Post-Transplant liver assessment: Practical applications of non-invasive testing

Liver transplantation (LT) has transformed the prognosis of patients with end-stage liver disease and hepatocellular carcinoma, offering excellent long-term survival. However, post-transplant outcomes can be jeopardized by allograft rejection and by recurrent or de novo liver disease, which may progress to graft fibrosis, cirrhosis, and liver-related complications. Non-invasive tests (NITs) have emerged as powerful tools for evaluating steatosis, fibrosis, and portal hypertension in native liver disease, but their optimal role after LT remains uncertain and variably defined. In this review, we summarize the current evidence regarding the performance of NITs for the assessment of graft fibrosis, steatosis, and portal hypertension in the post-transplant setting, contextualizing well-established principles regarding NITs derived from native liver disease within the post-LT setting, where NITs may have additional and still underexplored potential. We aim to provide a practical, clinically oriented use of NITs into routine post-LT care, for enabling earlier detection of complications and more personalized graft monitoring.