Objective To evaluate the role of contrast-enhanced ultrasound (CEUS) liver imaging reporting and data system (LI-RADS) in the malignant risk assessment of focal liver lesions in patients with chronic liver disease.Methods The clinical and imaging data of 197 nodules in 151 patients with focal liver lesions with high-risk factors of hepatocellular carcinoma (HCC) who underwent liver CEUS in Ruijin Hospital, Shanghai Jiao Tong University School of Medicine from Jan. 2018 to Oct. 2020 were analyzed retrospectively. The nodules were graded by CEUS LI-RADS according to the American College of Radiology (ACR) LI-RADS (2017). The diagnosis of target lesions was confirmed by histopathology or contrast-enhanced computed tomography/magnetic resonance imaging combined with follow-up. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CEUS LI-RADS classification standard in the diagnosis of liver malignant lesions were calculated by diagnostic test formula.Results Among the 197 lesions, 126 were malignant and 71 were benign. CEUS LI-RADS showed that there were 12 lesions for LR-1, 24 lesions for LR-2, 39 lesions for LR-3, 14 lesions for LR-4, 90 lesions for LR-5, and 18 lesions for LR-M. When LR-5 was recognized as HCC, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 77.57% (83/107), 92.22% (83/90), 92.22% (83/90), 77.57% (83/107), and 84.26% (166/197), respectively; when LR-4+5 was recognized as HCC, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 86.92% (93/107), 87.78% (79/90), 89.42% (93/104), 84.95% (79/93), and 87.31% (172/197), respectively; there was no significant difference in the diagnostic value between the 2 criteria (P > 0.05). In addition, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of LR-M in diagnosing non-HCC malignant lesions were 73.68% (14/19), 97.75% (174/178), 77.78% (14/18), 97.21% (174/179), and 95. 43% (188/197), respectively.Conclusion CEUS LI-RADS provides a standardized evaluation for focal liver lesions in patients with chronic liver diseases. It shows good diagnostic efficiency for HCC and high diagnostic specificity and accuracy for non-HCC malignant lesions.