Who is on the Liver Transplant Waitlist?
The number of adults with nonalcoholic steatohepatitis (NASH) waiting for liver transplants has almost tripled in the last 10 years, researchers report in the March issue of Gastroenterology. NASH is now the second leading liver disease of adults awaiting liver transplantation in the United States, the researchers found.
The prevalence of nonalcoholic fatty liver disease has increased rapidly during the worldwide epidemic of obesity, along with that of diabetes and metabolic syndrome. NASH is characterized by hepatic steatosis and inflammation, which can progress to fibrosis, cirrhosis, and hepatocellular carcinoma.
Although hepatitis C has been the leading etiology for liver transplantation, NASH is catching up: the number of liver transplantations for NASH increased 4-fold from 2002 to 2012.
Robert J Wong et al. evaluated the effects of the increasing incidence of NASH on liver transplant waitlist registrations in the US. They collected data from the United Network for Organ Sharing and Organ Procurement and Transplantation Network, from 2004 through 2013, on liver transplant waitlist registrants with hepatitis C virus (HCV) infection, NASH, alcoholic liver disease (ALD), or a combination of HCV infection and ALD.
They found that from 2004 through 2013, 35.2% of patients on the waitlist had hepatitis C, 18.3% had ALD, 15.8% had NASH, and 9.7% had hepatitis C and ALD.
However, over this period, the number of new waitlist registrants with NASH almost tripled, from 804 to 2174. The number of registrants with ALD increased from 1400 to 2024, and with hepatitis C increased from 2887 to 3291.
The data showed that in 2013, NASH became the second-leading disease among liver transplant waitlist registrants, after hepatitis C.
Furthermore, patients with NASH were less likely to undergo liver transplantation and less likely to survive for 90 days on the waitlist than patients with HCV, ALD, or a combination of HCV and ALD.
The authors say that patients with NASH might be less likely to receive livers because more aggressive diseases (hepatitis C and/or ALD) have more rapid increases in MELD score.
Wong et al predict that with the increasing incidence in NASH, coupled with the expected decrease in HCV-associated cirrhosis due to effective antiviral therapies, NASH will soon overtake hepatitis C as the most common chronic liver disease in the US.
Although the number of people awaiting liver transplants continues to increase, the number of donors is expected to decrease significantly in the next 15–20 years. Wong et al state that strategies are therefore needed to prevent or delay progression of liver disease, increase survival of patients awaiting liver transplants, and increase donors—especially for NASH patients.
In an editorial that accompanies the article, Sumeet K. Asrani and Jacqueline G. O’Leary state that better patient selection is equally as important. Although there are no stricter criteria for placing patients with NASH on liver transplant waitlist than for other etiologies, these should be considered, given that 50% of patients with NASH survive 1 year after receiving liver transplants. Patients with NASH on the waitlist were older, more frequently diabetic (46.3%), had the highest median body mass index (31.6 kg/m2), and the lowest glomerular filtration rate (55.2 mL/min), compared with other members of the waitlist, but had lower MELD scores.
Asrani and O’Leary say that given the conditions that often come with NASH, patients much be treated with a multidisciplinary approach that considers nutrition, endocrinology features, and bariatric surgery. Just as patients with ALD must achieve abstinence and usually participate in rehabilitation, similar programs are needed for NASH patients.
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