Metabolic dysfunction-associated steatotic liver disease (MASLD) -- formerly called non-alcohol related fatty liver disease (NASLD) -- is a condition in which fat builds up in your liver. Metabolic dysfunction-associated steatohepatitis (MASH) is the late stage of MASLD when extra fat creates inflammation. This inflammation causes scarring (cirrhosis) that permanently damages your liver and can lead to liver failure.
Once your liver stops working, a liver transplant may be the only treatment option. This surgery replaces your damaged liver with part or all of a liver from a donor. About 100 million Americans, or 25% of the population, have MASLD. MASH affects between 2%-5% of Americans overall, but up to 20% of people with obesity.
MASH is the second leading cause of liver transplants in the United States, after alcohol-associated liver disease (ALD). Almost 1 in 3 people who needs a liver transplant has MASH.
Who Would Need a Liver Transplant for Fatty Liver?
You'll need a liver transplant if treatments for fatty liver don't help enough and your liver stops working. The term for liver failure is end-stage liver disease. Cirrhosis, or scar tissue in the liver, is a common cause of end-stage liver disease in people with fatty liver. Hepatitis is another possible cause.
Eligibility Criteria for Liver Transplant With MASLD/MASH
To qualify for a liver transplant, you'll need to meet certain criteria. First, you must be in liver failure, which means your liver is too damaged to work. Liver failure can't be reversed with other treatments.
Your liver specialist and transplant surgeon will evaluate you to see if you're a good choice for a transplant. They'll make sure that you're healthy enough to survive the surgery and that the new liver will improve your quality of life.
You may not qualify for a liver transplant if you have:
- Cancer in or around your liver
- Severe heart or lung disease
- An active infection like sepsis or HIV
- Alcohol or substance use disorder
- A history of not taking your medicine or following your doctor's advice
- No social support
- A BMI of 40 or higher
- A severe mental health disorder that isn't well managed
Once you are on a waiting list for a donor liver, your doctor will assign you a priority score called a Model for End-Stage Liver Disease (MELD) score. The MELD score is based on liver function test results. The more damaged your liver is and the less it works, the higher your MELD score and the faster you'll need a new liver.
Types of Liver Transplant for Fatty Liver
A donor liver can come from one of three options:
Deceased donor transplant. Also known as a conventional liver transplant, this surgery uses a liver from a donor who has just died. Most livers transplanted in the United States come from deceased donors. This type of transplant may be an option if you don't have a living donor. The downside is that you may have to wait years on an organ donation list for a liver to become available.
Split liver transplant. Most adults get a whole liver from a deceased donor. But your surgeon may split one liver into two parts and give part to you and part to someone else. Splitting a liver makes more organs available to people who are on the waiting list. The liver is the only organ in the body that can regrow. The piece of liver you receive will grow to a normal size in a few weeks.
Living donor transplant. A living donor is usually someone close to you, like a family member or close friend. Surgeons remove part of their liver and use it to replace your damaged liver. Both the piece of liver you receive and the part of your donor's liver that remains will regrow to normal size.
Expanded (extended) criteria organs
Transplant centers have certain rules about which livers they can use. For example, they may require that the donor is younger than 55 and doesn't have liver disease. But because of the organ shortage, sometimes doctors use organs that don't meet these criteria. This is called expanded or extended criteria organs.
Expanded criteria organs may include donors who:
- Are over age 60
- Have medical conditions
- Have been exposed to hepatitis B or C
- Practiced high-risk behaviors like intravenous drug use or sex work
These organs aren't preferred, but your doctor may recommend it if no other options are available and your particular situation makes it an acceptable choice.
What to Expect When You Get a Liver Transplant for Fatty Liver
If you have a living donor, your surgery will be scheduled ahead of time. With a deceased donor transplant, the hospital will notify you when a liver becomes available and you'll have to go there right away. A liver can only keep working for 12 hours outside the body.
Before the transplant
Your medical team will make sure you're healthy enough for surgery. You may need:
- Blood and urine tests
- An exam to check your overall health and test you for diseases like cancer
- A liver ultrasound or other imaging tests
- Tests like an electrocardiogram (EKG) to check your heart health
Your surgeon will ask you not to eat or drink anything before your surgery.
At the hospital, your medical team will place an intravenous (IV) line in your arm or hand. You'll get fluids and medicine through this tube. Another tube placed in your neck or thigh will check your heart and blood pressure and take blood samples during the surgery.
