Rising Rates of Hepatocellular Carcinoma Leading to Liver Transplantation in Baby Boomer Generation with Chronic Hepatitis C, Alcohol Liver Disease, and Nonalcoholic Steatohepatitis-Related Liver Disease.
Cholankeril G et al.
Diseases 2017, 5, 20; doi:10.3390/diseases5040020

Abstract
We aim to study the impact of the baby boomer (BB) generation, a birth-specific cohort (born 1945–1965) on hepatocellular carcinoma (HCC)-related liver transplantation (LT) in patients with HCV, alcoholic liver disease (ALD), and NASH.
We performed a retrospective analysis using the United Network for Organ Sharing
(UNOS)/Organ Procurement Transplant Network (OPTN) database from 2003 to 2014 to compare HCC-related liver transplant surgery trends between two cohorts—the BB and non-BB—with a secondary diagnosis of HCV, ALD, or NASH.

From 2003–2014, there were a total of 8313 liver transplant recipients for the indication of HCC secondary to HCV, ALD, or NASH. Of the total, 6658 (80.1%) HCC-related liver transplant recipients were BB. The number of liver transplant surgeries for the indication of HCC increased significantly in NASH (+1327%), HCV (+382%), and ALD (+286%) during the study period. The proportion of BB who underwent LT for HCC was the highest in HCV (84.7%), followed by NASH (70.3%) and ALD (64.7%). The recommendations for birth-cohort specific HCV screening stemmed from a greater understanding of the high prevalence of chronic HCV and HCV-related HCC within BB. The rising number of HCC-related LT among BB with ALD and NASH suggests the need for increased awareness and improved preventative screening/surveillance measures within NASH and ALD cohorts as well

Liver Transplantation for Nonalcoholic Steatohepatitis in the US: Temporal Trends and Outcomes.
Cholankeril G et al.
Dig Dis Sci 2017 ; 62 :2915-22

Background and Aims
NASH is a rapidly growing etiology of end-stage liver disease in the US. Temporal trends and outcomes in NASH-related liver transplantation (LT) in the US were studied.

Methods
A retrospective cohort study utilizing the United Network for Organ Sharing and Organ Procurement and Transplantation (UNOS/OPTN) 2003–2014 database was conducted to evaluate the frequency of NASH-related LT. Etiology-specific post-transplant survival was evaluated with Kaplan–Meier methods and multivariate Cox proportional hazards models.

Results
Overall, 63,061 adult patients underwent LT from 2003 to 2014, including 20,782 HCV (32.96%), 9470 ALD (15.02%), and 8262 NASH (13.11%). NASH surpassed ALD and became the second leading indication for LT beginning in 2008, accounting for 17.38% of LT in 2014. From 2003 to 2014, the number of LT secondary to NASH increased by 162%, whereas LT secondary to HCV increased by 33% and ALD increased by 55%. Due to resurgence in ALD, the growth in NASH and ALD was comparable from 2008 to 2014 (NASH + 50.15% vs. ALD + 41.87%). The post-transplant survival in NASH was significantly higher compared to HCV (5-year survival: NASH - 77.81%, 95% CI 76.37–79.25 vs. HCV - 72.15%, 95% CI 71.37–72.93, P\ .001). In the multivariate Cox proportional hazards model, NASH demonstrated significantly
higher post-transplant survival compared to HCV (HR 0.75; 95% CI 0.71–0.79, P\ .001).

Conclusions 
Currently, NASH is the most rapidly growing indication for LT in the US. Despite resurgence in ALD, NASH remains the second leading indication for LT.

Expert's Commentary

Using the Organ and Transplantation Database from the USA, these 2 studies report on temporal trends over more than a decade – 2003 to 2014 of etiologies of end-stage liver disase (ESLD) and of HCC leading to liver transplantation (LT). Of the over 60,000 adults who underwent LT during the period of the study, the 3 leading etiologies were HCV infection, NASH or alcoholic liver disease (ALD). Although HCV was the predominant etiology over the period, the increase for NASH was significantly more pronounced (+ 162% over the period) than for HCV or ALD (+ 33% and  + 55%, respectively). Interestingly, post-transplant survival was significantly better for NASH or ALD than for HCV. When considering LT for HCC related to the 3 leading etiologies (HCV, NASH and ALD), it appears that 80% were in patients of the baby boomer generation (born 1945–1965) and that the number of LT for HCC increased significantly more in NASH (+1327%) than in HCV (+382%), or ALD (+286%) during the study period.
Taken together these results

• confirm the leading role of HCV in LT indications, including for HCC,
• show the more rapidly increase of NASH versus other etiologies between 2003 and 2014,
• suggest that, with universal HCV treatment and high cure rate, HCV etiology will soon be overrided by ALD and even more NASH,
• highlight the need to increased screening, surveillance and prevention of the baby-boomer generation for ALD and even more importantly NASH-related end-stage liver disease.

Whether these epidemiological trends, shown in the USA, are true for other regions of the world, specifically Europe, has yet to be determined. We can anticipate, anyhow, that NASH-related morbidities, including liver complications will cosnstitute an emerging and increasing challenge in most healthcare environments in the near future

Pr François Raffi, Nantes