Divergent trajectories of lean vs obese non-alcoholic steatohepatitis patients from listing to post-transplant: A retrospective cohort study

doi:10.3748/wjg.v28.i26.3218

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World Journal of Gastroenterology

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Retrospective Cohort Study

World J Gastroenterol. Jul 14, 2022; 28(26): 3218-3231
Published online Jul 14, 2022. doi: 10.3748/wjg.v28.i26.3218

Table 1 Pre-liver transplant clinical and laboratory variables

	Total (n = 176)	BMI groups after ascites correction		P value
	Total (n = 176)	Overweight or obese (n = 122)	Underweight or normal (n = 54)	P value
Age at listing, median (range) years	61.0 (32.0–71.4)	60.3 (32.0–71.4)	61.6 (45.2–71.0)	0.048^a
Age at end of listing, median (range) years	61.0 (32.0–72.0)	61.0 (32.0–71.0)	62.0 (48.0–72.0)	0.09
Female sex, n (%)	81 (46.02)	53 (43.44)	28 (51.85)	0.30
Height at listing, median (range) cm	168.0 (148.0–193.0)	168.0 (148.0–188.0)	168.0 (150.0–193.0)	0.23
Weight at listing, median (range) kg	88.3 (39.6–146.5)	94.9 (69.0–146.5)	72.0 (39.6–94.2)	< 0.001^c
Ascites adjusted weight at listing, median (range) kg	77.4 (33.7–140.0)	85.1 (60.5–140.0)	64.4 (33.7–80.1)	< 0.001^c
Weight at end of listing, median (range) kg	86.9 (39.6–161.8)	92.9 (50.7–161.8)	73.9 (39.6–94.2)	< 0.001^c
BMI at listing, median (range) kg/m²	31.0 (17.6–48.9)	33.7 (25.6–48.9)	25.4 (17.6–30.8)	< 0.001^c
Ascites adjusted BMI at listing, median (range) kg/m²	27.4 (15.0–45.3)	29.2 (25.0–45.3)	22.6 (15.0–24.9)	< 0.001^c
Na MELD (at listing), median (range)	22.0 (10.0–48.0)	21.0 (11.0–48.0)	22.0 (10.0–43.0)	0.34
Na MELD at end of listing, median (range)	23.0 (6.0–45.0)	23.0 (6.0–44.0)	23.0 (10.0–45.0)	0.41
Creatinine at listing, median (range) μmol/L	98.5 (51.0–564.0)	96.5 (55.0–564.0)	103.0 (51.0–399.0)	0.50
Creatinine at end of listing, median (range) μmol/L	112.5 (44.0–719.0)	115.0 (44.0–719.0)	109.0 (49.0–483.0)	0.50
eGFR at listing, median (range) mL/min/1.73 m²	63.0 (17.0–120.0)	65.5 (18.0–117.0)	56.0 (17.0–120.0)	0.11
eGFR at end of listing, median (range) mL/min/1.73 m²	52.5 (17.0–116.0)	57.0 (17.0–116.0)	48.0 (20.0–98.0)	0.017^a
Bilirubin at listing, median (range) μmol/L	49.0 (8.0–955.0)	51.0 (8.0–755.0)	45.5 (14.0–955.0)	0.11
Bilirubin at end of listing, median (range) μmol/L	56.5 (3.0–927.0)	58.0 (8.0–927.0)	50.0 (3.0–802.0)	0.19
INR at listing, median (range)	1.5 (1.1–4.7)	1.5 (1.1–4.7)	1.5 (1.1–3.9)	0.05
INR at end of listing, median (range)	1.7 (1.1–7.6)	1.7 (1.1–7.6)	1.8 (1.1–5.0)	0.46
Na at listing, median (range) mEq/L	134.0 (116.0–147.0)	135.0 (120.0–147.0)	133.0 (116.0–142.0)	0.014^a
Na at end of listing, median (range) mEq/L	135.0 (116.0–159.0)	135.0 (116.0–159.0)	134.0 (120.0–152.0)	0.10
Albumin at listing, median (range) g/L	30.5 (9.0 – 47.0)	29.5 (20.0–47.0)	31.0 (9.0–42.0)	0.08
Albumin at end of listing, median (range) g/L	30.0 (10.0–54.0)	30.0 (12.0–54.0)	30.0 (10.0–50.0)	0.28
Frailty score (n = 159), median (range)	4.0 (2.0–8.0)	4.0 (2.0–8.0)	5.0 (3.0–8.0)	0.25
None to mild, n (%)	116 (72.96)	78 (71.56)	38 (76)	0.56
Moderate to severe, n (%)	43 (27.04)	31 (28.44)	12 (24)
Missing, n (%)	17 (9.66)	13 (10.66)	4 (7.41)
Encephalopathy, n (%)	141 (80.11)	99 (81.15)	42 (77.78)	0.61
Ascites, n (%)	161 (91.48)	109 (089.34)	052 (096.30)	0.15
Degree of ascites, n (%)
None	14 (07.95)	13 (10.66)	1 (1.85)	0.030^a
Mild	41 (23.30)	30 (24.59)	11 (20.37)
Moderate	30 (17.05)	24 (019.67)	6 (11.11)
Severe	91 (51.70)	55 (45.08)	36 (66.67)
Need for LVP, n (%)	103 (58.86)	64 (52.89)	39 (72.22)	0.016^a
SBP, n (%)	46 (26.44)	33 (27.05)	13 (25.00)	0.78
Variceal bleed, n (%)	53 (30.11)	34 (27.87)	19 (35.19)	0.33
Hepatorenal syndrome, n (%)	48 (27.27)	30 (24.59)	18 (33.33)	0.23
Hypertension, n (%)	80 (45.45)	58 (47.54)	22 (40.74)	0.40
Diabetes, n (%)	104 (59.09)	68 (55.74)	36 (66.67)	0.17
Hyperlipidemia, n (%)	57 (32.39)	35 (28.69)	22 (40.74)	0.12
CKD, n (%)	18 (10.23)	12 (9.84)	6 (11.11)	0.80
CAD, n (%)	29 (16.48)	22 (18.03)	7 (12.96)	0.40
Time on waiting list, median (range) days	136.0 (1.0–1566.0)	139.5 (1.0–1497.0)	117.0 (1.0–1566.0)	0.42
ICU stay within 90 d before end of listing, n (%)	30 (17.05)	21 (17.21)	9 (16.67)	0.93
No of hospitalizations within 90 d before end of listing, median (range), n (%)	1.0 (0.0–5.0)	1.0 (0.0–5.0)	1.0 (0.0–5.0)	0.42
< 2	151 (85.80)	105 (86.07)	46 (85.19)	0.88
≥ 2	25 (14.20)	17 (13.93)	8 (14.81)
Bacteraemia/sepsis within 90 d before end of listing, n (%)	19 (11.66)	12 (10.62)	7 (14.00)	0.54
Outcome, n (%)
Active living	1 (0.57)	1 (0.82)	0 (00)	0.26
De-listed	22 (12.50)	14 (11.48)	8 (14.81)
Died	42 (23.86)	25 (20.49)	17 (31.48)
Transplanted	111 (63.07)	82 (67.21)	29 (53.70)
Type of LT received, n (%)
DDLT	78 (70.27)	57 (69.51)	21 (72.41)	0.77
LDLT	33 (29.73)	25 (30.49)	8 (27.59)

