What it Was Like to Have a Liver Biopsy

At one year post-liver transplant, you'll probably be required to have a liver biopsy. You may also undergo a biopsy as a diagnostic test, often paired with a liver ultrasound, to confirm liver disease. I had one at the one-year milestone, and I'd like to share what a NASH liver biopsy is like from my own experience.

My liver biopsy experience

My transplant was followed by a one-month hospitalization for COVID, and I was probably still traumatized by my experience with medical procedures. Even so, I found the liver biopsy to be a distressing experience. It's like any other medical procedure in that you're in a hospital gown, cold, unsure of what will happen, and feeling very vulnerable. These experiences are heavily influenced by the attitudes and level of care (or lack thereof) from the healthcare workers providing the service.

The biopsy procedure: A patient’s view

They gave me a local anesthetic injection in my abdomen. That local felt like any other injection—it hurt, but it was tolerable. On the other hand, the biopsy needle that is used is very large. I didn't feel that large needle when it went through my skin, but I felt it when it popped into my liver. It hurt a bit, but it's likely that my distress colored my experience of the liver biopsy. Compared to what you have already been through, this procedure may not be a big deal. I didn't enjoy it at all, but while invasive, it is not overly painful. This procedure gives your physician a lot of information they need to know about what is happening with your liver, especially for those concerned about fatty liver disease.

Receiving and deciphering the results

When I got the results back, they confirmed that I had steatotic (fatty) liver disease in my new liver! A resident called to deliver the results and read them off to me. This is what she said: "You have recurrent steatohepatitis, with 40% mixed steatosis; you have mild periportal fibrosis, fibrosis stage 2 out of four; you have an RAI of two out of nine; and you have mild activity or an NAS score of five out of eight." She told me that I had fat in my liver and needed to "be careful." She did not explain what that meant, which was confusing and frustrating. My experience highlights the need for clear communication, particularly for those trying to understand what a NASH liver biopsy is like.

My research and its surprising findings

I researched everything. I found out that 34 to 64% steatosis is considered moderate.¹ Stage 2 liver fibrosis (or liver scarring) is caused by chronic inflammation. Scarred tissue begins to replace healthy tissue, which reduces how well your liver functions. Liver scar tissue also reduces blood flow to your liver. RAI stands for Rejection Activity Index, and a score of 0 to 2 indicates no rejection. So, I had no rejection.

The NAS is the Activity Score and ranges from zero to eight points. A score of 5 or higher indicates NASH, and a score of less than 3 makes NASH unlikely. To me, this meant I had NASH again. I made an appointment with a gastroenterologist to discuss the results with them. She told me that I do not have NASH, but I do have what is now called MASLD (Metabolic Dysfunction-Associated Steatotic Liver Disease). This was a crucial clarification.

The accuracy and limitations of a biopsy

It is important to realize that the accuracy of liver biopsies can be questionable. There may be bias or sampling errors that skew the results.² The interpretation of a liver biopsy relies on human assessment, and there is evidence that the interpretation can differ depending on the person reading it. Sometimes the part of the liver that is collected may not be representative of the entire liver. This is a key detail to remember for anyone concerned about what a NASH liver biopsy is like.

My advice to you

My experience wasn't the best, but it might not be an issue for you. Make sure that the technicians explain everything and that you keep calm and still during the procedure. When you get your results, insist that someone explains them to you in a way you can understand, and explain what you should be doing to manage whatever level of disease exists, if any. Some people do not get MASLD or MASH in their transplanted liver, but for those who do, understanding the results of a biopsy is essential.