Patients with non-alcoholic steatohepatitis have inferior liver transplant outcomes

Background and aims: Non-alcoholic steatohepatitis (NASH) is an increasing indication for liver transplantation (LT). Historically, patients with NASH are reported to have similar outcomes after LT compared to patients without NASH. The current study revisits this question. Post-transplant outcomes were evaluated among three major etiologies: NASH, hepatitis C (HCV), and alcoholic liver disease (ALD) to determine risks in LT associated with the NASH population. Method: Data from the UNOS registry were analysed. Patients were divided into those with a diagnosis of NASH, HCV or ALD. Patients with overlapping diagnoses were excluded. LT was divided into four groups by era: Era 1: 2008–2010, Era 2: 2011–2013, Era 3: 2014–2015, Era 4: 2016–2017. Primary outcome was one year patient survival. Outcomes were compared among disease groups using Cox regression models adjusting for donor/recipient characteristics, except for recipient age, body mass index, and diabetes, which were considered NASH-associated characteristics. All patients had at least one year follow-up. Results: There were 6, 344 patients with NASH, 17, 037 with HCV, and 9, 279 with ALD. The percent of patients with NASH and ALD rose significantly across eras from 14.0% to 27.9% and from 24.7% to 36.8%, respectively. The percent with HCV declined from 61.3% to 36.3%. In Era 1, the HCV group showed significantly worse one-year patient survival of 87.4% than the NASH and ALD groups at 90.3% (p = 0.007) and 90.6% (p \u3c 0.001), respectively, whereas in Era 4, the NASH group showed significantly worse survival at 90.4% compared to 92.8% in the HCV (p = 0.004) and 93.5% in the ALD (p \u3c 0.001) groups. The risk of one-year mortality in the NASH group became higher than the HCV and ALD groups in Era 4 with hazard ratios of 1.29 (p = 0.047) and 1.52; (p \u3c 0.001). There was significant improvement in one-year [Figure Presented] patient survival over eras in the HCV (p \u3c 0.001) and ALD groups (p = 0.001), whereas no improvement was seen in the NASH group. The NASH group contained the fastest growing population of older patients. The annual number of patients over 65 years was largest in the HCV group in Era 1 at 144 per year compared to 103 in NASH and 94 in ALD. In Era 4, the NASH group has the largest number of patients over 65 at 422 per year compared to 369 in HCV and 227 in ALD. In addition, the effects of increasing age were most pronounced in the NASH group. Compared to patients \u3c 50 years, the hazard of mortality in age 50-59, 60-64, 65-69 and 370 years was 1.32 (p = 0.022), 1.64 (p \u3c 0.001), 2.05 (p \u3c 0.001), and 2.61 (p \u3c 0.001). Mortality from cardiovascular/cerebrovascular disease was greatest in the NASH group accounting for 11.5% of deaths compared to 7.0% and 9.6% in HCV and ALD (p \u3c 0.001). Conclusion: The risk of LT in the NASH population has become higher than in HCV or ALD. This is likely to have profound implications in a time of shifting indications for LT