Abstract
Little is known about outcomes of liver transplantation for patients with non-alcoholic steatohepatitis (NASH). We aimed to determine the frequency and outcomes of liver transplantation for patients with NASH in Europe and identify prognostic factors. We analysed data from patients transplanted for end-stage liver disease between January 2002 and December 2016 using the European Liver Transplant Registry database. We compared data between patients with NASH versus other aetiologies. The principle endpoints were patient and overall allograft survival. Among 68,950 adults undergoing first liver transplantation, 4.0% were transplanted for NASH - an increase from 1.2% in 2002 to 8.4% in 2016. A greater proportion of patients transplanted for NASH (39.1%) had hepatocellular carcinoma (HCC) than non-NASH patients (28.9%, p <0.001). NASH was not significantly associated with survival of patients (hazard ratio [HR] 1.02, p = 0.713) or grafts (HR 0.99; p = 0.815) after accounting for available recipient and donor variables. Infection (24.0%) and cardio/cerebrovascular complications (5.3%) were the commonest causes of death in patients with NASH without HCC. Increasing recipient age (61-65 years: HR 2.07, p <0.001; >65: HR 1.72, p = 0.017), elevated model for end-stage liver disease score (>23: HR 1.48, p = 0.048) and low (<18.5 kg/m2: HR 4.29, p = 0.048) or high (>40 kg/m2: HR 1.96, p = 0.012) recipient body mass index independently predicted death in patients transplanted for NASH without HCC. Data must be interpreted in the context of absent recognised confounders, such as pre-morbid metabolic risk factors. The number and proportion of liver transplants performed for NASH in Europe has increased from 2002 through 2016. HCC was more common in patients transplanted with NASH. Survival of patients and grafts in patients with NASH is comparable to that of other disease indications. The prevalence of non-alcoholic fatty liver disease has increased dramatically in parallel with the worldwide increase in obesity and diabetes. Its progressive form, non-alcoholic steatohepatitis, is a growing indication for liver transplantation in Europe, with good overall outcomes reported. However, careful risk factor assessment is required to maintain favourable post-transplant outcomes in patients with non-alcoholic steatohepatitis.
Highlights
The prevalence of non-alcoholic fatty liver disease (NAFLD) has increased dramatically, in parallel with the worldwide increase in obesity and diabetes.[1,2] Approximately a quarter of the European adult population have NAFLD, representing an increase of 10% since 2005.3Non-alcoholic steatohepatitis (NASH) and any associated fibrosis, confer a greater risk of liver-related morbidity and mortality amongst patients with NAFLD.[4]
Data were analysed for patients transplanted for alcohol-related liver disease (ALD), hepatitis C virus infection (HCV), hepatitis B virus infection (HBV), autoimmune liver disease (AiLD), cryptogenic cirrhosis (CC), non-alcoholic steatohepatitis (NASH) and ‘‘other” including non-B, non-C chronic viral hepatitis, polycystic liver disease, Wilson’s disease, hereditary haemochromatosis and alpha-1antitrypsin deficiency
The primary liver diagnosis stated in the European Liver Transplant Registry (ELTR) database was used to assign diagnoses in these analyses; secondary diagnoses were disregarded unless the primary diagnosis was hepatocellular carcinoma (HCC) or cryptogenic, for which the secondary diagnosis was considered as the primary
Summary
The prevalence of non-alcoholic fatty liver disease (NAFLD) has increased dramatically, in parallel with the worldwide increase in obesity and diabetes.[1,2] Approximately a quarter of the European adult population have NAFLD, representing an increase of 10% since 2005.3. Non-alcoholic steatohepatitis (NASH) and any associated fibrosis, confer a greater risk of liver-related morbidity and mortality amongst patients with NAFLD.[4] NASH is an increasingly common indication for liver transplantation (LT), and is second only to alcohol-related liver disease (ALD) in the US.[5] NASH accounts for an increasing proportion of patients undergoing LT in the UK (4% in 1995; 12% in 2013).[6] pan-European data to describe the burden of NASH on transplantation services are lacking. Little is known about outcomes of liver transplantation for patients with non-alcoholic steatohepatitis (NASH). A greater proportion of patients y Denotes joint first authorship. A greater proportion of patients y Denotes joint first authorship. à Denotes joint senior authorship
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