Are we standing on the shifting sands of post-transplant metabolic-associated steatotic liver disease?

Table 2 Management of post-liver transplantation metabolic dysfunction-associated steatotic liver disease

Topics	Management
Lifestyle modifications	Dietary modifications; regular physical activity
Aggressive control of CMRFs
Weight control	Highly recommended due to the undisputable overall benefits; orlistat (adequate safety profile but limited benefits); bariatric surgery/gastric sleeve (promising approach but ideal timing and patient selection remain uncertain)
Glycemic control	General management similar to general population; early postoperative period preference for insulin therapy; transition to oral antidiabetics when steroid dosage is reduced or stopped, and insulin needs decrease; choice of oral therapy follows current guidelines
Arterial hypertension	General management follows guidelines for general population; preferred first-line therapy is calcium channel blockers
Dyslipidemia	General management follows guidelines for general population; LTx recipients considered high or very high risk for therapeutic cholesterol targets; preferred drugs are hydrophilic statins (e.g., pravastatin, rosuvastatin)
Immunosuppression	No specific guidance for immunosuppressant choice in post-LTx MASLD or MASH; immunosuppressive regimen must be tailored individually
Specific therapies for MASLD and MASH	Resmetirom, pioglitazone, and GLP-1 RAs show promise in the general population, but there is insufficient evidence to support their use in LTx recipients at this time

CMRF: Cardiovascular metabolic risk factor; GLP-1 RAs: Glucagon-like peptide-1 receptor agonists; LTx: Liver transplantation; MASH: Metabolic dysfunction-associated steatohepatitis; MASLD: Metabolic dysfunction-associated steatotic liver disease.