Objectives: Liver transplant has significantly improved the survival of patients with end-stage liver disease, yet long-term transplant recipients often face challenges related to graft function and well-being. We aimed to evaluate the clinical role of vibration-controlled transi-ent elastography for assessment of liver fibrosis and steatosis, with a focus on fibrosis and steatosis, in liver transplant recipients who were over 10 years posttrans-plant. In addition, we aimed to identify factors that influ-ence liver function and quality of life in these patients.
Materials and Methods: This prospective, crosssec-tional study included 105 liver transplant recipients. Vibration-controlled transient elastography measure-ments (controlled attenuation parameter and liver stiffness measurement) were used to assess liver steatosis and fibrosis, and the Short Form 36 quality of life questionnaire was use to evaluate overall health of patients. Demographic data, medical history, and laboratory results were also collected. Generalized linear models identified significant factors that may affect liver function and quality of life.
Results: No significant differences were observed between liver transplant recipients with living donors versus recipients with deceased donors with regard to fibrosis, quality of life, or other factors. The study found that diabetes mellitus (controlled attenuation parameter: P = 0.278; 95% CI, 0.193-0.363; P < .001) and history of biopsy-proven rejection (liver stiffness measurement: β = 0.814; 95% CI, 0.653-0.975; P < .001) were key factors associated with greater severity of liver steatosis and fibrosis. Significant fibrosis was associated with lower physical function scores (β = -0.207; P = .040).
Conclusions: Vibration-controlled transient elastography is a valuable tool for assessment of liver fibrosis and steatosis in long-term liver transplant recipients and thereby facilitates optimization of posttransplant care and improved outcomes.

Key words : Elasticity imaging techniques, Fatty liver, Liver transplantation, Severity of illness index

Introduction

Liver transplant (LT) is the only curative treatment for end-stage liver disease and markedly improves both survival and quality of life.1 Liver transplant is indicated for various conditions, including cirrhosis due to hepatitis B virus (HBV) or hepatitis C virus (HCV), alcoholic liver disease, and metabolic dysfunction-associated steatohepatitis, as well as acute liver failure, hepatocellular carcinoma within transplant criteria, and certain metabolic liver diseases.² Recently, indications for LT have expanded to include select cases of unresectable colorectal liver metastases, intrahepatic cholangiocarcinoma, and neuroendocrine liver metastases.²

Despite advances in surgical techniques and immunosuppression regimens, long-term graft sur-vival remains a clinical challenge due to complications such as chronic rejection, metabolic syndrome, and progressive graft fibrosis.^3-6 Acute rejection, which typically occurs within the first year after transplant, is generally well controlled with immunosup-pression therapy.^3,4 In contrast, chronic rejection, albeit less common, can lead to irreversible bile duct injury and graft failure.^5,6 Therefore, long-term posttransplant care must focus on immunosuppression optimization, management of cardiovascular and metabolic risks, and monitoring for graft fibrosis and rejection.^7,8

Graft fibrosis and hepatic steatosis are major determinants of long-term liver function in LT recipients.^9,10 Fibrosis results from chronic injury and excessive extracellular matrix deposition, whereas steatosis reflects fat accumulation in hepatocytes and is often associated with metabolic risk factors such as obesity and type 2 diabetes mellitus (T2DM).⁹ The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) is high among patients with T2DM, and posttransplant metabolic syndrome may accelerate both steatosis and fibrosis in the graft.^8,9

Vibration-controlled transient elastography (VCTE) is a noninvasive imaging modality that quantifies liver stiffness and hepatic fat content.¹¹ It provides 2 parameters: liver stiffness measurement (LSM, in kPa) for fibrosis assessment and the controlled attenuation parameter (CAP, in dB/m) for steatosis quantification.^11-13 The VCTE modality has demons-trated good diagnostic performance for evaluation of graft fibrosis and steatosis in LT recipients and is a practical alternative to liver biopsy.^12,13

Several studies have explored the use of VCTE in posttransplant settings, including the assessment of HCV-related fibrosis, acute and chronic rejection, metabolic liver disease, and cardiovascular outcomes.^14-19 In addition, fibrosis scoring systems such as fibrosis 4 (FIB4), aspartate aminotransferase-to-platelet ratio index (APRI), and nonalcoholic fatty liver disease fibrosis score (NFS) have been evaluated for the utility of these scoring systems versus VCTE in this patient population.^16,20

Our present study evaluated the clinical utility of VCTE for assessment of graft fibrosis and steatosis in LT recipients more than 10 years after transplant. The >10-year cutoff was chosen so that we could focus on long-term survivors, a growing yet understudied cohort, for whom chronic complications become increasingly relevant. We also investigated factors that influence liver graft function and quality of life, as reported by patients, using validated instruments.