^aP < 0.05.

^cP < 0.001.

BMI: Body mass index; CAD: Coronary artery disease; CKD: Chronic kidney disease; DDLT: Deceased donor liver transplant; eGFR: Estimated glomerular filtration rate; ICU: Intensive care unit; INR: International normalized ratio; LT: Liver transplant; LDLT: Living donor liver transplant; LVP: Large volume paracentesis; MELD: Model for end stage liver disease; Na: Sodium; SBP: Spontaneous bacterial peritonitis.

Table 2 Percentage of patients who changed body mass index groups after ascites correction

Reduction in BMI after ascites correction					Original/uncorrected	Unchanged
Underweight	Normal	Overweight	Obesity 1	Obesity 2	Original/uncorrected	Unchanged
					Underweight, 2 (1.1%)	2 (100%)
5 (22.73%)					Normal, 22 (12.5%)	17 (77.27%)
	29 (55.77%)				Overweight, 52 (29.55%)	23 (44.23%)
	1 (1.82%)	42 (76.36%)			Obesity 1, 55 (31.25%)	12 (21.82%)
			17 (62.96%)		Obesity 2, 27 (15.34%)	10 (37.04%)
			2 (11.11%)	11 (61.11%)	Obesity 3, 18 (10.23%)	5 (27.78%)
All BMI group had some level of decrease after correctionEspecially higher BMI groups have more % reduction					Total (n = 176)	% of unchanged are higher among low BMI groups

BMI: Body mass index.

