An update of liver transplantation for nonalcoholic steatohepatitis

Nonalcoholic steatohepatitis (NASH), obesity, and the metabolic syndrome are highly prevalent before and after liver transplantation, with NASH currently the second most common indication. This review considers established and new aspects of liver transplantation for NASH. NASH is one of many sequelae of obesity and most frequently occurs on a background of the metabolic syndrome. While recurrence of steatosis is common, recurrence of NASH with advanced stages of fibrosis is unusual, with graft loss due to recurrence of NASH cirrhosis occurring with a frequency of less than 5 %. In contrast, the components of the metabolic syndrome, which are important predictors of posttransplant outcomes, are nearly ubiquitous following liver transplantation and are exacerbated by factors such as immunosuppression. As many aspects of the metabolic syndrome are modifiable, screening for and treating complications of obesity and minimization of immunosuppression are cornerstones of optimizing outcomes for transplant recipients with NASH. The optimal approach to immunosuppression, the role of bariatric surgery, and nutritional and pharmacotherapy of NASH in liver transplant recipients are evolving rapidly. Overall, a minimalist approach to immunosuppression is advised.