Nonalcoholic fatty liver: optimizing pretransplant selection and posttransplant care to maximize survival

Nonalcoholic steatohepatitis (NASH) is projected to become the most common indication for liver transplantation in the near future. NASH recipients have concurrent obesity, metabolic, and cardiovascular risks, which directly impact patient selection, posttransplant morbidity and potentially long-term outcomes. The purpose of this review is to highlight strategies to optimize pretransplant selection, outcomes, and posttransplant risk modification to optimize patient and graft survival.

NASH recipients are at risk for pretransplant cardiovascular disease, diabetes mellitus, and related renovascular complications. Stringent selection criteria identify those patients most likely to benefit from liver transplantation without adverse cardiovascular events yet, the incidence of these events remains high in NASH recipients. High BMI imparts postoperative morbidity because of infections, wound complications, and longer lengths of hospital stay. Aggressive management of modifiable risk factors such as obesity, hyperlipidemia, diabetes mellitus, and hypertension is recommended.

Although patient and graft survival in NASH recipients is excellent, long-term reduction in healthcare utilization and outcomes in these patients would benefit from risk factor modification. Periodic reassessment of coronary artery disease and early consideration of bariatric surgery is recommended in this population.