Orthotopic liver transplant, recurrent non-alcoholic steatohepatitis Chapter 12 Liver Transplantation 1 Orthotopic liver transplant, recurrent non-alcoholic steatohepatitis Case 12.11

Clinical Presentation 12 Liver Transplantation 2 Clinical Presentation A 65-year-old woman with cirrhosis secondary to non-alcoholic fatty liver disease developed complications manifested by ascites, esophageal varices, and hepatic encephalopathy. Hepatocellular carcinoma was also diagnosed and treated, and liver transplantation was performed. She did well post-operatively but over time abnormal liver tests were noted.

Laboratory Values Course in Hospital AST: 137 ALT: 260 Alk Phos: 152 12 Liver Transplantation 3 Laboratory Values AST: 137 ALT: 260 Alk Phos: 152 Total Bilirubin: 0.4 Total Protein: 7.7 Albumin: 3.9 Course in Hospital A liver biopsy was performed 2 years 8 months post-transplant to rule out acute rejection.

12 Liver Transplantation 4 Pathology The portal tracts showed a moderate predominantly lymphocytic infiltrate with normal interlobular bile ducts, with the adjacent parenchyma showing prominent steatosis (a). Figure 12.11(a)

Pathology 12 Liver Transplantation 5 The parenchyma showed 2+ to 3+ predominantly macrovesicular steatosis with perivenular sinusoidal fibrosis, mild to moderate predominantly lymphocytic infiltrates, focal liver cell ballooning, and occasional probable Mallory-Denk body formation (arrows) (b, c). There was no evidence of acute rejection. Figure 12.11(b) Figure 12.11(c)

12 Liver Transplantation 6 Diagnosis Orthotopic liver transplant (OLT), recurrent non-alcoholic steatohepatitis with mild to moderate activity (2 years 8 months post-transplant)

12 Liver Transplantation 7 Comment Non-alcoholic fatty liver diseases may recur post-transplant, with about ⅔ of patients developing steatosis (involving over 25% of hepatocytes) within 1−2 years post-transplant and 30−50% of patients developing non-alcoholic steatohepatitis within 2 years. Up to 10% of patients may also progress to cirrhosis in long-term followup. Risk factors for recurrence include insulin resistance, hyperlipidemia, and corticosteroid therapy. Histopathology is the same as that seen in the non-transplant setting, with sinusoidal fibrosis, liver cell ballooning, and Mallory-Denk body formation indicative of more active disease (as in this case example).