Are we standing on the shifting sands of post-transplant metabolic-associated steatotic liver disease?

Table 1 Metabolic dysfunction-associated steatotic liver disease definition

Components	Criteria
Evidence of hepatic steatosis	Detected by imaging or histology
Presence of ≥ 1 CMRF
Overweight or obesity	BMI ≥ 25 kg/m2 (≥ 23 kg/m2 in people of Asian ethnicity) or WC ≥ 94 cm in males and ≥ 80 cm in females
Dysglycemia or T2DM	Fasting serum glucose ≥ 5.6 mmol/L (100 mg/dL) or 2-hour post-load glucose levels ≥ 7.8 mmol/L (≥ 140 mg/dL) or HbA1c ≥ 5.7% (39 mmol/L) or T2DM or treatment for T2DM
Arterial hypertension	Blood pressure ≥ 130/85 mmHg or specific antihypertensive drug treatment
Dyslipidemia	Plasma triglycerides ≥ 1.70 mmol/L (≥ 150 mg/dL) or lipid lowering treatment or plasma HDL-cholesterol ≤ 1.0 mmol/L (≤ 40 mg/dL) for males and ≤ 1.3 mmol/L (≤ 50 mg/dL) for females or lipid lowering treatment

BMI: Body mass index; CMRF: Cardiovascular metabolic risk factor; HbA1c: Glycated hemoglobin; HDL: High-density lipoprotein; T2DM: Type 2 diabetes mellitus; WC: Waist circumference.

Table 2 Management of post-liver transplantation metabolic dysfunction-associated steatotic liver disease

Topics	Management
Lifestyle modifications	Dietary modifications; regular physical activity
Aggressive control of CMRFs
Weight control	Highly recommended due to the undisputable overall benefits; orlistat (adequate safety profile but limited benefits); bariatric surgery/gastric sleeve (promising approach but ideal timing and patient selection remain uncertain)
Glycemic control	General management similar to general population; early postoperative period preference for insulin therapy; transition to oral antidiabetics when steroid dosage is reduced or stopped, and insulin needs decrease; choice of oral therapy follows current guidelines
Arterial hypertension	General management follows guidelines for general population; preferred first-line therapy is calcium channel blockers
Dyslipidemia	General management follows guidelines for general population; LTx recipients considered high or very high risk for therapeutic cholesterol targets; preferred drugs are hydrophilic statins (e.g., pravastatin, rosuvastatin)
Immunosuppression	No specific guidance for immunosuppressant choice in post-LTx MASLD or MASH; immunosuppressive regimen must be tailored individually
Specific therapies for MASLD and MASH	Resmetirom, pioglitazone, and GLP-1 RAs show promise in the general population, but there is insufficient evidence to support their use in LTx recipients at this time

CMRF: Cardiovascular metabolic risk factor; GLP-1 RAs: Glucagon-like peptide-1 receptor agonists; LTx: Liver transplantation; MASH: Metabolic dysfunction-associated steatohepatitis; MASLD: Metabolic dysfunction-associated steatotic liver disease.