LIVER TRANSPLANTATION 20:1064–1071, 2014
ORIGINAL ARTICLE
Recurrent or De Novo Nonalcoholic Fatty Liver Disease After Liver Transplantation: Natural History Based on Liver Biopsy Analysis lanie Vallin,1 Olivier Guillaud,1 Olivier Boillot,1,3 Vale rie Hervieu,2,3 Me 2,3 1,3 ro ^ me Dumortier Jean-Yves Scoazec, and Je 1 Hospices Civils de Lyon, Edouard Herriot Hospital, Department of Digestive Diseases; 2University Claude Bernard Lyon 1; and 3Hospices Civils de Lyon, Edouard Herriot Hospital, Department of Pathology, Lyon, France
Nonalcoholic fatty liver disease (NAFLD) is a potential long-term complication after liver transplantation (LT) and can occur as recurrent disease in patients undergoing transplantation for NAFLD or as de novo NAFLD in others. The aim of this study was to compare these 2 different entities. From a cohort of adult patients undergoing transplantation between 2000 and 2010, we selected all patients with a diagnosis of NAFLD made during liver biopsy examinations during post-LT followup; clinical, biological, and histological features of patients with recurrent NAFLD and patients with de novo NAFLD were compared. The diagnosis of post-LT NAFLD was made for 91 patients during the study period: 11 cases were classified as recurrent NAFLD, and 80 cases were classified as de novo NAFLD. The groups were not statistically different with respect to the sex ratio, age, prevalence of hypercholesterolemia, prevalence of obesity, or prevalence of hypertension. The prevalence of diabetes mellitus was higher in patients with recurrent NAFLD (100% versus 37.5%, p < 0.01). At 5 years, severe fibrosis (stage 3 or 4) and steatohepatitis were more frequent in patients with recurrent NAFLD versus patients with de novo NAFLD [71.4% versus 12.5% (P < 0.01) and 71.4% versus 17.2% (P < 0.01), respectively]. NAFLD was already present in 67% of the patients with de novo NAFLD and in 100% of the patients with recurrent NAFLD after 1 year. According to successive liver biopsies, steatosis disappeared in 18 patients (22.5%) with de novo NAFLD and in none of the patients with recurrent NAFLD. In conclusion, our results strongly suggest that recurrent NAFLD and de novo NAFLD after LT are different entities; recurrent NAFLD appears to be a more severe and irreversible disease with an earlier onset. Liver C 2014 AASLD. Transpl 20:1064-1071, 2014. V Received February 10, 2014; accepted May 28, 2014.
In the last decades, nonalcoholic fatty liver disease (NAFLD) has been increasingly recognized as the most common liver disease in Western countries, and it possibly affects up to 30% of individuals.1 NAFLD is associated with a potential risk of progression to liver fibrosis, cirrhosis, and eventually liver failure and hepatocellular carcinoma.2 Liver transplantation (LT) is the accepted treatment of end-stage liver disease. The short-term results of this procedure have dramat-
ically improved, whereas long-term outcomes are compromised by an increased risk of cancer and by the adverse effects of immunosuppressive treatment.3 NAFLD after LT can occur in 2 different settings. First, it can be the recurrence of the initial disease in patients undergoing transplantation for complications of NAFLD (mainly liver failure or hepatocellular carcinoma).4 In addition, because LT recipients accumulate several risk factors for NAFLD,5 they can develop
Abbreviations: LT, liver transplantation; NAFLD, nonalcoholic fatty liver disease; NAS, nonalcoholic fatty liver disease activity score; NS, not significant. Potential conflict of interest: Nothing to report. ro ^ me Dumortier, M.D., Ph.D., Fe de ration des Spe cialite s Digestives, Ho ^pital Edouard Herriot, Hospices Civils de Address reprint requests to Je Lyon, Pavillon H, 69437 Lyon Cedex 03, France. Telephone: (33) 4 72 11 75 08; FAX: (33) 4 72 11 75 76; E-mail: [email protected] DOI 10.1002/lt.23936 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
LIVER TRANSPLANTATION, Vol. 20, No. 9, 2014
de novo NAFLD.6 Indeed, calcineurin inhibitors (cyclosporine A and tacrolimus) have been associated with an increased risk of hypertension, hyperlipidemia, and diabetes mellitus.7 Moreover, the graft itself may contribute to the pathogenesis of NAFLD.6 At this point, there are few data regarding the histological evolution of NAFLD after LT, whatever its context (recurrence or de novo appearance), and the longterm natural history of NAFLD, and its potential severity and clinical impact remain questionable. The aim of the present study was to compare the clinical, biological, and histological features of recurrent NAFLD and de novo NAFLD in a cohort of patients with a diagnosis of NAFLD made at the time of liver biopsy examinations during post-LT follow-up.
