NASH grows as indication for liver transplant

While hepatitis C (HCV) currently remains the leading indication for liver transplant in Australia and New Zealand, non-alcoholic steatohepatitis (NASH) is expected to eventually take over given the drivers of overweight, obesity and diabetes.

NASH currently sits third behind both HCV and alcoholic liver disease.

A review of more than 5,000 adults activated for liver transplants in Australia and New Zealand between 1994 and 2017 confirms the trends here are following those in the US.

In the US, NASH has already overtaken alcoholic liver disease as an indication for liver transplant and is expected to pass HCV as infection rates and transmission of the virus are reduced by direct-acting antiviral therapy and risk factors for NASH continue to climb.

The review of data from the ANZ Liver Transplant Registry found NASH has already overtaken primary sclerosing cholangitis (PSC) and hepatitis B (HBV) as indications for liver transplant.

Across the 24-year period as a whole, HCV (34%), alcohol (16%), PSC (11%), HBV (9%) then NASH (5%) were the leading indications.

But by 2017, HCV represented 30.2% of indications, alcohol was 18.2% and NASH had risen substantially to 12.4%.

NASH increased marginally from 0% to 2.4% between 1994 and 2004 but rates almost doubled from 6.8% to 12.4% between 2005 and 2017.

“It is notable that the velocity of obesity rates increased significantly in Australia after 1995 from an average increase of 3.1% per decade to 6.0% increase per decade,” the study said.

“Subsequently, there was a significant increase in NASH-related transplantation 1 decade later demonstrating the long-term sequelae of obesity-related liver disease.

“Additionally, the epidemic of obesity, which underpins the development of NAFLD, occurred in Australia a decade later than the United States, suggesting that rates of end-stage liver disease and HCC related to NASH in Australia will continue to increase to mirror the experience in the United States.”

The authors, including Professor Leon Adams from the University of Western Australia and Sir Charles Gairdner Hospital, said early recognition of NASH was critical along with tailored management of high-risk patients to reduce progression to end-stage liver disease and liver cancer.

“In addition, with the increasing prevalence of metabolic factors (diabetes, overweight, or obesity), which have a negative impact on wait-list dropout rates and survival after liver transplant, strategies to optimize weight and diabetes control and avoid sarcopenia should be prioritized in these patients within liver transplant programs.”

A related editorial in Liver Transplantation said transplant centres around the world could expect to see increasing number of affected patients.

“These centres will need not only to be ready to manage these patients’ advanced liver diseases but also their associated metabolic disease and complications.”

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