Understanding Fontan-Associated Liver Disease (FALD)

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AJ Gumm, EB Rand. J Pediatr 2025; 277: 114389. Fontan-Associated Liver Disease

This review article provides a lot of useful advice regarding Fontan-Associated Liver Disease (FALD).

Key points:

  • FALD prevalence: “will be 70,000 by 2025, with the mean age of 23 years”
  • Early common manifestations are modest increases in AST and ALT. Elevation of bilirubin is a late finding. Mild elevation of INR is common in range of 1.4 to 1.8.
  • Ascites occurs in 2-17% of patients with FALD but can be due to other etiologies like PLE
  • Annual labs (HFP, GGT, CBC/d, PT/INR, AFP) recommended after 7 years post-Fontan
  • No special diet is recommended but it is worthwhile to avoid fatty liver disease
  • For varices, a TIPS procedure “may precipitate pulmonary hypertension resulting in cardiac failure.” ‘The safety of a nonselective beta-blocker to prevent a variceal bleed has not been established.” It is important to determine if there are cardiac options that could improve portal hypertension.
  • In patients with advanced liver disease, multidisciplinary teams are needed to determine if an isolated liver transplantation versus combined heart and liver transplantation (CHLT) is needed.
  • “If a patient requires a heart transplant, the presence of liver fibrosis or even cirrhosis alone is not an indication for liver transplantation, because cirrhosis has been reported to reverse after isolated heart transplantation in a single provocative case. However, if there is evidence of cirrhosis and liver decompensation, then a CHLT should be considered.”
  • Many hepatologists recommend trending elastography. Many recommend liver biopsy starting after 10 years status post Fontan

When to refer to hepatology:

  1. Concerning labs: high transaminases, GGT or bilirubin; low albumin (if liver-related), high INR (not due to warfarin), and high AFP
  2. Signs of portal hypertension (eg. splenomegaly, varies, reversal of flow on ultrasound)
  3. Liver masses
  4. More than 10 years post-Fontan. “100% of patients with Fontan circulation will develop liver disease in their lifetime”

My take: There is a lot that we do not know about FALD and management is complex due to coexistent abnormal cardiac physiology.

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