PATIENTS AND METHODS LT and Follow-Up From January 2000 to September 2010, LT was per^ pital Edouard Herriot (Lyon, France) for formed at Ho 532 adult patients, including 12 patients with NAFLD. All patients received blood group–compatible grafts from cadaveric or living donors. The initial immunosuppressive regimen was based on a calcineurin inhibitor: cyclosporine A or tacrolimus. In addition, patients received 500 mg of intravenous methylprednisolone after reperfusion. Patients could initially receive cyclosporine A (Neoral, Novartis Pharma, Rueil-Malmaison, France) or tacrolimus (Prograf, Astellas, Nanterre, France). If they received cyclosporine A, they were treated orally with a dosage of 2.0 to 4.0 mg/kg/day in 2 divided doses with target trough whole blood concentrations of 200 to 250 ng/mL for the first month after transplantation, which were followed by target trough blood concentrations of 100 to 200 ng/mL thereafter. If they received tacrolimus, they were treated orally with a dosage of 0.08 to 0.12 mg/kg/day in 2 divided doses with target trough whole blood concentrations of 10 to 15 ng/mL for the first month after transplantation, which were followed by target trough whole blood concentrations of 5 to 10 ng/mL thereafter. On postoperative day 1, methylprednisolone began to be tapered from 200 to 20 mg within 5 days; thereafter, the methylprednisolone dosage was maintained at 20 mg/day, and it was then tapered by 2.5 mg/month to a maintenance dosage of 0 to 5 mg/day 6 months after transplantation. Azathioprine, mycophenolate mofetil, everolimus or sirolimus was administered as a part of the initial triple-immunosuppression regimen, or it was introduced during follow-up as a maintenance immunosuppressive agent. Outpatient follow-up visits were usually conducted once a week during the first month after discharge from the hospital, twice a month during the second and third months, monthly for the rest of the first year, and every 3 or 4 months thereafter, regardless of the length of the observation period after transplantation. Additional visits were made when necessary. A complete laboratory investigation, including hematology, liver parameters, coagulation, electrolytes,
VALLIN ET AL. 1065
total protein, renal parameters, fasting blood glucose, a lipid profile, and blood calcineurin inhibitor trough levels, was conducted at each visit. As part of our routine management of all patients receiving transplants, we performed liver biopsy at 1, 5, and 10 years and when clinically indicated. Liver biopsy was performed at least every year for patients with hepatitis C virus infections. In all cases, informed consent was obtained from each patient before liver biopsy.
Patient Selection and Study Design Inclusion Criteria The study group included all patients undergoing transplantation between January 2000 and September 2010 for whom a histological diagnosis of NAFLD was made more than 6 months after LT. All patients with liver biopsy samples showing histological features of acute or chronic rejection were excluded from the analysis. All patients with clinical, histological, and/or biological features suggestive of recurrent liver disease except for NAFLD (alcohol intake relapse, hepatitis C virus RNA positivity, hepatitis B surface antigen positivity, recurrent primary biliary cirrhosis, or autoimmune hepatitis) were also excluded from the analysis. Two groups of patients were compared. The recurrent NAFLD group consisted of patients who underwent transplantation for complications of NAFLD (liver failure and/or hepatocellular carcinoma); all these patients had histologically documented NAFLD before transplantation (liver biopsy and/or liver explant). The de novo NAFLD group consisted of patients who underwent transplantation for complications of liver disease other than NAFLD and who presented with NAFLD during the post-LT follow-up.
