Metabolic dysfunction-associated steatotic liver disease throughout the liver transplant cycle: a comprehensive review

Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing in global prevalence and becoming a leading indication for liver transplantation (LT). The management of MASLD has been well-studied in the pre-LT setting, and we are entering into a golden era of pharmacologic options designed to resolve steatohepatitis and reverse fibrosis. However, the implications of MASLD on organ allocation, risk of post-LT recurrence, and optimal post-LT management remain topics of ongoing investigation. One such unique challenge is the growing necessity to use steatotic organs to address the shortage of available organs for all waitlisted patients, while ensuring acceptable outcomes through careful case selection. Additionally, how best to screen, diagnose, and manage post-LT graft steatosis remains an ongoing topic of debate, given the high rates of recurrence or de novo occurrence in patients transplanted for non-MASLD-related etiologies of liver disease. This comprehensive review explores the impact of MASLD across the disease continuum, given it is a chronic illness with a complex pathophysiology and is influenced by other comorbidities and certain medications.