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  • 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.


Liver biopsy: Mixed large and small droplet steatosis without significant liver injury (hematoxylin and eosin stain, 100×).


Liver biopsy: Mixed steatosis with delicate perisinusoidal fibrosis (trichrome stain, 100×).


Liver biopsy: Mixed steatosis with liver injury. Ballooned hepatocytes with Mallory-Denk bodies and mild parenchymal inflammatory activity (hematoxylin and eosin stain, 400×).


Liver biopsy: End-stage burned-out NASH. Parenchymal fibrosis without liver steatosis (trichrome stain, 400×).


Explanted liver: Macronodular cirrhosis due to burned-out NASH. Few hepatocytes with macrovesicular steatosis close to wide, fibrous septa with mixed inflammatory activity (trichrome stain, 100×).


  • 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 ...

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