Post-transplant MASLD: a risk-stratified approach to assessment and personalized management

Metabolic dysfunction-associated steatotic liver disease (MASLD) has become a major indication for liver transplantation (LT) and is expected to account for an increasing proportion of transplant candidates worldwide. As long-term post-transplant survival continues to improve, post-LT MASLD has increasingly emerged as a major metabolic complication affecting long-term prognosis. Unlike MASLD in the non-transplant setting, post-LT MASLD is strongly influenced by transplant-specific factors, including recipient metabolic dysfunction, immunosuppressant use, graft-related characteristics, and metabolic alterations following transplantation, resulting in substantial heterogeneity in clinical presentation and disease progression. Current evidence suggests that recipient-related metabolic factors, particularly obesity, type 2 diabetes, dyslipidemia, hypertension and post-transplant weight gain, play central roles in the pathogenesis, whereas donor-related characteristics may contribute predominantly to early liver fat accumulation. Importantly, the clinical significance of post-LT MASLD extends beyond simple steatosis and is closely associated with fibrosis progression, cardiovascular events, renal dysfunction, and other systemic metabolic complications. Nevertheless, the current literature remains highly heterogeneous. This variability likely reflects evolving disease definitions, the frequent failure to distinguish recurrent from de novo MASLD, and inconsistencies in diagnostic modalities across studies. Moreover, assessment models originally developed for MASLD in the general population may not be fully applicable to LT recipients. In this review, we comprehensively summarize the epidemiology, phenotypic heterogeneity, risk factors, pathogenesis, diagnostic and surveillance strategies, and emerging individualized management approaches for post-LT MASLD, with particular emphasis on a long-term management framework based on risk stratification. Accordingly, future management may need to focus less on steatosis alone and more on identifying patients at high risk for progressive hepatic and extrahepatic complications. A more comprehensive assessment integrating metabolic, hepatic, cardiovascular, and transplant-related factors may improve individualized surveillance and therapeutic decision-making. Advances in non-invasive imaging, multidisciplinary management, and artificial intelligence-based prediction models may further support individualized and risk-oriented care in post-LT MASLD.