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Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 28, 2020; 26(28): 4018-4035
Published online Jul 28, 2020. doi: 10.3748/wjg.v26.i28.4018
Clinical considerations in the management of non-alcoholic steatohepatitis cirrhosis pre- and post-transplant: A multi-system challenge
Justin A Steggerda, Krishnaraj Mahendraraj, Tsuyoshi Todo, Mazen Noureddin
Justin A Steggerda, Krishnaraj Mahendraraj, Tsuyoshi Todo, Department of Surgery, Division of Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
Mazen Noureddin, Division of Digestive and Liver Diseases, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
Author contributions: Steggerda JA and Noureddin M developed the concept and designed the research; Steggerda JA, Mahendraraj K, and Noureddin M participated in data acquisition; Steggerda JA, Mahendraraj K, Todo T, and Noureddin M participated in the drafting and editing of the manuscript; Steggerda JA and Noureddin M developed the tables and figures to accompany the manuscript.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Mazen Noureddin, MD, Doctor, Division of Digestive and Liver Diseases, Comprehensive Transplant Center, Cedars-Sinai Medical Center, 8900 Beverly Blvd, Suite 270, Los Angeles, CA 90048, United States. mazen.noureddin@cshs.org
Received: April 6, 2020
Peer-review started: April 6, 2020
First decision: April 26, 2020
Revised: May 7, 2020
Accepted: July 15, 2020
Article in press: July 15, 2020
Published online: July 28, 2020
Processing time: 112 Days and 23.9 Hours
Abstract

Non-alcoholic steatohepatitis (NASH) is the most common chronic liver disease worldwide, and the fastest growing indication for liver transplantation in the United States. NASH is now the leading etiology for liver transplantation in women, the second leading indication for men, and the most common cause amongst recipients aged 65 years and older. Patients with end-stage liver disease related to NASH represent a unique and challenging patient population due the high incidence of associated comorbid diseases, including obesity, type 2 diabetes (T2D), and hypertension. These challenges manifest in the pre-liver transplantation period with increased waitlist times and waitlist mortality. Furthermore, these patients carry considerable risk of morbidity and mortality both before after liver transplantation, with high rates of T2D, cardiovascular disease, chronic kidney disease, poor nutrition, and disease recurrence. Successful transplantation for these patients requires identification and management of their comorbidities in the face of liver failure. Multidisciplinary evaluations include a thorough pre-transplant workup with a complete cardiac evaluation, control of diabetes, nutritional support, and even, potentially, consultation with a bariatric surgeon. This article provides a comprehensive review of the conditions and challenges facing patients with NASH cirrhosis undergoing liver transplantation and provides recommendations for evaluation and management to optimize them before liver transplantation to produce successful outcomes.

Keywords: Liver transplantation; Non-alcoholic fatty liver disease; Obesity; Metabolic syndrome

Core tip: Non-alcoholic steatohepatitis (NASH) is the most common chronic liver disease worldwide, and the fastest growing indication for liver transplantation (LT) in the United States. Patients with NASH represent a unique and challenging population due the high incidence of associated conditions (i.e. obesity, diabetes, and hypertension), which carry considerable risk of morbidity and mortality before and after LT due to cardiovascular disease and kidney disease. This article provides a comprehensive review of the conditions and challenges facing patients with NASH and provides recommendations for evaluation and management to optimize them before LT.