Outcomes from Referral to Transplant for Patients with MASLD: A California Liver Network Study

Background: Metabolic dysfunction-Associated Steatotic Liver Disease (MASLD) is becoming a leading indication for liver transplantation in the United States. In this growing recipient population, the combined effects of underlying liver disease etiology and associated comorbidities on the evaluation pathway to transplantation warrant closer examination of patient outcomes. Methods: We analyzed adult liver transplant referrals (n = 9981) from the California Liver Network, a multi-center retrospective cohort spanning six high-volume California transplant centers between 2018 and 2020. A total of 6709 patients who underwent formal evaluation were included. Patients were stratified by MASLD vs. non-MASLD etiology and compared for demographics, comorbidities, transplant evaluation timelines, listing rates, and outcomes. Results: MASLD patients (n = 1477) were older, had higher BMI, and had greater prevalence of metabolic comorbidities than non-MASLD patients (n = 5232; p < 0.001 for all). Compared to non-MASLD candidates, MASLD patients were more likely to be waitlisted (OR 1.52, 95% CI 1.33-1.74; p < 0.001). However, MASLD and non-MASLD patients had no statistically significant difference in the rate of transplant (p = 0.182), with clinically similar but statistically inferior post-transplant survival outcomes at 5 years post-transplant (88% vs. 83%; p = 0.014). Competing-risk analysis showed that MASLD candidates had higher cumulative incidence of death on the waitlist (p < 0.001), although MASLD was not independently associated with waitlist mortality when adjusting for covariates (p = 0.300). MASLD patients demonstrated increased mortality following waitlist removal (HR 1.64, 95% CI 1.14-2.35; p = 0.008), primarily among those removed for clinical deterioration (HR 1.50, 95% CI 1.01-2.23; p = 0.044). Conclusions: MASLD patients face unique challenges in liver transplant evaluation. MASLD patients are associated with higher comorbidities, increased incidence of waitlist mortality, and significantly higher mortality rate following waitlist removal. However, transplantation provides significant survival benefit with comparable outcomes to non-MASLD recipients; thus, early access to transplant may optimize outcomes for MASLD liver transplant candidates.