Chapter 20: Liver Transplantation in Nonalcoholic Fatty Liver Disease

INTRODUCTION

• Due to the increasing incidence of obesity in recent years, nonalcoholic fatty liver disease (NAFLD) has become the most common chronic liver disease in the Western world.¹

• The spectrum of NAFLD goes through different stages, from simple steatosis and nonalcoholic steatohepatitis (NASH) to cirrhosis and end-stage liver disease. Figure 20-1 to 20-5

  • Recent data show a prevalence as high as 46% for NAFLD, 12% for NASH, and 2.7% for advanced fibrosis in the general U.S. population.²

• The United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) data demonstrate that NASH has become the second leading cause of chronic liver disease among new patients on waiting list for liver transplantation in 2013, showing an increase of 170%.³

• Data from the UNOS/OPTN registry showed that NASH etiology rose 4-fold from 2002 to 2012 in patients with hepatocellular carcinoma who underwent liver transplantation.⁴

• NASH is becoming the leading cause of LT in many regions. This is explained by the increasing number of patients with NASH-related liver disease and the emergence of highly effective antiviral therapies for HCV.

CHARACTERISTICS OF PATIENTS WITH CIRRHOSIS DUE TO NASH

• NAFLD is the hepatic manifestation of metabolic syndrome and is associated with insulin resistance, type 2 diabetes mellitus, obesity, and dyslipidemia.

• Patients with NAFLD have increased cardiovascular morbidity and mortality.⁵

• Specific characteristics of NASH patients presenting for LT are observed:^6–8

  • They are older patients at the time of transplantation.

  • Predominance of females over males is observed.

  • Cardiovascular comorbidities: diabetes mellitus, hypertension, dyslipidemia, and higher body mass index (BMI) than other indications for LT.

• NASH patients are twice as likely as patients with HCV to be denied for listing because of these comorbidities.⁹

• A high-risk phenotype for NASH patients was identified, which might predict poor outcomes 1 and 5 years after LT:^8,10

  • >60 years of age

  • BMI >30

  • Diagnosis of hypertension and diabetes

• Once on the waiting list, patients with ...