Association of liver biopsy pathology on outcome of patients undergoing heart transplantation

Background

Patients with advanced heart failure needing heart transplant commonly suffer liver dysfunction. However, there is limited data on the impact of liver fibrosis on outcomes for heart transplant (HT) candidates. We determine the relationship between liver fibrosis severity and mortality rates for HT patients.

Methods

A retrospective cohort study of adults listed for HT who underwent a liver biopsy for evaluation of early or advanced liver fibrosis from August 12, 2004 to February 16, 2022. Trend analysis was performed using Cox proportional hazard model, controlling for MELD-XI. At-risk period starts at the time of waitlist; the end of the follow-up period was mortality on the waitlist, mortality post-HT, or administrative censoring at the end of the study.

Results

There was no significant difference in the survival of patients with advanced fibrosis and early fibrosis over time (HR 1.54, CI 0.59–4.02, p = 0.5). Similarly, there was also no significant survival difference within groups who did (HR 0.78, CI = 0.26–2.33, p = 0.8) or did not (HR 1.00, CI 0.09–11.43, p = 0.9) receive transplants. However, most transplants were performed in patients with no or early fibrosis.

Conclusion

There was no significant difference in the survival rates between HT candidates with and without advanced fibrosis on the waitlist and post-HT, challenging the notion that advanced fibrosis should be an absolute contraindication for HT. However, our findings are limited by the small sample size, retrospective design, and focus on patients already deemed suitable for transplantation. These limitations highlight the need for prospective studies involving broader patient populations, including those excluded from transplant candidacy due to severe fibrosis or cirrhosis. Future research should evaluate whether pre-transplant liver biopsy is necessary for all HT candidates or if clinical assessments can adequately stratify risk.

Lay summary

This study found that the presence of advanced liver injury did not confer a difference in the waitlist and post heart transplant (HT) survival rates of patients on the HT transplant list. This finding suggests that patients listed for transplant may not need to undergo a liver biopsy as part of the transplant work up.