A 45 year old female with a body mass index (BMI) of 24 underwent successful
liver transplantation (LT) for
alcoholic cirrhosis using a donor liver from an obese woman with microvesicular steatosis (80%) and minimal macrovesicular steatosis (5-10%) on liver biopsy.
Ascites and hepatosplenomegaly developed soon after LT with progressive increase of serum
alkaline phosphatase to 1340 IU/L while
aspartate aminotransferase (AST), and
alanine transaminase (ALT), and total
bilirubin remained normal. Imaging showed marked
hepatomegaly, extensive fatty infiltration of the liver, and compression of the hepatic veins with narrowing of the intrahepatic inferior vena cava (IVC). Liver biopsy on post-operative day 39 revealed 90-100% macrovesicular steatosis,
steatohepatitis, and portal
fibrosis. A hepatic venogram showed a 10 cm segment of intrahepatic IVC
stenosis that was stented, improving portal venous pressure measurements. However,
portal hypertension requiring
diuretic therapy and multiple paracenteses remained. By 3 months after LT, her liver had grown to 22 cm,
transaminases increased 2-4 times the upper limit of normal with a 2:1 AST to ALT ratio. Liver biopsy at post-LT day 82 showed no change in steatosis and
steatohepatitis despite
corticosteroid withdrawal and interval periportal and perisinusoidal
fibrosis. 12 weeks after LT, the patient was found to have low
apolipoprotein B (65 mg/dL),
high-density lipoprotein (HDL) (<10 mg/dL),
low-density lipoproteins (
LDL) (9 mg/dL), and total
cholesterol (<50 mg/dL) levels.
Therapy was started for NASH with high dose (800 IU daily)
vitamin E and
pioglitazone 15 mg daily, and she received topical
vegetable oil and oral essential
fatty acid supplements. Liver
enzymes normalized after 3 months and her
lipid profile improved markedly (HDL 27 mg/dL, total
cholesterol 128 mg/dL), with progressive decrease in liver size and resolution of
ascites after 5 months of
therapy. At 2 years post-LT, the liver
enzymes remain normal and
lipids have normalized.