Elastography in the evaluation of liver allograft

  • P. J. Navin
  • M. C. Olson
  • J. M. Knudsen
  • S. K. VenkateshEmail author
Special Section: Liver Transplantation


Elastography is an established technique in the evaluation of chronic liver diseases. While there is a large clinical experience and data available regarding the performance of elastography in native liver, elastography experience with liver grafts is limited and still growing. Both ultrasound-based elastography techniques and MR Elastography (MRE) are useful in the assessment of liver fibrosis in liver transplants. Technical modifications for performing elastography will be required for optimum evaluation of the graft. In general, caution needs to be exercised regarding the use of elastography immediately following transplantation as post-operative changes, perioperative conditions/complications, inflammation, and rejection can cause increased stiffness in the graft. In the follow-up, detection of increased stiffness with elastography is useful for predicting development of fibrosis in the graft. Adjunctive MRI or ultrasound with Doppler also provides comprehensive evaluation of anatomy, vascular anastomosis and patency, biliary tree, and stiffness for fibrosis. In this review, we provide a brief overview of elastography techniques available followed by the literature review of elastography in the evaluation of grafts and illustration with clinical examples.


Liver grafts Liver transplants Magnetic resonance elastography Shear wave elastography Transient elastography 




Compliance with ethical standards

Conflict of interest

The authors disclose no potential conflicts of interest.


