Objectives High-grade and relevant strictures have recently been introduced in clinical guidelines for primary sclerosing cholangitis (PSC). However, the definition of relevant strictures differs between the two liver associations (AASLD, EASL). We aim to assess the prevalence, the agreement of identification of extrahepatic, high-grade, and relevant strictures, and their association with outcomes in PSC. Materials and methods In this retrospective single-center study, three radiologists, independently and in consensus, assessed MRCPs of 170 PSC individuals for the presence of extrahepatic and high-grade strictures. Interreader agreement was calculated with Fleiss kappa. Association of extrahepatic, high-grade, and relevant strictures with outcomes (hepatobiliary malignancy, liver transplantation, liver-related death) was assessed with Cox-regression, and outcome-free survival estimates with Kaplan–Meier. Results Median age was 40 years, and 62% were males. One hundred-seven (63%) individuals had high-grade strictures, 49 (29%), and 53 (31%) had relevant strictures according to EASL and AASLD, respectively. During the median follow-up of 10.3 years, 50 individuals developed outcomes (liver transplantation = 37, liver-related death = 5, hepatobiliary malignancy = 8). Agreement for high-grade strictures was fair (k = 0.31). All strictures types were associated with worse prognosis in the univariate and multivariate analysis with extrahepatic strictures having hazard ratio (HR) = 3.34 (95% CI: 1.42–7.86), high-grade strictures HR = 2.00 (95% CI: 1.02–3.90), relevant strictures according to EASL and AASLD had HR = 2.43 (95% CI: 1.34–4.42) and HR = 2.89 (95% CI:1.57–5.32), respectively, after adjusting for Mayo Risk Score. Conclusion Prevalence of high-grade strictures is high, but the agreement of their identification is unsatisfactory. High-grade and relevant strictures, regardless of their definition (EASL or AASLD), were associated with a worse prognosis. Key Points <Emphasis Type="BoldItalic">Question</Emphasis> What is the prevalence and the interreader agreement of high-grade and relevant strictures? Are they associated with a worse prognosis in PSC? <Emphasis Type="BoldItalic">Findings</Emphasis> High-grade and relevant strictures are relatively common in PSC and are associated with a worse prognosis; however, the agreement of their identification is unsatisfactory. <Emphasis Type="BoldItalic">Clinical relevance</Emphasis> High-grade and relevant strictures have a role in clinical practice; however, the low interreader agreement of the interpretation of MRCP of individuals with PSC remains an unmet challenge. Graphical Abstract

Prevalence, interreader agreement, and prognostic value of high-grade and relevant strictures in individuals with primary sclerosing cholangitis

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2026年3月13日

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Stefan Hamma,
Annika Bergquist,
Mats Andersson,
Christina Villard,
Aristeidis Grigoriadis

摘要

Objectives

High-grade and relevant strictures have recently been introduced in clinical guidelines for primary sclerosing cholangitis (PSC). However, the definition of relevant strictures differs between the two liver associations (AASLD, EASL). We aim to assess the prevalence, the agreement of identification of extrahepatic, high-grade, and relevant strictures, and their association with outcomes in PSC.

Materials and methods

In this retrospective single-center study, three radiologists, independently and in consensus, assessed MRCPs of 170 PSC individuals for the presence of extrahepatic and high-grade strictures. Interreader agreement was calculated with Fleiss kappa. Association of extrahepatic, high-grade, and relevant strictures with outcomes (hepatobiliary malignancy, liver transplantation, liver-related death) was assessed with Cox-regression, and outcome-free survival estimates with Kaplan–Meier.

Results

Median age was 40 years, and 62% were males. One hundred-seven (63%) individuals had high-grade strictures, 49 (29%), and 53 (31%) had relevant strictures according to EASL and AASLD, respectively. During the median follow-up of 10.3 years, 50 individuals developed outcomes (liver transplantation = 37, liver-related death = 5, hepatobiliary malignancy = 8). Agreement for high-grade strictures was fair (k = 0.31). All strictures types were associated with worse prognosis in the univariate and multivariate analysis with extrahepatic strictures having hazard ratio (HR) = 3.34 (95% CI: 1.42–7.86), high-grade strictures HR = 2.00 (95% CI: 1.02–3.90), relevant strictures according to EASL and AASLD had HR = 2.43 (95% CI: 1.34–4.42) and HR = 2.89 (95% CI:1.57–5.32), respectively, after adjusting for Mayo Risk Score.

Conclusion

Prevalence of high-grade strictures is high, but the agreement of their identification is unsatisfactory. High-grade and relevant strictures, regardless of their definition (EASL or AASLD), were associated with a worse prognosis.

Key Points

Question What is the prevalence and the interreader agreement of high-grade and relevant strictures? Are they associated with a worse prognosis in PSC?

Findings High-grade and relevant strictures are relatively common in PSC and are associated with a worse prognosis; however, the agreement of their identification is unsatisfactory.

Clinical relevance High-grade and relevant strictures have a role in clinical practice; however, the low interreader agreement of the interpretation of MRCP of individuals with PSC remains an unmet challenge.

Graphical Abstract