Health care utilization is higher among patients undergoing liver transplantation for nonalcoholic steatohepatitis (NASH)

Image: CC/Nephron. Histology of NASH

Key study points:

1. NASH patients undergoing liver transplant had significantly longer operative times (402 vs. 322 minutes, p < .001) versus patients undergoing transplants for other reasons. 
2. In multivariate regression analyses, NASH is not an independent predictor of prolonged length-of-stay after liver transplant

Primer: Nonalcoholic Steatohepatitis (NASH) is a form of fatty liver disease that is becoming ever more prevalent within the U.S. population given its association with obesity and the rapidly increasing prevalence of obesity.  NASH as the primary reason for liver transplant has gone from 3% 2002 to 19% 2011.  Fatty liver disease is caused by triglyceride accumulation in hepatocytes, and can result in anything from benign steatosis to fibrosis and cirrhosis, which may ultimately require a liver transplant for survival.  Given the increasing incidence of this condition, this study focused on analyzing the difference in incidence, outcomes, and utilization of health care resources in NASH patients undergoing liver transplant. 

 Background reading:

1. Charlton MR, Burns JM, Pedersen RA, et al. Frequency and outcomes of liver transplantation for nonalcoholic steatohepatitis in the United States. Gastroenterology. 2011;141:1249–1253.

2. Afzali A, Berry K, Ioannou GN. Excellent posttransplant survival for patients with nonalcoholic steatohepatitis in the United States. Liver Transpl. 2012;18:29–37.

This [retrospective] study: 144 adult NASH patients at UCLA that underwent primary liver transplant between December 1993 and August 2011 were followed in a prospective database, which was then reviewed retrospectively. These patients were compared to 1150 patients undergoing liver transplant for other reasons, including cryptogenic cirrhosis, hepatitis C, etc., and were then followed post-transplant for an average of 2.3 years.  NASH patients underwent rigorous evaluations to exclude other forms of liver disease, and all patients underwent testing for other surgical risk factors, especially cardiovascular risk factors.  Overall, NASH patients had a similar 90 day graft (86%), patient survival (90%), and re-transplant rate (7%) as the non-NASH patients.  They did have significantly longer operative times (402 vs. 322 minutes, p < .001) and post-transplant length of stays (35 vs 29 days).  7 independent risk factors for length of stay post-transplant were identified during multivariate analysis, but NASH was not one of them.

In sum: This study, the largest single-institution study of patients with NASH undergoing liver transplant, the authors provide useful data on the resource utilization of NASH patients undergoing liver transplants. They showed that in terms of operative time and length of stay, NASH patients utilize more resources.  Given the rapidly increasing incidence of NASH patients and their need for liver transplants, in the context of today’s increasingly cost-conscious health care system, these data are both significant and concerning.  The similar graft survival, patient survival, and re-transplant rates are reassuring for NASH patients and their caretakers. 

 Two limitations in this study are the significant differences in patient demographics for each group and the time periods during which data was collected.  NASH patients had a statistically significant difference in MELD scores, percentage of female patients, BMI values, hypertension rates, and prevalence of metabolic syndrome were all elevated relative to the control group.  As the authors acknowledge, many of these characteristics can be independent risk factors for operative time and resource utilization, suggesting that it is still unclear whether NASH itself is a reason for the resource utilization differences, or if they are simply caused by the other confounding factors.  With regards to time of the study, 8 of the 144 NASH patients were diagnosed before 2002, while all other NASH patients and non-NASH patients underwent surgery after 2002.  The difference in time period could impact the operative times and length of stay values, favoring the patients that underwent surgery more recently.

Click to read the study in Annals of Surgery

 By DM and AH

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