Recurrent nonalcoholic steatohepatitis and cirrhosis after liver transplantation

Abstract

Nonalcoholic steatohepatitis (NASH) may progress to cirrhosis and lead to liver failure. Histologically, NASH is often indistinguishable from liver disease caused by alcohol use; the cause of NASH remains unknown. A subgroup of patients with NASH eventually develops fibrosis and/or cirrhosis, and in many cases, transplantation is performed for end-stage liver disease attributed to steatohepatitis in patients who do not consume alcohol. The patient described received a transplant for end-stage liver disease secondary to NASH with cirrhosis. Postoperatively she did well, with a bout of mild rejection treated successfully at week 9 with prompt normalization of liver tests. Weight and glycemic control were optimized, and steroid therapy was minimized as safely as possible. Repeat liver biopsy at week 66, however, for persistent mild elevation of alkaline phosphatase and gamma-glutamyltransferase surprisingly revealed the ''recurrence'' of NASH. Subsequent biopsy revealed NASH with cirrhosis by week 76 after transplantation. Subsequent biopsy at week 87 has confirmed cirrhosis. The patient does not consume alcohol. It is believed to be the first reporting of such a case.

Nonalcoholic steatohepatitis: Summary of an AASLD Single Topic Conference

“…Many patients with advanced disease are poor candidates for transplantation due to comorbid conditions such as obesity and complications of diabetes. Both recurrence of NASH in patients with previously established NASH [215][216][217][218] and de novo occurrence of NASH after transplantation for cryptogenic cirrhosis 12,16 can occur. Posttransplantation progression to cirrhosis may develop although predictive factors and treatment have not been well defined.…”

Long-term management of the liver transplant patient: Diabetes, hyperlipidemia, and obesity

“…63 One unsettling feature of posttransplant obesity has been the finding of steatosis with inflammation and necrosis in the transplanted liver. 62 Not only have there been reports of recurrent NASH in the transplanted liver 64,65 with cirrhosis, 65 but patients with a "NASH phenotype" who undergo liver transplantation for cryptogenic cirrhosis are at 100% risk for developing steatosis within 5 years of transplantation, 66 with the attendant risks of steatohepatitis and fibrosis.…”

Outcomes of liver transplantation in patients with cirrhosis due to nonalcoholic steatohepatitis versus patients with cirrhosis due to alcoholic liver disease

“…5,6 NASH can progress to cirrhosis (in 22% of cases in 1 study) 3 and liver failure requiring liver transplantation (LT). 7,8 Hepatic steatosis may in fact disappear after the development of cirrhosis, which may mask the diagnosis of NASH in some patients with NASH-related endstage liver disease. 9 Cryptogenic cirrhosis accounts for 7% to 14% of LT procedures in the United States, 10 and there is strong evidence suggesting that NASH is the leading cause of cryptogenic cirrhosis.…”