Materials and Methods

Patients and data collection
This study was conducted among patients regularly followed at the Liver Transplantation Clinic of Dokuz Eylul University who met specific eligibility criteria. A total of 145 patients met the inclusion criteria. During their routine follow-up visits, patients underwent both the Short Form 36 (SF-36) quality of life questionnaire and VCTE measurements.

Eleven patients were excluded because of lack of follow-up data during the study period (from June 2024 to January 2025). Twenty-two patients declined to complete either the SF-36 or VCTE, and 7 were excluded based on other predefined exclusion criteria. These criteria were chosen because of the potential influence on both VCTE measurements and laboratory results used to calculate fibrosis scores. The final analysis included 105 patients.

Patients who were more than 10 years after LT were selected, and this criterion facilitated our focus on long-term graft health and patient-reported outcomes, which minimized the confounding effects of early posttransplant complications or acute changes in liver function.

Inclusion and exclusion criteria

Inclusion criteria included the following: liver transplant recipients who received grafts from either living or deceased donors; for recipients of living donor transplants, donors were either biologically related up to the fourth degree or legal spouses and were at least 18 years old at the time of donation. Other inclusion criteria included more than 10 years after LT, no missing clinical or laboratory data, and follow-up and treatment performed at our LT clinic.

Exclusion criteria included the following: age <18 years at the time of the study, presence of malignant or infiltrative diseases involving the liver, morbid obesity (defined as body mass index [BMI] ≥40 kg/m2), and incomplete VCTE and SF-36 questionnaire.

We collected demographic data such as age, sex, and BMI, as well as LT-related information including donor type, transplant age, biopsy-proven rejection history, and the primary disease causing liver failure prior to transplant. Comorbid conditions, such as hypertension and DM, were also recorded. Laboratory data included creatinine, international normalized ratio, aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, and bilirubin, all of which were routinely obtained during follow-up.

The obtained laboratory and clinical data were used to calculate fibrosis indexes, including FIB4 (FIB4 = [Age × AST]/[Platelets × √ALT]), APRI (APRI = [AST/40]/Platelets), and NFS (NFS = -1.675 + 0.037 × Age + 0.094 × BMI + 1.13 × DM + 0.99 × AST/ALT ratio - 0.013 × platelets).

Ethics and informed consent

The study was approved by the Non-Interventional Research Ethics Committee of Dokuz Eylul University on May 8, 2024 (Decision No. 2024/16-21). All procedures adhered to the ethical principles outlined in the 2013 Declaration of Helsinki and the 2018 Declaration of Istanbul. Written informed consent was obtained from all participants to ensure confidentiality and voluntary participation.

This study included both recipients with living donors and recipients with deceased donors; all living donors were biologically related up to the fourth degree or were spouses and were ≥18 years old at the time of donation.

Vibration-controlled transient elastography measu-rement

Patients fasted for at least 3 hours before VCTE. Measurements were performed by H. Döngelli and N. Dani? using a standardized protocol. At least 10 valid measurements were obtained per patient.

Liver fibrosis was assessed from median values of LSM (in kPa). Only results with a median value <20% were included. Significant fibrosis was defined as LSM >7.0 kPa. Liver steatosis was assessed from the CAP (in dB/m), and results were averaged.

Short Form 36 quality of life questionnaire

Health-related quality of life was evaluated using the SF-36, a validated questionnaire covering 8 domains: physical function, role limitations due to physical health, bodily pain, general health perceptions, vitality, social function, role limitations due to emotional problems, and mental health. Higher scores represent better perceived health. Patients completed the SF-36 during follow-up visits, and assistance was provided if needed.

