Potential missed opportunities to improve long-term liver allograft health

Long-term patient and allograft health after liver transplantation remains suboptimal because of alloimmune complications, malignancy, and consequences of the metabolic syndrome, often exacerbated by the current standard of care immunosuppression. There is emerging evidence that FDA-approved pharmacologic interventions and medications currently in clinical trials for other disease processes-including hydroxymethylglutaryl-coenzyme A reductase inhibitors, aspirin, obesity and metabolic dysfunction-associated steatohepatitis treatments, and microbiome interventions reduce complications of chronic liver injury in general and may offer promising off-label benefits to potentially enhance allograft and patient health post-liver transplant. These agents work through diverse mechanisms such as reducing inflammation, improving metabolic disorders, promoting immune tolerance, and preventing or even reversing fibrosis. By addressing both metabolic and immune pathways, these interventions represent a multifaceted approach to potentially optimize long-term liver allograft outcomes. Therefore, further research is warranted to determine their efficacy and safety in the liver transplant population.