Patients with nonalcoholic steatohepatitis who were deemed candidates for liver transplant were less likely to actually undergo the procedure than were candidates with hepatitis C, and more often died or were delisted for being too ill before transplant, wrote Dr. Jacqueline G. O’Leary and colleagues in the August issue of Clinical Gastroenterology and Hepatology.
Moreover, the study showed that the presence of comorbid conditions such as hypertension and obesity was the predominant reason for denial of liver transplant in nonalcoholic steatohepatitis (NASH).
The findings mean that "The primary focus of treatment in NASH/CC [cryptogenic cirrhosis] patients with a low MELD [model for end-stage liver disease] score needs to be aggressive treatment of their obesity, diabetes, lipid disorders, and hypertension so that they do not develop comorbid conditions that cause death or make them ineligible for transplant."
Dr. O’Leary, of the Annette C. and Harold C. Simmons Transplant Institute at the Baylor University Medical Center at Dallas, studied data from 415 patients with NASH and/or CC and 1,232 patients with hepatitis C virus (HCV)–associated cirrhosis who were evaluated for transplant at the Baylor facility (Clin. Gastroenterol Hepatol. 2011 [doi.10.1016/j.cgh.2011.04.007]).
All NASH/CC patients denied for transplant were compared to all HCV patients denied for transplant. "When patients are denied for OLT [orthotopic liver transplantation], they are recorded as excluded for medical comorbidities, psychosocial reasons, adequate hepatic reserve, exceeding tumor criteria, or death," wrote the investigators. "However, the specific comorbidities and psychosocial reasons are not recorded in our database."
Overall, Dr. O’Leary found that 197 NASH/CC patients were denied for listing (47%), as were 586 HCV patients (48%).
In general, the NASH/CC patients with denials were older (median age 60 years vs. 51 years; P less than .001), more likely to be female (57% vs. 35%; P less than .001), heavier (body mass index greater than 30 kg/m2: 59% vs. 40%; P less than .001), and had a lower glomerular filtration rate (74 mL/min vs. 88 mL/min; P = .004), compared with the HCV patients who were denied.
According to the analysis, among the NASH/CC patients, the existence of comorbid conditions was the most likely reason for denial (72% vs. 27% in the HCV group), whereas among the HCV patients, ongoing psychological issues – including recidivism and lack of social support – precluded the greatest percentage of candidates from transplant (39% vs. 8% in the NASH/CC cohort).
Among all denied patients, liver disease severity was similar for the two groups, with MELD scores of 12 among NASH/CC patients versus 11 for HCV patients.
The authors also compared the 217 NASH/CC patients who were listed for transplant with the 645 HCV patients who were listed.
NASH/CC patients were heavier (BMI greater than 30: 54% vs. 42%; P = .004), and were more likely to have diabetes (55% vs. 22%; P less than .001) and hypertension (46% vs. 28%; P less than .001) than the HCV patients. Liver disease severity, as measured by median MELD score (14 for both) and Child-Turcotte-Pugh point system (7 for both), was the same.
However, the authors found that among those listed, patients with NASH/CC were significantly less likely to ultimately be transplanted than patients with HCV (48% vs. 62%; P less than .001).
"While listed, 22% of NASH/CC patients and 16% of HCV patients either died on the list or were delisted for being too ill," the authors explained
"Although some have suggested that NASH cirrhosis would overtake HCV as the main indication for [transplant] by 2020, this does not seem likely, since coincident comorbid conditions often found in NASH/CC patients may often preclude [transplant]," wrote the authors.
"In fact, our data confirm this suspicion; NASH/CC patients were almost twice as likely as HCV cirrhosis patients to be denied for listing because of comorbid conditions."
The authors reported no grant support and no relevant conflicts of interest.