Pre-and-post transplant considerations in patients with nonalcoholic fatty liver disease

Abstract

Non-alcoholic fatty liver disease (NAFLD) is currently the third most common indication for liver transplantation in the United States. With the growing incidence of obesity, NAFLD is expected to become the most common indication for liver transplantation over the next few decades. As the number of patients who have undergone transplantation for NAFLD increases, unique challenges have emerged in the management and long-term outcomes in patients. Risk factors such as obesity, hypertension, diabetes, and hyperlipidemia continue to play an important role in the pathogenesis of the disease and its recurrence. Patients who undergo liver transplantation for NAFLD have similar long-term survival as patients who undergo liver transplantation for other indications. Research shows that post-transplantation recurrence of NAFLD is commonplace with some patients progressing to recurrent non-alcoholic steatohepatitis and cirrhosis. While treatment of comorbidities is important, there is no consensus on the management of modifiable risk factors or the role of pharmacotherapy and immunosuppression in patients who develop recurrent or de novo NAFLD post-transplant. This review provides an outline of NAFLD as indication for liver transplantation with a focus on the epidemiology, pathophysiology and risk factors associated with this disease. It also provides a brief review on the pre-transplant considerations and post-transplant factors including patient characteristics, role of obesity and metabolic syndrome, recurrence and de novo NAFLD, outcomes post-liver transplantation, choice of medications, and options for immunosuppression.

Keywords: Liver transplantation; Non-alcoholic fatty liver disease; Non-alcoholic fatty liver disease; Non-alcoholic steatohepatitis; Nonalcoholic steatohepatitis; Cirrhosis; Obesity

Core tip: Non-alcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease and one of the leading indication for liver transplantation (LT) nowadays. Although, it remains the third most common indication for LT in the United States, it is projected to become the most common indication by 2025. It presents a unique challenge for the transplant community in terms of management and long-term outcomes. Many risk factors for NAFLD pre-transplant such as obesity, hypertension, hyperlipidemia, diabetes continue to play an important role in the pathogenesis of post-transplant NAFLD. In addition to therapy focused on prevention and management of coexisting medical conditions, physicians must weight the benefits and harms of both medical and surgical options in patients undergoing LT.