Statistical analyses

We used SPSS software (version 25.0) for statistical analyses. Descriptive statistics were used to sum-marize demographic, clinical, and laboratory data. Continuous variables were expressed as means (with SD) or medians (with IQR) depending on the distribution. Categorical variables were presented as frequencies and percentages. We compared conti-nuous variables with independent t tests or Mann-Whitney U tests for nonnormally distributed data and analyzed categorical variables with χ2 tests.

Univariate generalized linear models (GLMs) were used to examine associations between independent variables (eg, age, sex, BMI, comorbidities) and outcomes (VCTE parameters and SF-36 scores). Multivariate GLMs were then conducted to identify independent predictors of liver fibrosis and steatosis. Clinical factors associated with quality of life were evaluated using only univariate GLMs, as our aim was to explore potential associations without overfitting the model given the sample size limitations. The results of the univariate and multivariate GLM analyses were reported as regression coefficients (β) and P values to quantify the strength and significance of associations between independent variables and outcomes.

Receiver operating characteristic (ROC) curve analysis was conducted to evaluate the diagnostic accuracy of VCTE parameters (CAP and LSM) and fibrosis indexes (FIB4, APRI, NFS). The ROC analyses were presented using area under the curve (AUC) values with corresponding 95% CI and P values. P < .05 was considered statistically significant.

Results

Baseline clinical characteristics and comparison between deceased donor and living donor liver transplant recipients
A total of 105 LT recipients were included, with a mean age of 59.3 ± 13.3 years; 63.8% were male. The median time since transplant was 15 years (IQR, 5 years). The most frequent primary etiologies for transplant were coinfection with HBV and hepatitis D virus (24.8%), HBV alone (22.9%), and other causes (16.2%) (Table 1).

For deceased donor recipients (n = 58) versus living donor recipients (n = 47), there were no significant differences in age, sex, BMI, or time since transplant. The prevalence of comorbidities such as hypertension (40.0%) and DM (30.5%) was similar across both groups. Laboratory parameters, including platelet count, AST, ALT, bilirubin, creatinine, albumin, and international normalized ratio, also showed no statistically significant differences.

Health-related quality of life scores, as assessed by the SF-36, were comparable across all domains between deceased donor and living donor recipients (Table 1).

Fibrosis and steatosis assessments using noninvasive methods also did not differ significantly between groups. Specifically, FIB4, APRI, and VCTE para-meters, including CAP and LSM, showed no significant variation. The prevalence of significant fibrosis (defined as LSM >7.0 kPa) was 24.1% in the deceased donor group versus 27.7% in the living donor group (P = .681).

A history of biopsy-proven rejection was similarly distributed (20.7% for deceased donor group vs 23.4% for living donor group; P = .738). Of the 23 patients with rejection history, 19 had experienced rejection within the first year, and 1 patient had experienced late rejection (year 11) due to patient nonadherence to immunosuppression regimen.

Factors associated with controlled attenuation parameter and liver stiffness measurement in generalized linear models In multivariate analysis, higher BMI (β = 0.018; 95% CI, 0.009-0.027; P < .001) and presence of DM (β = 0.197; 95% CI, 0.110-0.283; P < .001) were independently associated with higher CAP values, indicating that metabolic factors are significantly linked with hepatic steatosis (Table 2).

A borderline association between biopsy-proven rejection and CAP was observed in univariate analysis (P = .047), but this was not significant in the multivariate model (P = .052).

Regarding LSM (in kPa), a history of rejection was the strongest independent predictor (β = 0.793; 95% CI, 0.632-0.954; P < .001), suggesting that prior rejection episodes contribute to graft fibrosis. Although transplant age showed an association with increased stiffness in univariate analysis (P = .041), this did not persist in multivariate analysis (P = .241). Neither BMI nor DM were independently associated with LSM (Table 2).

Factors associated with the Short Form 36 quality of life scores
Multivariate analysis revealed that male sex was significantly associated with higher SF-36 scores in the domains of general health (β = 0.149, P = .016), social function (β = 0.197, P = .006), and role limitations due to emotional problems (β = 0.199, P = .010), suggesting possible sex-related differences in perceived quality of life (Table 3).

Importantly, the presence of significant fibrosis (LSM >7.0 kPa) was associated with lower physical function scores (β = -0.207, P = .040). We also noted a nonsignificant trend toward lower scores for role limitations due to physical problems (β = -0.143, P = .092). No independent associations were found between SF-36 scores and BMI, CAP, LSM, or donor type (Table 3).