Physical Examination Body measurements included the weight and standing height at the time of LT (the day on which the patient was discharged from the hospital) and at the time of the last liver biopsy. The body mass index (kg/m2) was calculated from these values. Obesity was defined as a body mass index equal to or greater than 30 kg/m2.
Histological Examination All liver biopsy samples were fixed in formalin, processed according to conventional procedures, and cut into 4-mm-thick sections stained with hematoxylineosin, sirius red, and Perls’ reaction. All biopsy samples were reviewed by a single referent pathologist. The evaluation and reporting of histopathological features were performed according to Clinical Research Network in Nonalcoholic Steatohepatitis proposals.8 Steatosis was graded on a 0 to 3 semiquantitative scale: (0) steatosis absent or in less than 5% of the hepatocytes, (1) steatosis in up to one-third of the hepatocytes, (2) steatosis in one- to two-thirds of the hepatocytes, (3) steatosis in more than two-thirds of the hepatocytes. Lobular inflammation was defined as sparse to mild focal
1066 VALLIN ET AL.
LIVER TRANSPLANTATION, September 2014
TABLE 1. Main Features of the Patients in the 2 Study Groups Recurrent NAFLD
De Novo NAFLD
(n 5 11)
(n 5 80)
P Value
56 6 10 2.7 (8/3)
52 6 7 2.2 (55/25)
NS NS Not relevant
0 (0) 0 (0) 0 (0) 11 (100) 0 (0) 24 6 4 8 (72.3) 624 6 170
62 (77.5) 6 (7.5) 2 (2.5) 0 (0) 10 (12.5) 23 6 4 46 (57.5) 631 6 177
NS NS NS
4.1 6 0.5 13 6 15 28 6 6
4.5 6 0.8 14 6 15 28 6 6
NS NS NS
0 (0) 1 (9) 10 (91) 9 (82) 11 (100) 4 (36.4) 5 (45.4) 9 (82) 6 (54.5)
8 (10) 16 (20) 64 (80) 60 (75) 30 (37.5) 14 (46.7) 34 (42.5) 50 (62.5) 42 (52.5)
NS NS NS NS
ORIGINAL ARTICLE
Recurrent or De Novo Nonalcoholic Fatty Liver Disease After Liver Transplantation: Natural History Based on Liver Biopsy Analysis lanie Vallin,1 Olivier Guillaud,1 Olivier Boillot,1,3 Vale rie Hervieu,2,3 Me 2,3 1,3 ro ^ me Dumortier Jean-Yves Scoazec, and Je 1 Hospices Civils de Lyon, Edouard Herriot Hospital, Department of Digestive Diseases; 2University Claude Bernard Lyon 1; and 3Hospices Civils de Lyon, Edouard Herriot Hospital, Department of Pathology, Lyon, France
Nonalcoholic fatty liver disease (NAFLD) is a potential long-term complication after liver transplantation (LT) and can occur as recurrent disease in patients undergoing transplantation for NAFLD or as de novo NAFLD in others. The aim of this study was to compare these 2 different entities. From a cohort of adult patients undergoing transplantation between 2000 and 2010, we selected all patients with a diagnosis of NAFLD made during liver biopsy examinations during post-LT followup; clinical, biological, and histological features of patients with recurrent NAFLD and patients with de novo NAFLD were compared. The diagnosis of post-LT NAFLD was made for 91 patients during the study period: 11 cases were classified as recurrent NAFLD, and 80 cases were classified as de novo NAFLD. The groups were not statistically different with respect to the sex ratio, age, prevalence of hypercholesterolemia, prevalence of obesity, or prevalence of hypertension. The prevalence of diabetes mellitus was higher in patients with recurrent NAFLD (100% versus 37.5%, p < 0.01). At 5 years, severe fibrosis (stage 3 or 4) and steatohepatitis were more frequent in patients with recurrent NAFLD versus patients with de novo NAFLD [71.4% versus 12.5% (P < 0.01) and 71.4% versus 17.2% (P < 0.01), respectively]. NAFLD was already present in 67% of the patients with de novo NAFLD and in 100% of the patients with recurrent NAFLD after 1 year. According to successive liver biopsies, steatosis disappeared in 18 patients (22.5%) with de novo NAFLD and in none of the patients with recurrent NAFLD. In conclusion, our results strongly suggest that recurrent NAFLD and de novo NAFLD after LT are different entities; recurrent NAFLD appears to be a more severe and irreversible disease with an earlier onset. Liver C 2014 AASLD. Transpl 20:1064-1071, 2014. V Received February 10, 2014; accepted May 28, 2014.
