We read with interest the article by Bhagat et al. 1 regarding outcomes of liver transplantation (LT) in patient with cirrhosis due to nonalcoholic steatohepatitis (NASH) versus patients with cirrhosis due to alcoholic liver disease. This retrospective study showed no statistical differences in posttransplant survival or cardiovascular mortality between the NASH and alcoholic liver disease groups. The authors also concluded that acute rejection and recurrent steatohepatitis were significantly more frequent in the NASH group but did not lead to higher rates of retransplantation.
There are significant questions regarding the methodology and hence findings of this study. Only 25 of the 71 patients had biopsy-proven NASH. Although the remaining 46 patients had phenotypic characteristics of NASH, by the authors' own admission, they were labeled cryptogenic prior to LT. Although a majority of patients with NASH will have features of metabolic syndrome, it remains by definition a diagnosis that requires histological examination. 2,3 Many of the features of metabolic syndrome (eg, triglyceride levels) can be deranged in patients with decompensated cirrhosis. Defining NASH patients in this matter also gives an inaccurate measure of the incidence of metabolic features in this group; that is, not all patients with NASH will necessarily have features of the metabolic syndrome.
We previously identified a subgroup of high-risk NASH patients (patients with NASH cirrhosis who were 60 years and had a body mass index 30 kg/m 2 as well as pre-LT diabetes and hypertension). 4 This group included 16 of our 98 patients with biopsy-proven NASH cirrhosis and had a 1-year mortality rate of 50% after LT. Reviewing the baseline characteristics of the 71 patients included in the Bhagat study, we suspect that a significant number of patients will meet the high-risk criteria. We suggest that the authors consider reanalyzing their data to determine what percentage of their patients met the high-risk criteria and whether this affected posttransplant mortality.
We agree with the authors that larger, randomized, multicenter, prospective studies are needed to help better elucidate the course of patients undergoing LT for NASH.