Changing Population of Liver Transplant Recipients in the Era of Direct-acting Antiviral Therapy

The changing epidemiology of adult liver transplantation in the United States in 2013-2022: The dominance of metabolic dysfunction-associated steatotic liver disease and alcohol-associated liver disease

BACKGROUND

The high prevalence of obesity in the United States drives the burden of NASH, recently renamed as metabolic dysfunction-associated steatohepatitis (MASH). We assessed the most recent trends in liver transplantation in the United States.

METHODS

The Scientific Registry of Transplant Recipients (SRTR 2013-2022) was used to select adult (18 years or above) candidates who underwent liver transplant.

RESULTS

There were 116,292 candidates who underwent liver transplant with known etiology of chronic liver disease. In candidates without HCC, the most common etiology was alcohol-associated liver disease (ALD), increasing from 23% (2013) to 48% (2022), followed by NASH/MASH, which increased from 19% to 27%; the rates of viral hepatitis decreased (chronic hepatitis C: 28%-4%; chronic hepatitis B: 1.8%-1.1%) (all trend p<0.01). The proportion of HCC decreased from 25% (2013-2016) to 17% (2021-2022). Among HCC cohort, the proportion of chronic hepatitis C decreased from 60% (2013) to 27% (2022), NASH/MASH increased from 10% to 31%, alcohol-associated liver disease increased from 9% to 24% (trend p<0.0001), and chronic hepatitis B remained stable between 5% and 7% (trend p=0.62). The rapid increase in the proportion of NASH/MASH in HCC continued during the most recent study years [20% (2018), 28% (2020), 31% (2022)]; the trend remained significant after adjustment for age, sex, ethnicity, obesity, and type 2 diabetes.

CONCLUSIONS

Liver transplant etiologies in the United States have changed over the last decade. Alcohol-associated liver disease and NASH/MASH remain the 2 most common indications for transplantation among those without HCC, and NASH/MASH is the most common in patients with HCC.

Impact of medical eligibility criteria and OPTN policy on simultaneous liver kidney allocation and utilization

BACKGROUND

Organ Procurement and Transplantation Network (OPTN) implemented medical eligibility and safety-net policy on 8/10/17 to optimize simultaneous liver-kidney (SLK) utilization. We examined impact of this policy on SLK listings and number of kidneys used within 1-yr. of receiving liver transplantation (LT) alone.

METHODS AND RESULTS

OPTN database (08/10/14-06/12/20) on adults (N = 66 709) without previous transplant stratified candidates to listings for SLK or LT alone with pre-LT renal dysfunction at listing (eGFR < 30 mL/min or on dialysis). Outcomes were compared for pre (08/10/14-08/09/17) vs. post (08/10/17-06/12/20) policy era. SLK listings decreased in post vs. pre policy era (8.7% vs. 9.6%; P < .001), with 22% reduced odds of SLK listing in the postpolicy era, with a decrease in all OPTN regions except regions 6 and 8, which showed an increase. Among LT-alone recipients with pre-LT renal dysfunction (N = 3272), cumulative 1-year probability was higher in post vs. prepolicy period for dialysis (5.6% vs. 2.3%; P < .0001), KT listing (11.4% vs. 2.0%; P < .0001), and KT (3.7% vs. .25%; P < .0001). Sixty-seven (2.4%) kidneys were saved in post policy era, with 18.1%, 16.6%, 4.3%, and 2.9% saving from regions 7, 2, 11, and 1, respectively.

CONCLUSION

Medical eligibility and safety-net OPTN policy resulted in decreased SLK use and improved access to LT alone among those with pre-LT renal dysfunction. Although decreased in postpolicy era, regional variation of SLK listings remains. In spite of increased use of KT within 1-year of receiving LT alone under safety net, less number of kidneys were used without impact on patient survival in postpolicy era.