Liver transplantation in patients with metabolic dysfunction-associated steatotic liver disease: a narrative review

Purpose: This review examines liver transplantation (LT) for metabolic dysfunction-associated steatotic liver disease (MASLD), including steatohepatitis (MASH): nomenclature, rising MASLD/MASH cirrhosis and hepatocellular carcinoma (HCC) as LT indications, candidate and donor graft evaluation, pretransplant progression prevention, posttransplant outcomes, recurrent and de novo disease, and current guidelines, with attention to living-donor LT (LDLT)-predominant Korea.Current concepts: Following the 2023 multisociety consensus, non-alcoholic fatty liver disease and steatohepatitis were renamed MASLD and MASH, reorganizing diagnosis around cardiometabolic risk factors rather than exclusion. Decompensated cirrhosis and HCC are among the fastest-growing LT indications. In deceased-donor systems, MASH cirrhosis is listed at lower model for end-stage liver disease (MELD) scores despite greater portal hypertension and waitlist mortality, so MELD may underestimate risk; in LDLT-predominant Korea, transplant timing, donor availability, and donor graft steatosis matter more than MELD alone. Long-term survival and post-LT oncologic outcomes resemble other etiologies, though comorbidities, especially diabetes, may worsen them. Recurrent and de novo graft steatosis are common and share insulin resistance but differ in metabolic burden, raising cardiovascular and malignancy burden rather than reducing survival.Discussion and conclusion: Nontransplant MASLD guidance is well established, but transplant-specific guidance on LT indications, candidate and graft selection, and posttransplant recurrent or de novo disease remains limited. A multidisciplinary approach combines cardiometabolic optimization, individualized immunosuppression, noninvasive steatosis and fibrosis monitoring, and emerging pharmacologic and weight-management strategies, though its criteria and long-term efficacy in recipients need further study. Consensus for the LDLT-predominant Asian setting should be supported by domestic cohort data.