Impact of Non-Malignant Portal Vein Thrombosis in Recipients with Metabolic Dysfunction-Associated Steatotic Liver Disease Compared to Other Transplant Indications

<b>Background/Objectives</b>: Metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with an increased risk of portal vein thrombosis (PVT), which may negatively affect post-liver transplant (LT) outcomes. We aimed to evaluate the impact of PVT on post-LT outcomes in MASLD versus non-MASLD recipients and assess outcomes in MASLD patients with PVT who received donation after circulatory death (DCD) grafts. <b>Methods</b>: Using the UNOS database, we analyzed adult LT recipients from 2002 to 2022. Kaplan-Meier and Cox regression models were used to assess one-year post-LT outcomes. <b>Results</b>: Among 46,933 LT recipients, 20% had MASLD (15% PVT prevalence) and 80% had non-MASLD etiologies (9% PVT prevalence). Overall, 3051 recipients (6.5%) received DCD grafts. PVT at the time of transplant was associated with significantly higher risks of all-cause mortality, graft failure, and death-censored graft failure (DCGF) in both MASLD and non-MASLD groups (<i>p</i> < 0.05), although no significant differences were observed between the two groups. In the DCD subgroup, MASLD recipients with PVT had a significantly higher risk of all-cause mortality compared to non-MASLD recipients without PVT (adjusted hazard ratio [aHR] 2.24, 95% CI 1.17-4.28, <i>p</i> = 0.01), but no differences were observed for graft failure or DCGF. <b>Conclusions</b>: PVT at the time of transplant is associated with poorer survival in MASLD and non-MASLD recipients. No difference was found between the two groups. In candidates receiving DCD grafts, the presence of PVT at time of transplant was associated with a marked increase in mortality risk, although this finding requires further validation in larger cohorts.