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Hepatic steatosis after pediatric liver transplant
Emily R Perito1,2, Tabitha Vase3, Rageshree Ramachandran4
1Departments of Pediatrics.
Insights
Hepatic steatosis is common early after pediatric liver transplantation but rarely persists long-term. Further studies are needed to assess if this condition poses a lasting risk for children post-transplant.
Area of Science:
- Hepatology
- Pediatric Gastroenterology
- Transplantation Medicine
Background:
- Hepatic steatosis affects 30% of adult liver transplant recipients.
- Nonalcoholic fatty liver disease (NAFLD) is prevalent in children.
- Post-transplant hepatic steatosis in pediatric liver transplant (LT) recipients is understudied.
Purpose of the Study:
- To determine the prevalence and persistence of hepatic steatosis in pediatric LT recipients.
- To investigate the association between hepatic steatosis and chronic liver damage in this population.
- To analyze the characteristics of steatosis, including nonalcoholic steatohepatitis (NASH), in pediatric LT patients.
Main Methods:
- Single-center study of 318 pediatric patients transplanted between 1988-2015.
- Analysis of post-transplant liver biopsies (n=271) for steatosis.
- Re-evaluation of 104 for-cause biopsies and 70 surveillance biopsies (3.6-20.0 years post-transplant).
Main Results:
- 31% of pediatric LT recipients had at least one biopsy with steatosis.
- Steatosis typically appeared early post-transplant (median 0.8 months) and rarely persisted.
- NASH/borderline NASH findings were infrequent and often confounded by cholestasis or rejection; steatosis did not correlate with fibrosis on long-term surveillance.
Conclusions:
- Hepatic steatosis is common but transient in pediatric LT recipients.
- NASH-like features in pediatric LT patients are often associated with other liver injury causes.
- Long-term risks of early-onset hepatic steatosis require further investigation in longitudinal studies.
Abstract:
Hepatic steatosis develops after liver transplantation (LT) in 30% of adults, and nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in nontransplanted children. However, posttransplant steatosis has been minimally studied in pediatric LT recipients. We explored the prevalence, persistence, and association with chronic liver damage of hepatic steatosis in these children. In this single-center study of pediatric patients transplanted 1988-2015 (n = 318), 31% of those with any posttransplant biopsy (n = 271) had ≥ 1 biopsy with steatosis. Median time from transplant to first biopsy with steatosis was 0.8 months (interquartile range [IQR], 0.3-6.5 months) and to last biopsy with steatosis was 5.5 months (IQR, 1.0-24.5 months); 85% of patients with steatosis also had for-cause biopsies without steatosis. All available for-cause biopsies were re-evaluated (n = 104). Of 9 biopsies that could be interpreted as nonalcoholic steatohepatitis (NASH)/borderline NASH, with steatosis plus inflammation or ballooning, 8 also had features of cholestasis or rejection. Among 70 patients with surveillance biopsies 3.6-20.0 years after transplant, only 1 overweight adolescent had a biopsy with NAFLD (grade 1 steatosis, mild inflammation, no ballooning or fibrosis)-despite a 30% prevalence of overweight/obesity in the cohort and 27% with steatosis on previous for-cause biopsy. Steatosis on preceding for-cause biopsy was not associated with portal (P = 0.49) or perivenular fibrosis (P = 0.85) on surveillance biopsy. Hepatic steatosis commonly develops early after transplant in children and adolescents, but it rarely persists. Biopsies that did have steatosis with NASH characteristics were all for-cause, mostly in patients with NAFLD risk factors and/or confounding causes of liver damage. Prospective studies that follow children into adulthood will be needed to evaluate if and when hepatic steatosis presents a longterm risk for pediatric LT recipients. Liver Transplantation 23 957-967 2017 AASLD.