Clinical considerations in the management of non-alcoholic steatohepatitis cirrhosis pre- and post-transplant: A multi-system challenge

Table 1 Metabolic syndrome criteria

Metabolic syndrome criteria
Characteristic	Description
Waist circumference	≥ 88 cm in females
	≥ 102 cm in males
Triglycerides	≥ 150 mg/dL
	On drug treatment for elevated triglycerides
HDL	≤ 40 mg/dL for men
	≤ 50 mg/dL for women
	On drug treatment for low HDL
Hypertension	Systolic blood pressure ≥ 130 mmHg
	Diastolic blood pressure ≥ 85 mmHg
	On anti-hypertensive drug treatment for history of hypertension
Diabetes	Elevated fasting glucose ≥ 100 mg/dL
	On drug treatment for elevated glucose

Patients must exhibit 3 of the 5 components to have the diagnosis with metabolic syndrome. Based on consensus statement from International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity[182]. HDL: High-density lipoprotein.

Table 2 Recommendations for pre-transplant evaluation in patients with non-alcoholic steatohepatitis cirrhosis

Evaluation and therapy for liver transplant candidates with non-alcoholic steatohepatitis
Hypertension	Target blood pressure 130/80
	Initiate anti-hypertensive medical therapy
Diabetes	Blood glucose control
	Monitor insulin resistance
	Hemoglobin A1c optimization
Hyperlipidemia	Initiate statin therapy as appropriate
Renal dysfunction	Renal ultrasound
	Measure GFR by quantitative method
	Consider simultaneous liver/kidney transplantation
Cardiovascular disease	Identify cardiovascular risk factors—hypertension, diabetes, hyperlipidemia
	Comprehensive cardiac evaluation to include EKG, DSE
	Strong consideration for coronary angiography, in addition to OR in place of DSE
	Carotid artery duplex
Obesity	Consultation with nutritionist or dietician and exercise therapist
	Consider consultation with bariatric surgeon
	Consider pre-transplant or simultaneous LT + bariatric surgery if fail weight loss strategies with concurrent comorbid conditions

GFR: Glomerular filtration rate; EKG: Electrocardiography; DSE: Dobutamine stress echocardiogram; LT: Liver transplantation.