  1. 1.
    Yin M, Venkatesh SK. Ultrasound or MR elastography of liver: which one shall I use? Abdominal radiology (New York). 2018;43(7):1546-51.CrossRefGoogle Scholar
  2. 2.
    Venkatesh SK, Ehman RL. Magnetic resonance elastography of liver. Magnetic resonance imaging clinics of North America. 2014;22(3):433-46.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Zhang YN, Fowler KJ, Ozturk A, Potu CK, Louie AL, Montes V, et al. Liver fibrosis imaging: A clinical review of ultrasound and magnetic resonance elastography. J Magn Reson Imaging. 2019.Google Scholar
  4. 4.
    Barr RG, Ferraioli G, Palmeri ML, Goodman ZD, Garcia-Tsao G, Rubin J, et al. Elastography Assessment of Liver Fibrosis: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2015;276(3):845-61.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Younossi ZM, Stepanova M, Rafiq N, Makhlouf H, Younoszai Z, Agrawal R, et al. Pathologic criteria for nonalcoholic steatohepatitis: interprotocol agreement and ability to predict liver-related mortality. Hepatology (Baltimore, Md). 2011;53(6):1874-82.CrossRefGoogle Scholar
  6. 6.
    OPTN. 2019 [Available from:
  7. 7.
    Adebajo CO, Talwalkar JA, Poterucha JJ, Kim WR, Charlton MR. Ultrasound-based transient elastography for the detection of hepatic fibrosis in patients with recurrent hepatitis C virus after liver transplantation: a systematic review and meta-analysis. Liver Transpl. 2012;18(3):323-31.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Lee VS, Miller FH, Omary RA, Wang Y, Ganger DR, Wang E, et al. Magnetic resonance elastography and biomarkers to assess fibrosis from recurrent hepatitis C in liver transplant recipients. Transplantation. 2011;92(5):581-6.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Singh S, Venkatesh SK, Keaveny A, Adam S, Miller FH, Asbach P, et al. Diagnostic accuracy of magnetic resonance elastography in liver transplant recipients: A pooled analysis. Annals of hepatology. 2016;15(3):363-76.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Yoon JH, Lee JM, Suh KS, Lee KW, Yi NJ, Lee KB, et al. Combined Use of MR Fat Quantification and MR Elastography in Living Liver Donors: Can It Reduce the Need for Preoperative Liver Biopsy? Radiology. 2015;276(2):453-64.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Piccinino F, Sagnelli E, Pasquale G, Giusti G. Complications following percutaneous liver biopsy. A multicentre retrospective study on 68,276 biopsies. J Hepatol. 1986;2(2):165-73.Google Scholar
  12. 12.
    Boyum JH, Atwell TD, Schmit GD, Poterucha JJ, Schleck CD, Harmsen WS, et al. Incidence and Risk Factors for Adverse Events Related to Image-Guided Liver Biopsy. Mayo Clinic proceedings. 2016;91(3):329-35.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Huwart L, Sempoux C, Vicaut E, Salameh N, Annet L, Danse E, et al. Magnetic resonance elastography for the noninvasive staging of liver fibrosis. Gastroenterology. 2008;135(1):32-40.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Singh S, Venkatesh SK, Wang Z, Miller FH, Motosugi U, Low RN, et al. Diagnostic performance of magnetic resonance elastography in staging liver fibrosis: a systematic review and meta-analysis of individual participant data. Clin Gastroenterol Hepatol. 2015;13(3):440-51.e6.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Wang QB, Zhu H, Liu HL, Zhang B. Performance of magnetic resonance elastography and diffusion-weighted imaging for the staging of hepatic fibrosis: A meta-analysis. Hepatology (Baltimore, Md). 2012;56(1):239-47.CrossRefGoogle Scholar
  16. 16.
    Tapper EB, Parikh ND. Mortality due to cirrhosis and liver cancer in the United States, 1999-2016: observational study. Bmj. 2018;362:k2817.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Venkatesh SK, Yin M, Ehman RL. Magnetic resonance elastography of liver: technique, analysis, and clinical applications. Journal of magnetic resonance imaging : JMRI. 2013;37(3):544-55.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Loomba R, Cui J, Wolfson T, Haufe W, Hooker J, Szeverenyi N, et al. Novel 3D Magnetic Resonance Elastography for the Noninvasive Diagnosis of Advanced Fibrosis in NAFLD: A Prospective Study. The American journal of gastroenterology. 2016;111(7):986-94.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Shi Y, Xia F, Li QJ, Li JH, Yu B, Li Y, et al. Magnetic Resonance Elastography for the Evaluation of Liver Fibrosis in Chronic Hepatitis B and C by Using Both Gradient-Recalled Echo and Spin-Echo Echo Planar Imaging: A Prospective Study. The American journal of gastroenterology. 2016;111(6):823-33.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Asbach P, Klatt D, Hamhaber U, Braun J, Somasundaram R, Hamm B, et al. Assessment of liver viscoelasticity using multifrequency MR elastography. Magnetic resonance in medicine. 2008;60(2):373-9.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Asbach P, Klatt D, Schlosser B, Biermer M, Muche M, Rieger A, et al. Viscoelasticity-based staging of hepatic fibrosis with multifrequency MR elastography. Radiology. 2010;257(1):80-6.