Steatotic liver disease and liver transplantation: Candidate selection and post-transplant management

Steatotic liver disease (SLD), which encompasses alcohol-related liver disease (ALD), metabolic dysfunction-associated steatotic liver disease (MASLD), and MASLD with increased alcohol intake (MetALD), is now the leading cause of liver transplantation (LT) worldwide. ALD and MASLD have become the first and second leading indications for LT (41% and 12% in Europe, respectively), with MetALD accounting for a rapidly increasing proportion of transplants (8-10%). Candidate evaluation must be multidisciplinary and account for the complex interplay between alcohol use, metabolic syndrome, cancer, cardiovascular disease, and obesity. Early LT for severe alcohol-related hepatitis is an established option in selected patients after the evaluation of alcohol use disorder (AUD) by addiction specialists. While the duration of abstinence remains a predictor of post-LT alcohol relapse in ALD recipients, an integrative assessment is required, and prolonged abstinence is no longer an absolute prerequisite. Cardiovascular risk stratification and assessment of frailty and metabolic comorbidities are essential. Obesity management includes lifestyle interventions, pharmacotherapy, and bariatric surgery in selected cases. SLD recipients generally demonstrate good 5-year survival (>75%), but long-term outcomes are influenced by cardiovascular events, malignancies, and alcohol relapse, with survival falling below 65% at 10 years. Early detection and management of alcohol relapse after LT are critical to optimising long-term outcomes. MASLD recurrence is common, but its impact on graft survival appears modest. Management focuses on controlling cardiometabolic risk factors, with emerging roles for GLP-1 receptor agonists and multidisciplinary care. Donor SLD is a growing concern. Normothermic and hypothermic oxygenated perfusion substantially expand donor utilisation - with up to ∼70% of marginal or previously discarded grafts now salvaged - and improve graft viability by reducing early allograft dysfunction by 60%. Further research is needed to refine risk stratification, develop effective pharmacotherapies, and optimise perfusion protocols for steatotic grafts.