Nonalcoholic steatohepatitis recurrence after liver transplant

Abstract

Nonalcoholic steatohepatitis (NASH) is the fastest growing indication for liver transplant (LT)worldwide and is deemed to be the foremost indication in the near future. Recurrence of NASH can occur post LT and has been observed to be a common phenomenon. Baseline metabolic co-morbidities and worsening of metabolic profile post LT are the principal drivers of NASH recurrence. Liver biopsy remains the gold standard for establishing the diagnosis. However, noninvasive methods including transient elastography (TE) and magnetic resonance imaging (MRI) seem to be promising. The implications of recurrent NASH on post LT outcomes, graft steatosis, progression to fibrosis, overall survival, and cardiovascular associations warrant careful evaluation. Control of metabolic parameters and weight gain along with tailored immunosuppression remain the cornerstone of management. Extrapolation of the everincreasing armamentarium of NASH pharmacotherapy specifically in this population of recurrent NAFLD remains a challenge for the future.

The Asian Pacific Association for the Study of the Liver clinical practice guidelines for the diagnosis and management of metabolic associated fatty liver disease

“…Recurrence of MAFLD in the graft is common, occurring in up to 90% of recipients [321]. A minority of patients have an accelerated disease course with graft cirrhosis developing in 2-4% of patients in less than a decade; however, death from graft cirrhosis is uncommon (0.2-3% of patients) [320,321].…”

“…Recurrence of MAFLD in the graft is common, occurring in up to 90% of recipients [321]. A minority of patients have an accelerated disease course with graft cirrhosis developing in 2-4% of patients in less than a decade; however, death from graft cirrhosis is uncommon (0.2-3% of patients) [320,321]. Corticosteroids and calcineurin antagonists are wellestablished immunosuppressive regime in LT with known risks to exacerbate hyperglycemia, hypertension, and dyslipidemia; hence the optimal regime in MAFLD recipients is unclear.…”

Clinical Practice Guidelines for Liver Transplantation in Saudi Arabia

“…Both NAFLD and NASH, recurrent and de novo, are common after LT. 9 Pre- and post-LT BMI, T2DM, arterial hypertension, and hyperlipidemia are the major risk factors for post-LT NAFLD/NASH. 12 , 318 , 319 Liver biopsy is required to confirm recurrent or de novo NAFLD/NASH, recognize fibrosis, and exclude alternate causes of altered liver chemistry tests (Grade III). Avoiding extreme weight gains and keeping hypertension, dyslipidemia, and T2DM in control are recommended (Grade III).…”

Bariatric surgery, obesity and liver transplantation

“…Genetic factor such as carriage of the D allele of the ACE gene is also found to be strong, independent risk factor for excess weight gain after LT (27). The potential impact of post-LT weight gain includes increased risk of new onset diabetes mellitus (NODM) (28,29), metabolic syndrome (30,31) and its associated complications, such as CVD (32), and de novo NASH in the allograft (33,34).…”