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

2. Clinical Presentation12
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.

3. Laboratory Values Course in Hospital AST: 137 ALT: 260 Alk Phos: 15212
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.

4. 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)

5. 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)

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

7. 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).