Table 2. Unique challenges in peri-transplant period for NASH patients with reference to guidelines.
| Peri transplant challenge | Impact on morbidity and mortality | Guideline recommendations |
|---|---|---|
| Obesity and metabolic syndrome | ● Increased primary graft nonfunction, and decreased survival at 30 days, 1-, and 2-year follow-up in morbidly obese patients undergoing LT (20) | ● AASLD considers morbid obesity [body mass index (BMI) ≥40 kg/m2] as a relative contraindication for liver transplantation, since these patients seem to be exposed to a higher risk of post-transplant complications and mortality (21) |
| ● Increased mortality risk and higher early postoperative complications, mainly due to cardiopulmonary complications in post-LT period (22) | ● EASL practice guidelines state that a multidisciplinary team should carefully evaluate patients with a BMI >35 before being included in the waiting list (23) | |
| Diabetes | ● Pretransplant diabetes is associated with inferior post-operative outcomes and increased resource utilization after liver transplantation (24) | ● Not enough of evidence to make recommendations for management of diabetes in early stages of cirrhosis (25) |
| Intraoperative hyperglycemia | ● Hyperglycemia increases risk of postoperative infection and mortality (26) | ● Not available |
| Cardiovascular disease | ● Mortality due to coronary artery disease and cerebrovascular disease is highest among patients with NASH within first year of liver transplantation compared to other liver disease etiologies (27) | ● ACC/AHA recommends coronary revascularization prior to liver transplant in candidates with severe CAD; bare metal stenting is the chosen approach |
| ● Occurrence of a cardiovascular event perioperatively associated with increased overall mortality (28) | ● In patients with nonobstructive CAD, medical management with beta blockers and statins is suggested | |
| ● AASLD recommends NASH patients should careful evaluation of identifying CVD during the transplant evaluation process (29). See Figure 1 for an algorithm | ||
| Acute kidney injury | ● Post-LT acute kidney injury associated with increased mortality and graft failure (30) | ● Not available |
| Chronic kidney disease | ● In patients with NASH, CKD was associated with increased overall mortality (31) | ● Not available |
| ● Pre-transplant renal impairment along with diabetes is a predictor for increased post-liver transplant cardiovascular disease mortality (32) | ||
| Sarcopenia | ● Sarcopenia increases risk for delisting and death (33) | ● ESPEN recommends a target intake of 35–40 kcal/kg/day and 1.2–1.5 g/kg/day of protein (34) |
| ● Sarcopenia is associated with post-LT infectious complications and sepsis-related mortality (35) | ||
| Portal vein thrombosis | ● PVT decreases post-LT graft and patient survival (36) | ● Not available |
| ● No impact on waitlist mortality (37) | ||
| ● Independent risk factor for 90-day mortality (38) |
PVT, portal venous thrombosis.