Recurrence of nonalcoholic steatohepatitis in a liver transplant recipient

Abstract

The cause of NASH remains unclear. Early studies suggested NASH occurred only in female patients with obesity, diabetes, and/or hyperlipidemia. However, recent data suggest NASH may more frequently be present in males in the absence of obesity, diabetes, or hyperlipidemia. 1 These data raise the possibility that genetically determined alterations in fatty acid oxidation or very low density lipoprotein metabolism may contribute to the disease. This represents the second reported case of NASH resulting in orthotopic liver transplantation with recurrence in the allograft, 2 suggesting that extrahepatic factors importantly contribute to the development of NASH. Case PresentationA 42-year-old morbidly obese white man presented with a 1-month history of intermittent right upper quadrant pain and a 9-kg weight loss. His past medical history was notable for hypertriglyceridemia treated with gemfibrizol. He denied ethanol use. Laboratory evaluation revealed amylase of 3,800 U/L, lipase of 13,000 U/L, cholesterol of 188 mg/dL, triglycerides of 171 mg/dL, and elevated transaminases. Serologic studies for hepatitis A, B, and C were negative. A laparoscopic cholecystectomy for presumed gallstone pancreatitis was performed. An intraoperative cholangiogram was normal. An intraoperative liver biopsy was performed, and specimen revealed moderate steatosis with low-grade hepatocyte injury, focal collections of mononuclear inflammatory cells, minimal portal inflammation, and central pericellular fibrosis. A few hepatocytes contained Mallory's hyaline (Fig. 1A).The patient lost 33 kg in the 3 months after his operation due to anorexia and pain. In addition, he became jaundiced and pruritic; his only medication was ursodeoxycholate. Liver biopsy specimen revealed NASH and micronodular cirrhosis.The patient experienced continued weight loss and worsening fatigue. Nine months after his initial presentation, he underwent an orthotopic liver transplantation. The allograft donor was a previously healthy, slim, 15-year-old male who received a gunshot wound to the head while playing with a firearm. The donor patient had normal serum transaminases, glucose, and cholesterol. The donor liver appeared grossly normal.

Frequency of nonalcoholic steatohepatitis as a cause of advanced liver disease

“…These prospectively collected data provide evidence that although NASH is generally a benign condition, it can be a severe progressive form of liver disease leading to the development of liver failure in a minority of patients. Although the progression of NASH to end-stage liver disease has been described, 17,20,21 the relative frequency of NASH as a cause of hepatic decompensation has not previously been reported.…”

Nonalcoholic Steatohepatitis: Summary of An Aasld Single Topic Conference

“…Many patients with advanced disease are poor candidates for transplantation due to comorbid conditions such as obesity and complications of diabetes. Both recurrence of NASH in patients with previously established NASH [215][216][217][218] and de novo occurrence of NASH after transplantation for cryptogenic cirrhosis 12,16 can occur. Posttransplantation progression to cirrhosis may develop although predictive factors and treatment have not been well defined.…”

Histopathology of Non-Alcoholic Fatty Liver Disease

“…NAFLD can occur in the allograft liver as recurrence or as a de novo process [125][126][127][128][129][130][131][132][133][134][135][136] . The incidence of recurrent steatosis in patients transplanted for cryptogenic cirrhosis or NASH-cirrhosis ranges from 25%-100%, while NASH development is observed in 10%-37.5% of these cases without leading to early allograft failure (reviewed in [135] ).…”