Liver transplant candidates with NASH cirrhosis less likely to receive new organ

Waitlisted registrants for liver transplantation (LT) who have nonalcoholic steatohepatitis (NASH) cirrhosis have a lower chance to receive a new organ and greater risk of waitlist mortality at 90 days and 1 year than patients with non-NASH cirrhosis, suggest the results of a Singapore study.

“NASH cirrhosis was associated with a lower probability of transplantation and higher waitlist mortality,” the investigators said.

In addition, serum creatinine was a major contributor to increases in model for end-stage liver disease (MELD) score leading to transplant in NASH cirrhosis patients.

“NASH cirrhosis is rapidly growing as an indication for LT,” the investigators said. “However, the natural history of NASH cirrhosis among LT waitlist registrants has not been established.”

This study, which sought to define the natural history of NASH cirrhosis using the Scientific Registry of Transplant Recipients databases, included patients registered on the LT waitlist between 1 January 2016 and 31 December 2021. The primary outcomes were LT probability and waitlist mortality between NASH (n=8,120) and non-NASH (n=21,409) cirrhosis patients.

Despite dealing with a greater portal hypertension burden, patients with NASH cirrhosis were listed with lower MELD scores. [J Hepatol 2023;79:1015-1024]

LT waitlist registrants with NASH had a significantly lower chance of receiving a transplant at 90 days (hazard ratio [HR], 0.873; p<0.001) and 1 year (HR, 0.867; p<0.001) than those with non-NASH cirrhosis. This effect is more evident in patients with MELD scores >30 (90 days: HR, 0.705; 1 year: HR, 0.672; p<0.001 for both).

Notably, serum creatinine served as the key driver of MELD score increases leading to LT among waitlist registrants with NASH cirrhosis. On the other hand, bilirubin was the key contributor in patients with non-NASH cirrhosis.

Waitlist mortality

Furthermore, patients with NASH cirrhosis had significantly higher waitlist mortality at 90 days (HR, 1.15; p<0.001) and 1 year (HR, 1.25; p<0.001) compared to those with non-NASH cirrhosis. These differences were more evident in patients who had lower MELD scores during LT waitlist registration.

“This study provides important insights into the distinct natural history of NASH cirrhosis among LT waitlist registrants, revealing that patients with NASH cirrhosis face lower odds of transplantation and higher waitlist mortality than those with non-NASH cirrhosis,” the investigators said.

“Our study underscores the significance of serum creatinine as a crucial contributor to MELD score in patients with NASH cirrhosis,” they added.

These findings could have significant implications for candidates of LT. Specifically, ongoing evaluation and refinement of the MELD score is necessary to capture the risk of mortality more accurately in patients with NASH cirrhosis who are on the LT waitlist, according to the investigators.

In addition, this study emphasized the need for further research on the effect of the implementation of MELD 3.0 on the natural history of NASH cirrhosis, the investigators said.