QUANTITATIVE magnetic resonance cholangiopancreatography (MRCP) could improve risk prediction in patients with primary sclerosing cholangitis (PSC), according to an international multi-centre study that established the first reference ranges for quantitative imaging metrics in the disease.
PSC is a chronic cholestatic liver disease marked by inflammation and fibrosis of the bile ducts, leading to progressive liver damage, biliary strictures and an increased risk of cholangiocarcinoma and gallbladder carcinoma. Median time from diagnosis to liver transplantation or death ranges from 13 to 21 years, and liver transplantation remains the only curative option.
The findings could help clinicians better identify patients at higher risk of disease progression while also supporting the development of future PSC treatments.
Quantitative MRCP Strengthens PSC Risk Modelling
The study evaluated quantified magnetic resonance cholangiopancreatography (MRCP+) metrics in 457 patients with PSC to establish reference ranges, with prognostic analysis performed in 320 participants.
Researchers developed a new prognostic model combining imaging findings with routine clinical and laboratory markers.
The model included factors such as age at diagnosis, inflammatory bowel disease status, liver biochemistry and the extent of bile duct abnormalities seen on imaging.
The quantitative MRCP-based model outperformed several existing risk scores used in PSC prognostication. It also showed stronger predictive performance than the MayoRisk Score in secondary analyses.
Bootstrap analysis across the full prognostic cohort also showed significantly stronger performance for qmAOM than AOM and M+BA, with scores of 0.82, 0.75 and 0.70, respectively.
Objective Imaging May Reduce Variability in PSC Assessment
Current radiological scoring systems rely on semi-quantitative assessments that remain vulnerable to interobserver variability, limiting reproducibility and standardisation.
MRCP+ metrics are generated using an independent algorithm, reducing reliance on subjective image interpretation. Researchers said this gives quantitative imaging an advantage when incorporated into composite risk scores such as qmAOM.
The findings may also help address the lack of validated surrogate endpoints in PSC, a longstanding barrier to drug development in the disease.
Implications for Future PSC Trials
Quantitative biliary metrics could improve discriminative performance for event-free survival in PSC and may support future prognostic tools and clinical trial design.
However, the authors acknowledged limitations, including the retrospective nature of some cohorts, which may have introduced selection bias. Despite this, the inclusion of prospective UK cohorts and nationwide Dutch data provided a heterogeneous population spanning the full spectrum of disease severity.
Reference
Middelburg TE et al. Quantitative magnetic resonance cholangiopancreatography metrics improve prognostication in primary sclerosing cholangitis. JHEP Rep. 2026;DOI: 10.1016/j.jhepr.2026.101892.
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