In the last decades, nonalcoholic fatty liver disease (NAFLD) has been increasingly recognized as the most common liver disease in Western countries, and it possibly affects up to 30% of individuals.1 NAFLD is associated with a potential risk of progression to liver fibrosis, cirrhosis, and eventually liver failure and hepatocellular carcinoma.2 Liver transplantation (LT) is the accepted treatment of end-stage liver disease. The short-term results of this procedure have dramat-
ically improved, whereas long-term outcomes are compromised by an increased risk of cancer and by the adverse effects of immunosuppressive treatment.3 NAFLD after LT can occur in 2 different settings. First, it can be the recurrence of the initial disease in patients undergoing transplantation for complications of NAFLD (mainly liver failure or hepatocellular carcinoma).4 In addition, because LT recipients accumulate several risk factors for NAFLD,5 they can develop
Abbreviations: LT, liver transplantation; NAFLD, nonalcoholic fatty liver disease; NAS, nonalcoholic fatty liver disease activity score; NS, not significant. Potential conflict of interest: Nothing to report. ro ^ me Dumortier, M.D., Ph.D., Fe de ration des Spe cialite s Digestives, Ho ^pital Edouard Herriot, Hospices Civils de Address reprint requests to Je Lyon, Pavillon H, 69437 Lyon Cedex 03, France. Telephone: (33) 4 72 11 75 08; FAX: (33) 4 72 11 75 76; E-mail: [email protected] DOI 10.1002/lt.23936 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
LIVER TRANSPLANTATION, Vol. 20, No. 9, 2014
de novo NAFLD.6 Indeed, calcineurin inhibitors (cyclosporine A and tacrolimus) have been associated with an increased risk of hypertension, hyperlipidemia, and diabetes mellitus.7 Moreover, the graft itself may contribute to the pathogenesis of NAFLD.6 At this point, there are few data regarding the histological evolution of NAFLD after LT, whatever its context (recurrence or de novo appearance), and the longterm natural history of NAFLD, and its potential severity and clinical impact remain questionable. The aim of the present study was to compare the clinical, biological, and histological features of recurrent NAFLD and de novo NAFLD in a cohort of patients with a diagnosis of NAFLD made at the time of liver biopsy examinations during post-LT follow-up.
PATIENTS AND METHODS LT and Follow-Up From January 2000 to September 2010, LT was per^ pital Edouard Herriot (Lyon, France) for formed at Ho 532 adult patients, including 12 patients with NAFLD. All patients received blood group–compatible grafts from cadaveric or living donors. The initial immunosuppressive regimen was based on a calcineurin inhibitor: cyclosporine A or tacrolimus. In addition, patients received 500 mg of intravenous methylprednisolone after reperfusion. Patients could initially receive cyclosporine A (Neoral, Novartis Pharma, Rueil-Malmaison, France) or tacrolimus (Prograf, Astellas, Nanterre, France). If they received cyclosporine A, they were treated orally with a dosage of 2.0 to 4.0 mg/kg/day in 2 divided doses with target trough whole blood concentrations of 200 to 250 ng/mL for the first month after transplantation, which were followed by target trough blood concentrations of 100 to 200 ng/mL thereafter. If they received tacrolimus, they were treated orally with a dosage of 0.08 to 0.12 mg/kg/day in 2 divided doses with target trough whole blood concentrations of 10 to 15 ng/mL for the first month after transplantation, which were followed by target trough whole blood concentrations of 5 to 10 ng/mL thereafter. On postoperative day 1, methylprednisolone began to be tapered from 200 to 20 mg within 5 days; thereafter, the methylprednisolone dosage was maintained at 20 mg/day, and it was then tapered by 2.5 mg/month to a maintenance dosage of 0 to 5 mg/day 6 months after transplantation. Azathioprine, mycophenolate mofetil, everolimus or sirolimus was administered as a part of the initial triple-immunosuppression regimen, or it was introduced during follow-up as a maintenance immunosuppressive agent. Outpatient follow-up visits were usually conducted once a week during the first month after discharge from the hospital, twice a month during the second and third months, monthly for the rest of the first year, and every 3 or 4 months thereafter, regardless of the length of the observation period after transplantation. Additional visits were made when necessary. A complete laboratory investigation, including hematology, liver parameters, coagulation, electrolytes,
VALLIN ET AL. 1065
total protein, renal parameters, fasting blood glucose, a lipid profile, and blood calcineurin inhibitor trough levels, was conducted at each visit. As part of our routine management of all patients receiving transplants, we performed liver biopsy at 1, 5, and 10 years and when clinically indicated. Liver biopsy was performed at least every year for patients with hepatitis C virus infections. In all cases, informed consent was obtained from each patient before liver biopsy.