Receiver operating characteristic analysis of fibrosis scores and controlled attenuation parameter for prediction of significant fibrosis
Among the clinical fibrosis scores, APRI showed the highest predictive ability with an AUC of 0.763 (95% CI, 0.657-0.869; P < .001), followed by FIB4 with an AUC of 0.732 (95% CI, 0.624-0.840; P < .001). In contrast, CAP had a more modest predictive power for fibrosis, with an AUC of 0.643 (95% CI, 0.519-0.767; P = .027) (Table 4).

Discussion

This study provides important insights into the metabolic and immunological factors that may affect liver graft health and patient-reported outcomes in long-term LT recipients. Our findings emphasize that DM and higher BMI are independent determinants of hepatic steatosis, and a history of biopsy-proven acute rejection is the most robust predictor of increased liver stiffness, indicating progressive graft fibrosis. Furthermore, significant fibrosis, as assessed by VCTE, was associated with diminished physical function, whereas male sex was linked to better quality of life in multiple domains, including general health, social function, and emotional well-being.

Acute rejection remains a clinically significant complication following LT, with reported incidence ranging from 14.8% to 34.9%; acute rejection predominantly occurs within the first year posttransplant.^3,4,21,22 Several factors have been identified as risk factors for the development of acute rejection, including ABO incompatibility, advanced recipient age, deceased liver donors, lack of aspirin use, primary biliary cirrhosis, primary sclerosing cholangitis, HCV infection, and female sex.^3,4,21,22 Furthermore, long-term outcomes in patients who experience acute rejection have been associated with reduced graft survival and patient survival.^4,21 Although our study was not designed to directly assess acute rejection episodes, we found a 21.9% prevalence of biopsy-confirmed rejection, which aligned with prior reports. Notably, no difference in rejection rates was observed between living donor recipients and deceased donor recipients, and no effect of donor type on fibrosis, steatosis, or quality of life was identified.

Previously published reports have established that MASLD is increasingly prevalent in LT recipients, with posttransplant hepatic steatosis rates reported between 12% and 88%.^9,23-28 Several risk factors for posttransplant hepatic steatosis have been identified, including DM, higher BMI, preoperative alcoholic cirrhosis, preexisting donor graft steatosis, HCV infection, sirolimus use, and female sex.^23-26 Although some previously published studies have reported that posttransplant hepatic steatosis increases the risk of de novo cirrhosis or hepatic fibrosis, others studies have found no significant effect on overall survival or fibrosis progression.^23,28 The long-term effects of posttransplant hepatic steatosis on hepatic fibrosis and mortality remain a subject of debate, although the prevailing view suggests that posttransplant hepatic steatosis contributes to fibrosis progression.

In our study, we used VCTE (CAP) to assess hepatic steatosis, and DM and increased BMI were found to be independently associated with hepatic steatosis. Unlike the results from previous studies, our findings did not identify a significant association between hepatic steatosis and factors such as sex, pretransplant HCV infection, or alcoholic cirrhosis.^27,28 These discrepancies likely reflect differences in cohort composition, as we exclusively included recipients with more than 10 years after transplant. Our findings underscore the central role of metabolic factors, particularly T2DM and obesity, to promote hepatic steatosis in the long-term. Although our analysis was cross-sectional, a trend between CAP (steatosis) and LSM (fibrosis) was observed in univariate models, which supports our hypothesis that steatosis may contribute to fibrosis progression in the long-term.

