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Transplantation. 2018 Nov 16. doi: 10.1097/TP.0000000000002497. [Epub ahead of print]

Future Trends in Demand for Liver Transplant: Birth-Cohort Effects among Patients with NASH and HCC.

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University of Washington, Division of Gastroenterology and Hepatology, Liver Care Line.
Center for Liver Investigation Fostering discovEry (C-LIFE), University of Washington.
University of Colorado Anschutz Medical Campus, Department of Radiology.
University of California San Francisco, Department of Transplant Surgery.
University of Colorado Anschutz Medical Campus, Departments of Pediatrics and Biostatistics & Informatics.
Section of Gastroenterology, The Vancouver Clinic, Vancouver, Washington.



With increasing U.S. adiposity, 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.


All new LT registrants in UNOS (1995-2015) were identified. Birth-cohorts were: 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, HCV, OTHER), and HCC.


We identified 182,368 LT registrants with median age 52 years (range 0-86). Nine-percent (n=16,160) had NASH, 38% (n=69,004) HCV, 53% (n=97,204) OTHER. HCC was present in: 13% (n=2,181), 27% (n=18,295), and 11% (n=10,902), of NASH, HCV, and OTHER, respectively. LT registration for HCC increased significantly from 2002-2015 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 1945-2015. 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 among younger NASH patients (35-55 years), mirroring the increasing adiposity across all age groups in the U.S.



NASH LT registrants, with and without HCC, 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 to 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.

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