High levels of hepatic steatosis in liver donors

By Kristina Fiore, Staff Writer, MedPage Today
Published: January 09, 2009

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco . Earn CME/CE credit
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CORDOBA, Spain, Jan. 9 -- Higher levels of hepatic steatosis in donor livers correspond to poorer outcomes for transplant patients with cirrhosis from hepatitis C virus infection, researchers here said.
Action Points
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■Explain that patient and graft survival significantly decreased among HCV patients given liver grafts with higher levels of steatosis.



■Explain that disease recurrence was earlier, more frequent, and more severe among these patients as well.
Patient and graft survival significantly decreased with degree of steatosis (P=0.008 and P=0.012, respectively), Ruben Ciria, M.D., of Reina Sofia University Hospital here, and colleagues reported in the January issue of Liver Transplantation.


And HCV recurrence was earlier, more frequent, and more severe among these patients (P=0.042), the researchers said.


"Our results show a direct relationship between marginal donors, graft steatosis, and more frequent, more severe, and earlier viral recurrence after orthotopic liver transplantation for HCV-related cirrhosis," the researchers said.


They said that recent studies have shown survival rates among transplanted HCV cirrhosis patients have been falling. A number of factors could be contributing to this decline, they said, but these have not been widely studied.


One possible explanation is that the limited number of available liver donors has led to the increased use of marginal livers that don't meet optimal criteria.


So to assess the influence of donor graft steatosis on outcomes including patient survival, graft survival, and viral recurrence, the researchers analyzed 120 patients who had a liver transplant as a result of HCV cirrhosis from 1995 through 2005 at Reina Sofia University Hospital (62.5% male, mean age 51).


Donor steatosis was categorized as absent (0% to 10%), mild (11% to 30%), moderate (31% to 60%), or severe (>60%).


Patient survival significantly decreased with the degree of hepatic steatosis, the researchers said. Those who received a liver with steatosis levels lower than 30% had a survival rate of 66% at three years, compared with 47% for those who received a liver with steatosis levels of 30% or more (P=0.008).


Graft survival also decreased significantly with the degree of fatty content. For those transplanted with steatosis-free livers, survival at three years was 72%. Survival was 58% for those transplanted with mildly steatotic livers and 43% for those with moderate steatosis. Patients transplanted with severely steatotic livers had a survival rate of 42% at three years (P=0.012).


In a multivariate analysis, the only other statistically significant predictors of graft survival were cold ischemia time greater than 12 hours (P=0.0001) and donor age greater than 55 (P=0.048).


The researchers also found an increased risk of earlier and more frequent viral recurrence associated with donor graft steatosis (P=0.042).


The severity of viral recurrence was greater for patients who received more steatotic livers. For example, at 12 months, 40% of patients given a liver with steatosis of 30% or more had fibrosis scores higher than two, compared with 17% of patients given a liver with steatosis less than 30% (P=0.035).


The researchers compared these findings to 87 patients with end-stage alcoholic liver disease who had a liver transplant during the same time period.


Overall survival at 12 months for these patients given a liver with steatosis of 30% or more was 81%, compared with 63% for the hepatitis C transplant patients.


"These results clearly show the higher impact of donor steatosis on graft survival in [hepatitis C] recipients versus non-[hepatitis C] recipients," the researchers said.


They added that what constitutes a "marginal donor" is not the same for all transplant surgeons, so the definition of a marginal graft will continue to vary between centers "until reliable parameters are available for prospectively predicting early graft function."


They concluded that "further multicenter studies and a global consensus may be necessary to finally assess if the use of expanded criteria grafts is safe for HCV-positive recipients and if the organ allocation system needs to be changed for this cohort of patients."


In an accompanying editorial, Nevin Yilmaz, M.D., and Mitchell L. Shiffman, M.D., of Virginia Commonwealth in Richmond, said they were concerned with the study's conclusions.


They said there was not enough data on the patients with alcohol-induced cirrhosis to be sure the populations were comparable.


They were, however, "intrigued" by the finding that a combination of donor graft steatosis and a prolongation in cold ischemic time was associated with severe reperfusion injury.


"We strongly suggest that cold ischemia time should be limited when the donor graft contains greater than 30% steatosis and that such grafts should be used only with caution for patients with chronic HCV infection."



The researchers and editorialists reported no conflicts of interest.


Primary source: Liver Transplantation
Source reference:
Briceno J, et al "Impact of donor graft steatosis on overall outcome and viral recurrence after liver transplantation for hepatitis C virus cirrhosis" Liver Transpl 2009; 15: 37-48.

Additional source: Liver Transplantation
Source reference:
Yilmaz N, Shiffman ML "Impact of the donor liver with steatosis in patients with hepatitis C virus: Not so fast" Liver Transpl 2009; 15: 4-6.