Bone marrow R2* correlates with liver iron load and is associated with decreased survival in patients with cirrhosis without liver iron overload.

objectivesTo evaluate vertebral bone-marrow (BM) iron content using R2* relaxometry in patients with cirrhosis, determine its correlation with hematologic and hepatic indices, and assess the relationship between BM iron overload and survival. MATERIALS AND

methodsThis retrospective study analyzed 190 patients who underwent liver magnetic resonance elastography between January 2018 and October 2024. Liver and vertebral BM R2* values were measured, and liver iron concentration (LIC) was estimated. Patients were categorized into normal, mild, or moderate liver and vertebral BM iron overload groups. Correlations were assessed using Spearman's rank correlation coefficient, independent predictors were assessed using binary logistic regression, and survival was analyzed using Cox proportional hazards regression.

resultsVertebral BM iron overload was observed in 28.7%, 51.5%, and 85.6% of patients with normal, mild, and moderate liver iron overload, respectively, wherein moderate iron overload comprised of 23.3%, 35.2%, and 50.0% of these groups. Vertebral BM R2* correlated with liver R2* and LIC (r = 0.347; p < 0.001), ferritin (r = 0.210; p = 0.004), and total iron-binding capacity (TIBC) (r = -0.186; p = 0.019). Liver R2* (odds ratio (OR), 1.010; p = 0.002) and TIBC (OR, 0.990; p = 0.035) were independent predictors of moderate vertebral BM iron overload. Vertebral BM R2* showed no correlation with liver function markers or Child-Pugh score. However, among patients without liver iron overload, moderate vertebral BM iron overload was associated with 5-year overall mortality (hazard ratio (HR), 3.981; p = 0.014).

conclusionVertebral BM R2* correlated with LIC and was associated with decreased survival in patients with normal liver iron. KEY POINTS: Question Do vertebral bone-marrow R2* values correlate with liver iron metrics in patients with cirrhosis, and are they associated with overall survival? Findings Higher vertebral bone-marrow R2* values were observed across liver iron categories and were associated with poorer survival among patients with normal liver iron. Clinical relevance Vertebral bone-marrow R2* quantification may provide additional information for risk assessment in patients with cirrhosis with normal liver iron.