Liver transplantation for nonalcoholic fatty liver disease with chronic kidney disease

The article is written by Master, Doctor Mai Vien Phuong - Gastroenterologist - Department of Medical Examination & Internal Medicine - Vinmec Central Park International General Hospital.

Nonalcoholic steatohepatitis has become more common and has become the most common cause for liver transplantation. Patients with non-alcoholic steatohepatitis have a higher incidence of chronic kidney disease than other causes, so non-alcoholic steatohepatitis is the cause leading to the indication for concurrent liver-kidney transplantation.

Nonalcoholic fatty liver disease covers a spectrum of chronic liver diseases, from steatosis on one end to fibrosis and cirrhosis on the other. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis (NASH) are manifestations of the metabolic syndrome (MetS) leading to a multitude of comorbidities, such as insulin resistance, cardiovascular disease (CVD), chronic kidney disease, obstruction, obstructive sleep apnea (OSA) and increased risk of malignancy.
While nonalcoholic steatohepatitis is the second indication for liver transplantation, it is expected that nonalcoholic steatohepatitis will surpass hepatitis C virus (the leading cause of liver transplantation) in efficacy of direct-acting antiviral therapy.

The prevalence of comorbidities with a direct pathogenesis link nonalcoholic fatty liver disease to the risk of developing chronic kidney disease. However, there are few options for treating this group of patients. Regardless, strategies can be implemented at various levels, including monitoring, prevention and management. Regarding the association of nonalcoholic fatty liver with chronic kidney disease, a recent epidemiological study confirmed a decreasing trend in hepatitis C virus-associated liver transplantation in the United States. Nonalcoholic fatty liver disease is strongly associated with baseline insulin resistance and other comorbidities. There is increasing evidence that nonalcoholic fatty liver disease is a risk factor for chronic kidney disease due to shared metabolic risk factors.
Notably, several studies have shown an association between the severity of nonalcoholic steatohepatitis and chronic kidney disease. A meta-analysis of 33 studies found that diabetes status and metabolic risk factors had no impact on the correlation between the severity of NAFLD and chronic kidney disease. .

In recent decades, nonalcoholic steatohepatitis has become more common and has become the most common cause for liver transplantation. Patients with non-alcoholic steatohepatitis have a higher incidence of chronic kidney disease than with other causes, therefore, non-alcoholic steatohepatitis is the leading cause of indications for concomitant liver-kidney transplantation (SLKT). ) in the United States.
Dialysis status are important components of the end-stage liver disease (MELD) model. Considering the increased prevalence of renal dysfunction in liver transplants due to preference based on the MELD allocation system in the United States, the prevalence of SLKT increased from 2.7% of all liver transplants in 2000 to 9.3% in the year 2000. 2016. Non-alcoholic steatohepatitis is currently the leading and fastest-growing indicator for SLKT in the United States, with a 200% increase in SLKT between 2002 and 2010. Patients with nonalcoholic steatohepatitis have a higher probability of undergoing ESRD than liver transplantation alone, as they are highly susceptible to chronic kidney disease over a long period of time, possibly meeting the criteria for SLKT (chronic kidney disease patients: GFR ≤ 60) mL/min for ≥ 3 months with recent GFR ≤ 30 mL/min or on hemodialysis; AKI patients: Hemodialysis for > 6 weeks GFR ≤ 25 for > 6 weeks).
Patients with nonalcoholic steatohepatitis were independently associated with a higher risk of chronic kidney disease or progressive kidney damage after liver transplantation compared with patients without NAFLD . In general, post-transplant renal dysfunction is influenced not only by immunosuppressants (especially calcineurin inhibitors), pre-transplant renal dysfunction, but also by persistent co-metabolic diseases. persistent or de novo such as hypertension, diabetes and obesity - all of which are highly likely to occur in nonalcoholic steatohepatitis patients undergoing liver transplantation.
Therefore, special attention should be paid to the recognition of chronic kidney disease in patients with non-alcoholic steatohepatitis when deciding on SLKT liver transplantation. It is extremely important to control metabolic complications and to avoid or maintain low doses of calcineurin inhibitors as much as possible, which will reduce the risk of chronic kidney disease complications and the risk of chronic kidney disease progression. after liver transplantation in patients with nonalcoholic steatohepatitis.

Despite extensive research, minimally guided management of patients with nonalcoholic steatohepatitis and chronic kidney disease is available. However, the important pathogenic associations as well as common risk factors between NAFLD and chronic kidney disease emphasize the importance of early surveillance, close control of risk factors. general metabolism.
Although strategies for the prevention of chronic kidney disease in nonalcoholic steatohepatitis are limited, future treatment is hoped to improve progression of renal dysfunction in patients with chronic kidney disease. affected. There are numerous clinical trials underway that, if these drugs are shown to be safe and effective in improving nonalcoholic steatohepatitis, may translate into improved kidney function.
Specific interventions to prevent progression of chronic kidney disease using liver transplant SG inhibitors 2, PPAR agonists, SAM, XO and Vitamin D inhibitors have been tested but need to be investigated. further confirmation.
However, for patients with non-alcoholic hepatitis with renal dysfunction, early intervention is required. Genetic links between nonalcoholic fatty liver disease and chronic kidney disease have also been suggested, specifically in the G allele of PNPLA3, the T allele of TM6SF2. Future studies targeting patients with such genetic makeup to prevent progression to chronic kidney disease are needed.
In short, periodic health check-ups help detect diseases early, thereby creating a treatment plan for optimal results. Currently, Vinmec International General Hospital has general health checkup packages suitable for each age, gender and individual needs of customers with a reasonable price policy.
The patient's examination results will be returned to the home. After receiving the results of the general health examination, if you detect diseases that require intensive examination and treatment, you can use services from other specialties at the Hospital with quality treatment and services. outstanding customer service.

References:
Heda R, Yazawa M, Shi M, Bhaskaran M, Aloor FZ, Thuluvath PJ, Satapathy SK. Nonalcoholic fatty liver and chronic kidney disease: Retrospective, introspective and prospective. World J Gastroenterol 2021; 27 (17): 1864-1882 [DOI: 10.3748 / wjg.v27.i17.1864]