, independent predictor of hepatic decompensation (hazard ratio 14.5), regardless of prior LSM trajectory or biochemical response category. Once LSMc was included in multivariable models, neither earlier LSM values, percentage LSM change, LSM slope nor biochemical response added meaningful predictive value. Risk rose in a “rule-of-five” fashion across higher LSM strata and appeared to plateau above 15 kPa, but the 10 kPa threshold remained the key discriminator between low- and high-risk groups.
Simplifying Follow-up in PBC Clinics
Clinically, the results support using LSMc ≥10 kPa as a practical cut-off to define compensated advanced chronic liver disease in PBC and to guide intensified surveillance or therapy escalation. Importantly, even in patients with good biochemical response, an LSMc above this threshold signalled a substantially higher risk of ascites, variceal bleeding, or other liver-related events, whereas decompensation below 10 kPa was rare.
For busy hepatology services, the message is both reassuring and actionable: when serial elastography, changing biochemistry and second-line agents complicate the picture, it is the current liver stiffness value that should anchor risk assessment and follow-up decisions in PBC.
Reference
Wong YJ et al. Prognostic value of liver stiffness measurement vs. biochemical response in primary biliary cholangitis. J Hepatol. 2025. 124(6):1223-34.
