Liver transplantation for non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is considered the hepatic manifestation of metabolic syndrome, and it is defined by the presence of steatosis in >5% of hepatocytes, according to histological analysis or detected by specific proton density fat fraction obtained magnetic resonance imaging. The term NAFLD covers two pathologically distinct conditions: non-alcoholic fatty liver and non-alcoholic steatohepatitis (NASH), which can have similar clinical presentation, but with different prognosis. Both conditions can lastly lead to the development of cirrhosis. End stage liver-disease and hepatocellular carcinoma represent the two standard indications for liver transplantation (LT) in patients affected by NAFLD. Despite the evolution to end stage liver disease occur in 15-20% of NASH cases, the absolute number of LT performed for NAFLD is dramatically increased in the last decade. Between 2004 and 2013 new waitlist registrants for NAFLD as indication increased from 804 to 2174, becoming rapidly the second most common indication for liver transplantation in the USA. During the same period, indications to LT such as hepatitis C virus-related and alcohol-related cirrhosis increased only by 14% and 45% respectively. This review will focus on the management before and after LT for patients with NAFLD, with particular interest to comorbidities and outcomes.