Patient Selection and Study Design Inclusion Criteria The study group included all patients undergoing transplantation between January 2000 and September 2010 for whom a histological diagnosis of NAFLD was made more than 6 months after LT. All patients with liver biopsy samples showing histological features of acute or chronic rejection were excluded from the analysis. All patients with clinical, histological, and/or biological features suggestive of recurrent liver disease except for NAFLD (alcohol intake relapse, hepatitis C virus RNA positivity, hepatitis B surface antigen positivity, recurrent primary biliary cirrhosis, or autoimmune hepatitis) were also excluded from the analysis. Two groups of patients were compared. The recurrent NAFLD group consisted of patients who underwent transplantation for complications of NAFLD (liver failure and/or hepatocellular carcinoma); all these patients had histologically documented NAFLD before transplantation (liver biopsy and/or liver explant). The de novo NAFLD group consisted of patients who underwent transplantation for complications of liver disease other than NAFLD and who presented with NAFLD during the post-LT follow-up.
Physical Examination Body measurements included the weight and standing height at the time of LT (the day on which the patient was discharged from the hospital) and at the time of the last liver biopsy. The body mass index (kg/m2) was calculated from these values. Obesity was defined as a body mass index equal to or greater than 30 kg/m2.
Histological Examination All liver biopsy samples were fixed in formalin, processed according to conventional procedures, and cut into 4-mm-thick sections stained with hematoxylineosin, sirius red, and Perls’ reaction. All biopsy samples were reviewed by a single referent pathologist. The evaluation and reporting of histopathological features were performed according to Clinical Research Network in Nonalcoholic Steatohepatitis proposals.8 Steatosis was graded on a 0 to 3 semiquantitative scale: (0) steatosis absent or in less than 5% of the hepatocytes, (1) steatosis in up to one-third of the hepatocytes, (2) steatosis in one- to two-thirds of the hepatocytes, (3) steatosis in more than two-thirds of the hepatocytes. Lobular inflammation was defined as sparse to mild focal
1066 VALLIN ET AL.
LIVER TRANSPLANTATION, September 2014
TABLE 1. Main Features of the Patients in the 2 Study Groups Recurrent NAFLD
De Novo NAFLD
(n 5 11)
(n 5 80)
P Value
56 6 10 2.7 (8/3)
52 6 7 2.2 (55/25)
NS NS Not relevant
0 (0) 0 (0) 0 (0) 11 (100) 0 (0) 24 6 4 8 (72.3) 624 6 170
62 (77.5) 6 (7.5) 2 (2.5) 0 (0) 10 (12.5) 23 6 4 46 (57.5) 631 6 177
NS NS NS
4.1 6 0.5 13 6 15 28 6 6
4.5 6 0.8 14 6 15 28 6 6
NS NS NS
0 (0) 1 (9) 10 (91) 9 (82) 11 (100) 4 (36.4) 5 (45.4) 9 (82) 6 (54.5)
8 (10) 16 (20) 64 (80) 60 (75) 30 (37.5) 14 (46.7) 34 (42.5) 50 (62.5) 42 (52.5)
NS NS NS NS
