Rinella Mary E, Satapathy Sanjaya K, Brandman Danielle, Smith Coleman, Elwir Sal, Xia Jonathan, Gibson Meg, Figueredo Carlos, Angirekula Mounika, Vanatta Jason M, Sarwar Raiya, Jiang Yu, Gregory Dyanna, Agostini Tandy, Ko JimIn, Podila Pradeep, Gallo Grace, Watt Kymberly D, Siddiqui Mohammad S
Pritzker School of Medicine, University of Chicago, Chicago, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Division of Hepatology at Sandra Atlas Bass Center for Liver Diseases & Transplantation, Barbara and Zucker School of Medicine/Northwell Health, Manhasset, New York.
Clin Gastroenterol Hepatol. 2023 Feb;21(2):445-455.e2. doi: 10.1016/j.cgh.2022.02.028. Epub 2022 Feb 18.
BACKGROUND & AIMS: Nonalcoholic steatohepatitis (NASH) is the leading indication for liver transplant (LT) in women and the elderly. Granular details into factors impacting survival in this population are needed to optimize management and improve outcomes.
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.
Nine hundred thirty-eight 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 = .04), end-stage renal disease (HR, 1.55; 95% CI, 1.04-2.31; P = .03), black race (HR, 5.25; 95% CI, 2.12-12.96; P = .0003), and non-calcineurin inhibitors-based regimens (HR, 2.05; 95% CI, 1.19-3.51; P = .009) were associated with increased mortality. Statin use after LT favorably impacted survival (HR, 0.38; 95% CI, 0.19-0.75; P = .005).
Despite excellent long-term survival, patients transplanted for NASH at >65 years or with type 2 diabetes mellitus at transplant had higher mortality. Statin use after transplant 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.
非酒精性脂肪性肝炎（NASH）是女性和老年人肝移植（LT）的主要适应证。需要详细了解影响该人群生存的因素，以优化管理并改善预后。
分析了1997年至2017年期间在7个移植中心（NailNASH联盟）接受NASH肝硬化肝移植的患者。主要结局是全因死亡率，并列举了死亡原因。所有结局均与器官共享联合网络进行交叉核对，并在每个中心进行判定。构建Cox回归模型以阐明影响死亡率的临床因素。
纳入938例患者，中位随访时间为3.8年（四分位间距，1.60 - 7.05年）。该队列的1年、3年、5年、10年和15年生存率分别为93%、88%、83%、69%和46%。在该队列的195例死亡中，最常见的原因是感染（19%）、心血管疾病（18%）、癌症（17%）和肝脏相关（11%）。65岁以上患者的生存率较低。多变量分析显示，年龄>65岁（风险比[HR]，1.70；95%置信区间[CI]，1.04 - 2.77；P = .04）、终末期肾病（HR，1.55；95% CI，1.04 - 2.31；P = .03）、黑人种族（HR，5.25；95% CI，2.12 - 12.96；P = .0003）以及基于非钙调神经磷酸酶抑制剂的方案（HR，2.05；95% CI，1.19 - 3.51；P = .009）与死亡率增加相关。肝移植后使用他汀类药物对生存有有利影响（HR，0.38；95% CI，0.19 - 0.75；P = .005）。
尽管长期生存率良好，但65岁以上接受NASH肝移植的患者或移植时患有2型糖尿病的患者死亡率较高。移植后使用他汀类药物可降低风险，并与所有亚组的生存改善相关，这表明仔细的患者选择和基于方案的代谢合并症管理可能会进一步改善临床结局。
