Retrospective Cohort Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jan 28, 2017; 9(3): 139-146
Published online Jan 28, 2017. doi: 10.4254/wjh.v9.i3.139
Advanced non-alcoholic steatohepatitis cirrhosis: A high-risk population for pre-liver transplant portal vein thrombosis
Jonathan G Stine, Curtis K Argo, Shawn J Pelletier, Daniel G Maluf, Stephen H Caldwell, Patrick G Northup
Jonathan G Stine, Curtis K Argo, Stephen H Caldwell, Patrick G Northup, Division of Gastroenterology and Hepatology, Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, University of Virginia, Charlottesville, VA 22908-0708, United States
Shawn J Pelletier, Daniel G Maluf, Division of Transplant, Department of Surgery, University of Virginia, Charlottesville, VA 22908-0708, United States
Author contributions: Stine JG and Northup PG planned and conducted study, collected and/or interpreted data; Stine JG, Argo CK, Pelletier SJ, Maluf DG, Caldwell SH and Northup PG drafted the manuscript and approved final version.
Institutional review board statement: Institutional review board approval was not required for this study as the UNOS/OPTN dataset is deidentified.
Conflict-of-interest statement: The authors of this manuscript have no conflicts of interest to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Patrick G Northup, MD, MHS, Division of Gastroenterology and Hepatology, Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, University of Virginia, JPA and Lee Street, MSB 2145, PO Box 800708, Charlottesville, VA 22908-0708, United States.
Telephone: +1-434-2437741 Fax: +1-434-2447529
Received: April 26, 2016
Peer-review started: April 26, 2016
First decision: July 20, 2016
Revised: October 25, 2016
Accepted: December 13, 2016
Article in press: December 14, 2016
Published online: January 28, 2017

To examine if liver transplant recipients with high-risk non-alcoholic steatohepatitis (NASH) are at increased risk for pre-transplant portal venous thrombosis.


Data on all liver transplants in the United States from February 2002 through September 2014 were analyzed. Recipients were sorted into three distinct groups: High-risk (age > 60, body mass index > 30 kg/m2, hypertension and diabetes), low-risk and non-NASH cirrhosis. Multivariable logistic regression models were constructed.


Thirty-five thousand and seventy-two candidates underwent liver transplantation and of those organ recipients, 465 were transplanted for high-risk and 2775 for low-risk NASH. Two thousand six hundred and twenty-six (7.5%) recipients had pre-transplant portal vein thrombosis; 66 (14.2%) of the high-risk NASH group had portal vein thrombosis vs 328 (11.8%) of the low-risk NASH group. In general, all NASH recipients were less likely to be male or African American and more likely to be obese. In adjusted multivariable regression analyses, high-risk recipients had the greatest risk of pre-transplant portal vein thrombosis with OR = 2.11 (95%CI: 1.60-2.76, P < 0.001) when referenced to the non-NASH group.


Liver transplant candidates with high-risk NASH are at the greatest risk for portal vein thrombosis development prior to transplantation. These candidates may benefit from interventions to decrease their likelihood of clot formation and resultant downstream hepatic decompensating events. Prospective study is needed.

Keywords: Liver transplantation, Non-alcoholic fatty liver disease, Portal hypertension, Hepatology, Coagulopathy

Core tip: Non-alcoholic steatohepatitis (NASH) is increasing in prevalence and is expected to be the leading indication for liver transplantation in the foreseeable future. There is a growing body of evidence supporting the clinical importance of a thrombophilic state in patients with NASH. In NASH patients, the most severe hypercoagulable environment is found in patients with NASH cirrhosis. High-risk NASH patients (concomitant age > 60 years, obesity, diabetes and hypertension) have inferior post transplantation outcomes, however, how this group’s risk of clotting compares to other etiologies of liver disease is unknown. In a retrospective nationwide United States based cohort, we provide further evidence of coagulation derangement in NASH and identify a new high-risk subtype in the high-risk NASH population. Whether or not this high-risk group may benefit from preventative anticoagulation remains unknown.