MASLD Liver Transplant: Evolution of Frequency, Age Trends, and Factors Associated With Outcomes

BACKGROUND: Metabolic dysfunction-associated steatotic liver disease (MASLD) has rapidly emerged as a leading indication for liver transplantation (LT) in the United States. There remains a need to understand the evolution of transplant volumes and recipient profiles and outcomes. In this study, we aim to analyze current MASLD LT trends to aid in identifying opportunities for this patient population. METHODS: We analyzed UNOS data for primary liver transplants (2010-2024), identifying MASLD by diagnosis codes and stratifying transplants into three eras (2010-2014, 2015-2019, and 2020-2024). Analyses included annual MASLD transplant counts and proportions, era-specific annual percent change, comparisons of donor, operative, and recipient characteristics, Kaplan-Meier curves, multivariable Cox regression for overall post-LT mortality, and competing-risk regression for waitlist outcomes. RESULTS: In total, 18 153 MASLD LT recipients were included (Era 1: 2734; Era 2: 6127; Era 3: 9292). Annual MASLD LT volume increased from 461 in 2010 to 2090 in 2024. Annual percent change was +10.6% (Era 1), +20.1% (Era 2), and +5.9% (Era 3). In Era 3, recipients were as young as 8 y. Era 3 waitlist candidates had significantly higher likelihood of transplant (sHR 1.52; 95% CI, 1.46-1.58) and lower risk of waitlist mortality (sHR 0.44; 95% CI, 0.40-0.48). Recipient survival increased from 97.0% to 98.3% at 30 d, and 90.5% to 92.6% at 1 y (both P < 0.01). CONCLUSIONS: From 2010 to 2024, MASLD LT rose markedly but relative growth plateaued. Increasing age diversity, including pediatric recipients, highlights the need for earlier recognition and optimized management.