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Chen J, Talwalkar JA, Yin M, Glaser KJ, Sanderson SO, Ehman RL. Early detection of nonalcoholic steatohepatitis in patients with nonalcoholic fatty liver disease by using MR elastography. Radiology. 2011;259(3):749-56.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Godfrey EM, Patterson AJ, Priest AN, Davies SE, Joubert I, Krishnan AS, et al. A comparison of MR elastography and 31P MR spectroscopy with histological staging of liver fibrosis. European radiology. 2012;22(12):2790-7.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Rustogi R, Horowitz J, Harmath C, Wang Y, Chalian H, Ganger DR, et al. Accuracy of MR elastography and anatomic MR imaging features in the diagnosis of severe hepatic fibrosis and cirrhosis. Journal of magnetic resonance imaging : JMRI. 2012;35(6):1356-64.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Yin M, Talwalkar JA, Glaser KJ, Manduca A, Grimm RC, Rossman PJ, et al. Assessment of hepatic fibrosis with magnetic resonance elastography. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2007;5(10):1207-13.e2.CrossRefGoogle Scholar
  26. 26.
    Hoodeshenas S, Welle CL, Navin PJ, Dzyubak B, Eaton JE, Ehman RL, et al. Magnetic Resonance Elastography in Primary Sclerosing Cholangitis: Interobserver Agreement for Liver Stiffness Measurement with Manual and Automated Methods. Academic radiology. 2019.Google Scholar
  27. 27.
    Sandrin L, Fourquet B, Hasquenoph JM, Yon S, Fournier C, Mal F, et al. Transient elastography: a new noninvasive method for assessment of hepatic fibrosis. Ultrasound Med Biol. 2003;29(12):1705-13.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Castera L, Forns X, Alberti A. Non-invasive evaluation of liver fibrosis using transient elastography. J Hepatol. 2008;48(5):835-47.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Bamber J, Cosgrove D, Dietrich CF, Fromageau J, Bojunga J, Calliada F, et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology. Ultraschall Med. 2013;34(2):169-84.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Bende F, Mulabecirovic A, Sporea I, Popescu A, Sirli R, Gilja OH, et al. Assessing Liver Stiffness by 2-D Shear Wave Elastography in a Healthy Cohort. Ultrasound in medicine & biology. 2018;44(2):332-41.CrossRefGoogle Scholar
  31. 31.
    Bruno C, Minniti S, Bucci A, Pozzi Mucelli R. ARFI: from basic principles to clinical applications in diffuse chronic disease-a review. Insights Imaging. 2016;7(5):735–746. doi:10.1007/s13244-016-0514-5CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Kennedy P, Wagner M, Castera L, Hong CW, Johnson CL, Sirlin CB, et al. Quantitative Elastography Methods in Liver Disease: Current Evidence and Future Directions. Radiology. 2018;286(3):738-63.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Park CC, Nguyen P, Hernandez C, Bettencourt R, Ramirez K, Fortney L, et al. Magnetic Resonance Elastography vs Transient Elastography in Detection of Fibrosis and Noninvasive Measurement of Steatosis in Patients With Biopsy-Proven Nonalcoholic Fatty Liver Disease. Gastroenterology. 2017;152(3):598-607.e2.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Cui J, Heba E, Hernandez C, Haufe W, Hooker J, Andre MP, et al. Magnetic resonance elastography is superior to acoustic radiation force impulse for the Diagnosis of fibrosis in patients with biopsy-proven nonalcoholic fatty liver disease: A prospective study. Hepatology (Baltimore, Md). 2016;63(2):453-61.CrossRefGoogle Scholar
  35. 35.
    Singh S, Muir AJ, Dieterich DT, Falck-Ytter YT. American Gastroenterological Association Institute Technical Review on the Role of Elastography in Chronic Liver Diseases. Gastroenterology. 2017;152(6):1544-77.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Ferraioli G, Wong VW-S, Castera L, Berzigotti A, Sporea I, Dietrich CF, et al. Liver Ultrasound Elastography: An Update to the World Federation for Ultrasound in Medicine and Biology Guidelines and Recommendations. Ultrasound in Medicine and Biology. 2018;44(12):2419-40CrossRefGoogle Scholar
  37. 37.
    Yamaoka Y, Washida M, Honda K, Tanaka K, Mori K, Shimahara Y, et al. Liver transplantation using a right lobe graft from a living related donor. Transplantation. 1994;57(7):1127-30.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Northup PG, Abecassis MM, Englesbe MJ, Emond JC, Lee VD, Stukenborg GJ, et al. Addition of adult-to-adult living donation to liver transplant programs improves survival but at an increased cost. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. 2009;15(2):148-62.CrossRefGoogle Scholar
  39. 39.
    Lai JC, Pichardo EM, Emond JC, Brown RS, Jr. Resource utilization of living donor versus deceased donor liver transplantation is similar at an experienced transplant center. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2009;9(3):586-91.CrossRefGoogle Scholar
  40. 40.
    Middleton PF, Duffield M, Lynch SV, Padbury RT, House T, Stanton P, et al. Living donor liver transplantation–adult donor outcomes: a systematic review. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. 2006;12(1):24-30.CrossRefGoogle Scholar
  41. 41.
