Nonalcoholic steatohepatitis (NASH) is becoming a common cause of liver cirrhosis requiring liver transplantation (LT). Cardiovascular complications related to metabolic syndrome and NASH recurrence in the transplanted liver may affect the outcome of LT in these patients. We compared the outcomes of LT for NASH cirrhosis and alcoholic cirrhosis (ETOH) in a large transplant center. A retrospective chart review was performed for all patients who underwent LT for cryptogenic cirrhosis with the NASH phenotype (the NASH group) or ETOH (the ETOH group) at the University of Miami from January 1997 to January 2007. There was no significant difference in survival between the NASH and ETOH groups, despite a trend toward lower survival in the former (P ϭ 0.1699). Sepsis was the leading cause of posttransplant death in both groups, and it was followed by cardiovascular causes in the NASH group (26% versus 7% in the ETOH group, P ϭ 0.21) and malignancies in the ETOH group (29% versus 0% in the NASH group, P ϭ 0.024). Recurrent steatohepatitis (33% versus 0%, P Ͻ 0.0001) and acute rejection (41% versus 23%, P Ͻ 0.023) were significantly more frequent in the NASH group than in the ETOH group. There was no difference in graft failure between the groups (24% in the NASH group versus 18% in the ETOH group, P ϭ 0.3973).In conclusion, despite a numerical trend favoring the ETOH group, there were no statistically significant differences in posttransplant survival and cardiovascular mortality between the NASH and ETOH groups. Acute rejection and recurrent steatohepatitis were significantly more frequent in the NASH group but did not lead to higher rates of retransplantation. Liver

Conventional creatinine-based glomerular filtration rate (GFR) equations are insufficiently accurate for estimating GFR in cirrhosis. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) recently proposed an equation to estimate GFR in subjects without cirrhosis using both serum creatinine and cystatin C levels. Performance of the new CKD-EPI creatinine-cystatin C equation (2012) was superior to previous creatinine- or cystatin C-based GFR equations. To evaluate the performance of the CKD-EPI creatinine-cystatin C equation in subjects with cirrhosis, we compared it to GFR measured by non-radiolabeled iothalamate plasma clearance (mGFR) in 72 subjects with cirrhosis. We compared the “bias”, “precision” and “accuracy” of the new CKD-EPI creatinine-cystatin C equation to that of 24-hour urinary creatinine clearance (CrCl), Cockcroft-Gault (CG) and previously reported creatinine- and/or cystatin C-based GFR-estimating equations. Accuracy of CKD-EPI creatinine-cystatin C equation as quantified by root mean squared error of difference scores [differences between mGFR and estimated GFR (eGFR) or between mGFR and CrCl, or between mGFR and CG equation for each subject] (RMSE=23.56) was significantly better than that of CrCl (37.69, P=0.001), CG (RMSE=36.12, P=0.002) and GFR-estimating equations based on cystatin C only. Its accuracy as quantified by percentage of eGFRs that differed by greater than 30% with respect to mGFR was significantly better compared to CrCl (P=0.024), CG (P=0.0001), 4-variable MDRD (P=0.027) and CKD-EPI creatinine 2009 (P=0.012) equations. However, for 23.61% of the subjects, GFR estimated by CKD-EPI creatinine-cystatin C equation differed from the mGFR by more than 30%. CONCLUSIONS The diagnostic performance of CKD-EPI creatinine-cystatin C equation (2012) in patients with cirrhosis was superior to conventional equations in clinical practice for estimating GFR. However, its diagnostic performance was substantially worse than reported in subjects without cirrhosis.

In stark contrast to short-term survival, there have been no appreciable improvements in long-term survival following liver transplantation among 1-year survivors. Long-term sequelae of immunosuppression, including malignancy and infection, are the most common causes of death. This study highlights the need for better long-term immunosuppression management.

Previous studies of men and women on the liver transplant (LT) waiting list suggested a higher risk of mortality for women while on the waiting list without taking transplantation rates into account. The objective of this study was to compare men and women with respect of dying within three years of registration on the LT waiting list taking into account both the immediate mortality risks and transplantation rates. The analysis was based on Organ Procurement and Transplantation Network data of patients with End-Stage Liver Disease (ESLD) on the waiting list registered between February 2002 and August 2009. Competing risk survival analysis was performed to assess gender disparity in waiting list mortality. 42,322 patients and 610,762 person-months of waiting list experience were included in the analysis. The risk of dying within three years of listing was 19% and 17% in women and men, respectively (P<0.0001). Among patients with kidney disease, especially those with estimated glomerular filtration rate (eGFR) ≥ 15 and < 30 ml/min/1.73m2, not on dialysis, women had a substantially higher risk of dying on the waiting list within three years of registration than men (26% vs. 20%, P=0.001). This disparity was related to lower transplantation rates in women; (transplantation rate ratio=0.68, P<0.0001). Controlling for eGFR and other variables related to mortality risk, the overall female-male disparity disappeared. In conclusion, among patients with ESLD with kidney dysfunction, not on dialysis, there is a substantial gender disparity in LT waiting list mortality. Our analysis suggests that this is explained by the fact that, in this group, women had lower transplant rates than men. The lower transplant rates can be explained, in part, by the fact that MELD scores tend to be lower for women than for men as they are based on serum creatinine rather than GFR.