Table 3 Post transplant outcomes

	Total (n = 111)	BMI after ascites correction		P value
	Total (n = 111)	Overweight or obese (n = 82)	Underweight or normal (n = 29)	P value
Biliary stricture, n (%)	22 (19.8)	16 (19.5)	6 (20.7)	0.97
Biliary leak, n (%)	10 (9)	7 (8.5)	3 (10.3)	1.0
Hepatic artery thrombosis, n (%)	2 (1.8)	0 (0)	2 (6.9)	0.07
90-d re-hospitalization (n = 103), n (%)	23 (22.3)	17 (22.6)	6 (21.4)	0.89
Recurrent NAFLD, n (%)	57 (51.4)	44 (53.7)	13 (44.8)	0.59
Time to recurrent NAFLD, median (range) days	568 (13–2135)	489 (13–1821)	757 (80–2135)	0.21
Recurrent NASH, n (%)	7 (6.3)	5 (6.1)	2 (6.9)	1.0
Time to recurrent NASH, median (range) days	812 (363–1119)	802 (363–1119)	957.5 (812–1103)	0.28
BMI at 1 yr (n = 83), median (range) kg/m²	30.3 (19.2–44.0)	31.7 (23.2–44.0)	26.1 (19.2–34.2)	< 0.001^c
BMI at 5 yr (n = 17), median (range) kg/m²	33.9 (20.3–47.9)	35.1 (26.6 – 47.9)	27.0 (20.3–31.5)	0.004^b
Creatinine at 1 yr (n = 70), median (range) μmol/L	114.0 (54.0–279.0)	117.5 (63.0–279.0)	106.0 (54.0–178.0)	0.21
Creatinine at 5 yr (n = 19), median (range) μmol/L	143.0 (67.0-257.0)	153.5 (78.0–257.0)	111.0 (67.0–127.0)	0.019^a
Diabetes at 1 yr (n = 82), n (%)	36 (43.9)	27 (45.8)	9 (39.1)	0.59
Diabetes at 5 yr (n = 20), n (%)	10 (50)	8 (53.3)	2 (40)	0.72
Hypertension at 1 yr (n = 83), n (%)	44 (53)	33 (55)	11 (47.8)	0.56
Hypertension at 5 yr (n = 20), n (%)	12 (60)	10 (66.7)	2 (40)	0.35
Cardiovascular events post LT, n (%)	22 (19.8)	14 (17)	8 (27.6)	0.45
Fibroscan Elastography (n = 48), median (range) kPa	6.4 (2.3–21.8)	6.8 (3.5–21.8)	4.8 (2.3–14.5)	0.011^a
Fibroscan CAP (n = 48), median (range) dB/m	286.5 (181.0–400.0)	298.0 (198.0–400.0)	283.5 (181.0–400.0)	0.26
Graft loss within 90 d post LT, n (%)	5 (4.5)	1 (1.2)	4 (13.8)	0.032^a
Graft survival post LT 1 yr (n = 101), n (%)	94 (93.1)	72 (98.6)	22 (78.6)	0.002^b
Graft survival post LT 3 yr (n = 72), n (%)	65 (90.3)	48 (96)	17 (77.3)	0.025^a
Graft survival post LT 5 yr (n = 32), n (%)	22 (68.8)	17 (85)	5 (41.7)	0.018^a
Deaths post LT, n (%)	7 (6.3)	2 (2.4)	5 (17.2)	0.029^a
Time to death post LT (n = 7), median (range) days	224 (13–1176)	192.5 (20–365)	224 (13–1176)	0.42
Death within 90 d post-LT, n (%)	2 (1.8)	1 (1.2)	1 (3.4)	0.38
Patient survival at 1 yr (n = 108), n (%)	104 (96.3)	78 (98.7)	26 (89.7)	0.06
Patient survival at 3 yr (n = 97), n (%)	66 (91.7)	48 (96)	18 (81.8)	0.07
Patient survival at 5 yr (n = 32), n (%)	25 (78.1)	18 (90)	7 (58.3)	0.07

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

BMI: Body mass index; CAP: Controlled attenuation parameter; LT: Liver transplant; NAFLD: Non-alcoholic fatty liver disease; NASH: Non-alcoholic steatohepatitis.

Citation: Qazi-Arisar FA, Uchila R, Chen C, Yang C, Chen SY, Karnam RS, Azhie A, Xu W, Galvin Z, Selzner N, Lilly L, Bhat M. Divergent trajectories of lean vs obese non-alcoholic steatohepatitis patients from listing to post-transplant: A retrospective cohort study. World J Gastroenterol 2022; 28(26): 3218-3231
URL: https://www.wjgnet.com/1007-9327/full/v28/i26/3218.htm
DOI: https://dx.doi.org/10.3748/wjg.v28.i26.3218