Liver and Bile
Clin Gastroenterol Hepatol. 2023;21(2):445–55.e2
Factors impacting survival in those transplanted for NASH cirrhosis: Data from the NailNASH consortium
Background and aims: Non-alcoholic steatohepatitis (NASH) is the leading indication for liver transplantation (LT) in women and the elderly. Granular details into factors impacting survival in this population are needed to optimize management and improve outcomes.
Methods: Patients receiving LT for NASH cirrhosis from 1997 to 2017 across 7 transplant centers (NailNASH consortium) were analyzed. The primary outcome was all-cause mortality, and causes of death were enumerated. All outcomes were cross-referenced with United Network for Organ Sharing and adjudicated at each individual center. Cox regression models were constructed to elucidate clinical factors impacting mortality.
Results: 938 patients with a median follow-up of 3.8 years (interquartile range, 1.60–7.05 years) were included. The 1-, 3-, 5-, 10-, and 15-year survival of the cohort was 93%, 88%, 83%, 69%, and 46%, respectively. Of 195 deaths in the cohort, the most common causes were infection (19%), cardiovascular disease (18%), cancer (17%), and liver-related (11%). Inferior survival was noted in patients > 65 years. On multivariable analysis, age > 65 (hazard ratio [HR] = 1.70; 95% confidence interval [CI]: 1.04–2.77; p = 0.04), end-stage renal disease (HR = 1.55; 95% CI: 1.04–2.31; p = 0.03), black race (HR = 5.25; 95% CI: 2.12–12.96; p = 0.0003), and non-calcineurin inhibitor-based regimens (HR = 2.05; 95% CI: 1.19–3.51; p = 0.009) were associated with increased mortality. Statin use after LT favorably impacted survival (HR = 0.38; 95% CI: 0.19–0.75; p = 0.005).
Conclusions: Despite excellent long-term survival, patients transplanted for non-alcoholic steatohepatitis at > 65 years or with type 2 diabetes mellitus at transplantation had higher mortality. Statin use after transplantation attenuated risk and was associated with improved survival across all subgroups, suggesting that careful patient selection and implementation of protocol-based management of metabolic comorbidities may further improve clinical outcomes.