In a study that investigated the prevalence of hepatic steatosis and hepatic fibrosis in the posttransplant period, the prevalence of significant fibrosis was reported to be 33%, with pretransplant HCV-related cirrhosis identified as a risk factor for significant hepatic fibrosis.10 Another study evaluated the diagnostic accuracy of VCTE for detection of posttransplant hepatic fibrosis and found that, based on histopathology assessment via liver biopsy, the prevalence of significant fibrosis was 22%, and VCTE demonstrated a sensitivity of 90% for detection of significant fibrosis.¹³ Additional risk factors for posttransplant hepatic fibrosis reported in the literature include DM, increased BMI, male sex, low immunosuppression levels, deceased donor transplant, and older donor age.^29-31 In our study, however, biopsy-proven acute rejection history was the only independent factor associated with post-transplant hepatic fibrosis. Previous studies have demonstrated that acute rejection is linked to long-term graft failure.^4,21 Although most of the patients had unremarkable liver function test results, our study confirmed that fibrosis can progress subclinically, reinforcing the value of noninvasive imaging in long-term monitoring. We also evaluated the performance of noninvasive fibrosis indexes for detection of significant fibrosis (as defined by VCTE). Both FIB4 and APRI demonstrated good diagnostic accuracy, consistent with recent meta-analyses that have validated these tools in posttransplant populations.²⁰

With regard to quality of life, our findings partially aligned with prior research. A recent biopsy-based study has reported that hepatic steatosis was associated with impaired quality of life and that fibrosis was associated with poorer general health in posttransplant patients.³² Similarly, a study in patients with T2DM has identified hepatic fibrosis, as evaluated with VCTE, and obesity as key factors that erode quality of life.³³ To our knowledge, our present study is the first study to assess the relationship between quality of life and hepatic steatosis/fibrosis as evaluated with VCTE in LT recipients.

We observed that significant fibrosis may adversely affect the physical role domain of the SF-36 quality of life survey, whereas male sex appeared to be associated with better scores in general health, emotional role limitations, and social function domains. This negative association between fibrosis and physical role limitations aligns with findings in MASLD, where higher degrees of fibrosis have been linked to increased fatigue, thereby impairing physical function.^34,35 It is plausible that similar mechanisms were present in our cohort. Furthermore, although histopathology was not performed, we hypothesize that a subset of patients within the significant fibrosis group may have progressed to early-stage liver cirrhosis, which could further contribute to the observed decline in quality of life.³⁶ This underscores the potential of graft fibrosis to impair daily activities and physical well-being in long-term LT recipients. As fibrosis advances, fatigue, decreased exercise tolerance, and physical limitations may arise, all of which diminish quality of life.

Limitations

This study had several limitations that should be acknowledged. First, the cross-sectional design limited the ability to evaluate longitudinal changes in liver fibrosis, steatosis, and quality of life in the long-term and as such prevents conclusions about disease progression or response to interventions.

A prospective follow-up study could provide more robust insights. Second, VCTE, despite its nonin-vasive nature, is subject to variability due to operator dependency, probe selection, and patient-related factors such as obesity and hepatic congestion, all of which potentially degrade measurement accuracy.

In addition, although fibrosis indexes such as FIB4, APRI, and NFS were included for comparison, these scores were originally developed for nontrans-plant populations and may not be fully reliable in LT recipients, necessitating further validation by histopathology. The absence of liver biopsy data in this study prevented direct histological correlation, which is essential to distinguish fibrosis from other graft-related complications such as rejection or recurrent disease. Furthermore, potential confounding factors, including immunosuppression regimens, patient adherence to medication regimens, and unmeasured metabolic variables, may have influenced both liver function and quality of life outcomes.

The fact that VCTE measurements were perfor-med by only 2 operators may have influenced the results. Restriction of the study population to LT recipients more than 10 years posttransplant may have reduced the applicability of the results to patients in earlier stages of follow-up, as graft function, complication rates, and quality of life parameters can vary substantially over time.

Finally, as a single-center study conducted at a tertiary referral hospital, the results may not be fully representative of LT recipients seen in other types of health care settings. Future multicenter, longitudinal studies that include histopathology validation and a broader patient population are needed to refine the clinical utility of VCTE in posttransplant assessment.

Conclusions

Vibration-controlled transient elastography is a valuable tool for assessment of liver fibrosis and steatosis in long-term LT recipients and provides critical insights beyond standard liver function tests. This study highlights the observation that hepatic steatosis and fibrosis can progress even when conventional biomarkers remain within normal ranges. In addition, DM emerged as a key factor associated with liver graft function, emphasizing the need for metabolic monitoring in posttransplant care. Quality of life was influenced by both fibrosis and demographic factors, underscoring the importance of a holistic approach to patient management. Given its ability to detect subclinical graft changes, VCTE should be integrated into routine posttransplant monitoring to optimize long-term outcomes.

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