Introduction: There is increasing data to support the beneficial effects of statin medications on liver disease including reducing the development of hepatic fibrosis in metabolic associated steatotic liver disease (MASLD)/metabolic associated steatohepatitis (MASH) and reducing mortality in patients with compensated cirrhosis. In this analysis, we evaluated the impact of statins on pre and post liver transplant outcomes in patients with and without MASLD.

Methods: We performed a single-center retrospective review of patients evaluated for liver transplant between January 1, 2018- June 30, 2021. Demographic and clinical data were collected through review of electronic medical records. Patients were categorized by statin prescription (statin vs. no statin) and liver disease etiology (MASH vs. non-MASH). The primary outcome was pre- liver transplant death. Variables were assessed for association using chi-squared and t-tests, and for independent predictability of the primary outcome using multivariable backward logistic regression.

Results: A total of 623 patients were analyzed, of which 115 were on a statin medication. Patients on a statin were significantly more likely to have cirrhosis secondary to MASH/MASLD (53% vs. 17%, p<0.001). Routine outpatient care occurred at a similar rate in each group (p=0.231). Patients taking a statin had lower MELD-Na scores at the time of liver transplant evaluation (17 vs. 14, p<0.001), despite higher serum creatinine, that persisted on subgroup analyses in patients with MASH (p=0.005) and in patients without MASH (p=0.012). There was no difference in transplant rate in patients on statin compared to not on statins, though patients on a statin remained well on the waitlist for longer than patients not on statins (360 days vs. 260 days, p=0.06). In the total cohort, pre-transplant mortality did not differ in patients on statins compared to not on statins. However, in patients with MASH (n=145), waitlist mortality was lower in patients on a statin than in patients not on a statin (13% vs. 29%, p=0.027). On multivariate backward logistic regression, patients on a statin were 0.36 times as likely to die on the waiting list than patients not on a statin (OR 0.14-0.92, p=0.033). Post-transplant survival at 1 year did not differ between groups (82% vs. 86%, p=0.520).

Conclusions: In this analysis, we found that patients with MASH who were on statin therapy at the time of transplant evaluation had lower MELD-Na scores and had lower waitlist mortality. These findings were unlikely related to age, race, or access to care. Our results may suggest that patients on a statin have better pre transplant outcomes. Further research is needed to evaluate the benefits of statin therapy in patients decompensated cirrhosis pending liver transplant.

<b>Table 1: Demographic and clinical characteristics by statin therapy statu</b>s. Variables were compared between patients on a statin and patients not on a statin at the time of liver transplant evaluation. In all patients, statin therapy was associated with lower MELD-Na score, lower rate of malnutrition, and lower bilirubin but did not affect waitlist mortality or transplant rate.

Table 1: Demographic and clinical characteristics by statin therapy status. Variables were compared between patients on a statin and patients not on a statin at the time of liver transplant evaluation. In all patients, statin therapy was associated with lower MELD-Na score, lower rate of malnutrition, and lower bilirubin but did not affect waitlist mortality or transplant rate.

<b>Table 2: Predictors of pre-liver transplant death in patients with MASH cirrhosis. </b>Variables with p<0.05 on univariate analyses were entered were included as potential multivariable backward logistic regression with probability to enter p=0.05 and probability to remove p=0.10. Odds ratios are reported for potential independent predictors of death; dashes (-) indicate variables entered but removed on backward logistic regression. Statin therapy was ultimately associated with 2.7 times <i><b>lower risk </b></i>of waitlist mortality (OR 0.36).

Table 2: Predictors of pre-liver transplant death in patients with MASH cirrhosis. Variables with p<0.05 on univariate analyses were entered were included as potential multivariable backward logistic regression with probability to enter p=0.05 and probability to remove p=0.10. Odds ratios are reported for potential independent predictors of death; dashes (-) indicate variables entered but removed on backward logistic regression. Statin therapy was ultimately associated with 2.7 times lower risk of waitlist mortality (OR 0.36).

Alessandro Colletta

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