    Muzaale AD, Dagher NN, Montgomery RA, Taranto SE, McBride MA, Segev DL. Estimates of early death, acute liver failure, and long-term mortality among live liver donors. Gastroenterology. 2012;142(2):273-80.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    UNOS. How We Match Organs: United Network for Organ Sharing; 2019 [Available from:
  43. 43.
    LaPointe Rudow D, Warburton KM. Selection and Postoperative Care of the Living Donor. The Medical clinics of North America. 2016;100(3):599-611.CrossRefGoogle Scholar
  44. 44.
    Gallegos-Orozco JF, Silva AC, Batheja MJ, Chang YH, Hansen KL, Lam-Himlin D, et al. Magnetic resonance elastography can discriminate normal vs. abnormal liver biopsy in candidates for live liver donation. Abdominal imaging. 2015;40(4):795-802.CrossRefGoogle Scholar
  45. 45.
    Kim KM, Choi WB, Park SH, Yu E, Lee SG, Lim YS, et al. Diagnosis of hepatic steatosis and fibrosis by transient elastography in asymptomatic healthy individuals: a prospective study of living related potential liver donors. Journal of gastroenterology. 2007;42(5):382-8.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Mancia C, Loustaud-Ratti V, Carrier P, Naudet F, Bellissant E, Labrousse F, et al. Controlled Attenuation Parameter and Liver Stiffness Measurements for Steatosis Assessment in the Liver Transplant of Brain Dead Donors. Transplantation. 2015;99(8):1619-24.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Zahr Eldeen F, Mabrouk Mourad M, Liossis C, Bramhall SR. Liver retransplant for primary disease recurrence. Experimental and clinical transplantation : official journal of the Middle East Society for Organ Transplantation. 2014;12(3):175-83.Google Scholar
  48. 48.
    Crespo G, Castro-Narro G, Garcia-Juarez I, Benitez C, Ruiz P, Sastre L, et al. Usefulness of liver stiffness measurement during acute cellular rejection in liver transplantation. Liver Transpl. 2016;22(3):298-304.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Klatt D, Kamphues C, Hirsch S, Papazoglou S, Braun J, Sack I, editors. MR elastography of liver transplant patients using parallel imaging techniques. Proc Intl Soc Mag Reson Med; 2011.Google Scholar
  50. 50.
    Wang Y, Ganger DR, Levitsky J, Sternick LA, McCarthy RJ, Chen ZE, et al. Assessment of chronic hepatitis and fibrosis: comparison of MR elastography and diffusion-weighted imaging. AJR American journal of roentgenology. 2011;196(3):553-61.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    El-Meteini M, Sakr M, Eldorry A, Abdelkader NA, Dabbous H, Montasser I, et al. Non-Invasive Assessment of Graft Fibrosis After Living Donor Liver Transplantation: Is There Still a Role for Liver Biopsy? Transplantation proceedings. 2019.Google Scholar
  52. 52.
    Carrion JA, Navasa M, Bosch J, Bruguera M, Gilabert R, Forns X. Transient elastography for diagnosis of advanced fibrosis and portal hypertension in patients with hepatitis C recurrence after liver transplantation. Liver Transpl. 2006;12(12):1791-8.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Harada N, Soejima Y, Taketomi A, Yoshizumi T, Ikegami T, Yamashita Y, et al. Assessment of graft fibrosis by transient elastography in patients with recurrent hepatitis C after living donor liver transplantation. Transplantation. 2008;85(1):69-74.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Rigamonti C, Donato MF, Fraquelli M, Agnelli F, Ronchi G, Casazza G, et al. Transient elastography predicts fibrosis progression in patients with recurrent hepatitis C after liver transplantation. Gut. 2008;57(6):821-7.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 55.
    Beckebaum S, Iacob S, Klein CG, Dechene A, Varghese J, Baba HA, et al. Assessment of allograft fibrosis by transient elastography and noninvasive biomarker scoring systems in liver transplant patients. Transplantation. 2010;89(8):983-93.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Kamphues C, Lotz K, Rocken C, Berg T, Eurich D, Pratschke J, et al. Chances and limitations of non-invasive tests in the assessment of liver fibrosis in liver transplant patients. Clin Transplant. 2010;24(5):652-9.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Yoon JH, Lee JY, Woo HS, Yu MH, Lee ES, Joo I, et al. Shear wave elastography in the evaluation of rejection or recurrent hepatitis after liver transplantation. Eur Radiol. 2013;23(6):1729-37.PubMedCrossRefPubMedCentralGoogle Scholar
  58. 58.
    Perry MT, Savjani N, Bluth EI, Dornelles A, Therapondos G. Point Shear Wave Elastography in Assessment of Hepatic Fibrosis: Diagnostic Accuracy in Subjects With Native and Transplanted Livers Referred for Percutaneous Biopsy. Ultrasound Q. 2016;32(3):201-7.PubMedCrossRefPubMedCentralGoogle Scholar
  59. 59.
    Korda D, Lenard ZM, Gerlei Z, Jakab Z, Haboub-Sandil A, Wagner L, et al. Shear-wave elastography for the assessment of liver fibrosis in liver transplant recipients treated for hepatitis C virus recurrence. Eur J Gastroenterol Hepatol. 2018;30(1):27-32.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Department of RadiologyMayo ClinicRochesterUSA

Personalised recommendations