NAFLD: A pretransplant and post-transplant conundrum

The management of NAFLD may be uniquely challenging as conventional strategies, such as calorie restriction and rapid weight loss, may not be feasible in advanced disease states. The optimization of metabolic dysfunction requires a multidisciplinary approach with the use of pharmacotherapy that favors glycemic and cardiometabolic risk benefits. Surgical and medically achieved weight loss in LT candidates also raises concern for precipitating liver decompensation. However, gastric sleeve may be an option for highly selected patients with compensated disease in centers with expertise in BS (Figure 2). Management of post-LT NAFLD is equally complex. There is a paucity of society guidance on how to prevent de novo and recurrent NAFLD and manage comorbidities in these patients. After LT, the maintenance of weight loss and reduction of comorbidities may be achieved with the same antidiabetic agents as in the pre-LT setting. Alterations in immunosuppressive regimens, such as minimization of CNIs, may also reduce weight gain and post-LT diabetes.