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Future Trends in Demand for Liver Transplant

Birth Cohort Effects Among Patients With NASH and HCC

Shingina, Alexandra, MD1,2; DeWitt, Peter E., PhD3; Dodge, Jennifer L., MPH2,4; Biggins, Scott W., MD1,2; Gralla, Jane, PhD5; Sprague, David, MD6; Bambha, Kiran, MD1,2

doi: 10.1097/TP.0000000000002497
Original Clinical Science—Liver
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Background With increasing US adiposity, nonalcoholic steatohepatitis (NASH) is now a leading liver transplant (LT) indication. Given its association with hepatocellular carcinoma (HCC), the burden of NASH is substantial. We analyzed birth cohort effects among NASH LT registrants, with and without HCC.

Methods All new LT registrants in United Network for Organ Sharing (1995-2015) were identified. Birth cohorts were defined as: 1936-1940, 1941-1945, 1946-1950, 1951-1955, 1956-1960, 1961-1965, 1966-1970, 1971-2015. Poisson regression examined trends in LT registration, by disease etiology (NASH, hepatitis C virus [HCV], other liver disease etiologies [OTHER]), and HCC.

Results We identified 182 368 LT registrants with median age of 52 years (range, 0-86 years). Nine percent (n = 16 160) had NASH, 38% (n= 69 004) HCV, 53% (n = 97 204) OTHER. HCC was present in: 13% (n = 2181), 27% (n = 18 295), and 11% (n = 10 902), of NASH, HCV, and OTHER, respectively. Liver transplant registration for HCC increased significantly from 2002 to 2015 across all etiologies (NASH, 6%-18%; HCV, 19%-51%; OTHER, 9%-16%; P < 0.0001 for all). NASH LT registrations, with and without HCC, increased sharply in patients born from 1945 to 2015. This upward NASH trend is in stark contrast to HCV LT registrations, which showed a general decline. Notably, a sharp rise in LT registrations is occurring among younger NASH patients (35-55 years), mirroring the increasing adiposity across all age groups in the US population.

Conclusions NASH LT registrants, with and without HCC, have increased over time, and are projected to increase unabated in the future, notably among younger birth cohorts (“Adipose Wave Effect”). HCC LT registration patterns demonstrate that, compared with HCV, NASH patients encompass younger birth cohorts. These data illustrate that the full impact of NASH on demand for LT is yet to be realized.

1 Division of Gastroenterology and Hepatology, Liver Care Line, University of Washington, Seattle, WA.

2 Center for Liver Investigation Fostering discovEry (C-LIFE), University of Washington, Seattle, WA.

3 Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO.

4 Department of Transplant Surgery, University of California San Francisco, San Francisco, CA.

5 Departments of Pediatrics and Biostatistics & Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO.

6 Section of Gastroenterology, The Vancouver Clinic, Vancouver, WA.

Received 7 July 2018. Revision received 16 September 2018.

Accepted 15 October 2018.

The authors declare no funding or conflicts of interest.

Only the authors participated in the creation of this article. K.B. participated in the study concept and design, acquisition of data, analysis and interpretation of data, drafting of the article, critical revision of the article for important intellectual content, and study supervision. A.S. participated in the analysis and interpretation of data; drafting of the manuscript; critical revision of the article for important intellectual content; administrative and technical material support. P.DW. participated in the statistical analysis and interpretation of data; critical revision of the article for important intellectual content. J.D. participated in the statistical analysis and interpretation of data; drafting of the article; critical revision of the article for important intellectual content. S.W.B. participated in the study concept and design; acquisition of data; analysis and interpretation of data; drafting of the article; critical revision of the manuscript for important intellectual content. J.G. participated in the statistical analysis and interpretation of data; drafting of the article; critical revision of the article for important intellectual content. D.S. participated in the drafting and critical revision of the article.

Correspondence: Kiran Bambha, MD, 1959 NE Pacific St, Box 356175, Seattle, WA 98195. (kbambha@medicine.washington.edu).

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