During the transplant
You'll get medicine to make you sleep and keep you pain-free during the surgery. A machine called a ventilator will push air into your lungs through a tube to help you breathe during the procedure. A tube in your nose will drain fluid from your stomach, and a tube in your bladder will drain urine.
The surgeon will first clean the skin over your liver with a sterile solution. Then they'll make a cut across your belly. A liver transplant is done through one of two methods:
Orthoptic approach. This is the most common type of liver transplant surgery. The surgeon separates your damaged liver from its blood vessels and the tissues that hold it in place, and removes it. Then they connect the donor liver to your blood vessels and bile duct, the tube that carries bile from your liver to your intestines.
Heterotopic approach. In this procedure, the surgeon leaves your liver in place and implants the new liver near it. The heterotropic approach may be an option if your own liver still works a little bit.
Once the new liver is in place, the surgeon will close the incision with stitches or staples. Then they'll place a sterile bandage or dressing on top. Liver transplant surgery can take up to 12 hours.
After the transplant
You'll stay in the intensive care unit (ICU) for a few days. Doctors and nurses will check your breathing, blood pressure, oxygen level, and liver function. Then you'll move to a regular hospital room and stay there for one to two weeks. You'll get nutrition through an IV until your liver works well enough for you to process solid food. The doctors and nurses will make sure your body doesn't reject the new organ.
Once you've recovered and can eat solid foods, you can go home. You'll have to take immune-suppressing medicines for the rest of your life to prevent your body from rejecting your new liver. You'll also take other medicines to prevent complications after surgery. During regular follow-up visits your treatment team will make sure you're healthy and that your new liver is working.
Post-transplant management
You'll see your transplant team often to make sure you're healing well and your new organ is working. You'll need someone to care for you 24 hours a day and drive you to appointments for at least six weeks after you leave the hospital.
To keep you and your new liver healthy, follow these tips:
- Take your medicine just like your doctor prescribed it.
- Eat a well-balanced diet that's low in salt and sugar.
- Get regular exercise.
- Avoid alcohol and tobacco.
Postsurgical Complications in People With Fatty Liver Disease
Any surgery can have complications. These are some of the most common problems that occur after a liver transplant and how your doctor will manage them:
Bleeding. If you bleed too much during the procedure, your surgeon can stop the bleeding with medicine or extra stitches. For bleeding after surgery, you may need another procedure or a blood transfusion to replace the blood you've lost.
Infection. The medicines you take to prevent organ rejection weaken your immune system and put you at greater risk for infections. To avoid illness, wash your hands often, stay away from people who are sick, and don't eat raw or undercooked foods. If you do get an infection, your doctor may treat it with antibiotics.
Rejection. Your immune system could see your new liver as foreign and attack it. Up to 30 out of 100 people who have transplant surgery reject their new liver in the first year afterward. Taking anti-rejection drugs after surgery reduces your risk of rejection. If you do reject the new liver, your doctor can treat you with high-dose steroids.
The new liver doesn't work. Up to 6% of donated livers don't work right. If that happens, you may need another transplant.
Other possible risks from liver transplant or the anti-rejection medicines you'll take afterward are:
- A blood clot in the liver or in the artery that carries blood to the liver
- A leak in the connection between your bile duct and new liver
- An increased risk for cancers like lymphoma
- High blood sugar, high blood pressure, or kidney failure
Graft steatosis
Steatosis is fat buildup in the liver. If it happens after transplant surgery, it can cause complications or make the new liver stop working. Having obesity or a weakened immune system increases your risk for graft steatosis.
The risk also increases if your donor's liver has steatosis. Because there's a shortage of donor organs, some transplant surgeons use livers with steatosis. New techniques to remove fat may improve the outcome and prevent problems if your new liver does have steatosis.
Metabolic syndrome after transplant
More than half of people who have a liver transplant develop metabolic syndrome afterward. Taking anti-rejection drugs and gaining a lot of weight after transplant surgery can cause metabolic syndrome. This group of conditions includes obesity, high cholesterol, high triglycerides, high blood pressure, and type 2 diabetes.
Having metabolic syndrome increases your risk for surgical complications and for heart and kidney problems after the transplant. Your surgeon should screen you for risks like obesity and diabetes before your transplant procedure. Following a healthy diet and exercise program before and after surgery may lower your risk for metabolic syndrome.
Post-Transplant MASLD
Getting a liver transplant doesn't always mean you're done with MASLD. This condition can affect the transplanted liver, too. Fatty liver disease after transplant surgery happens in one of two ways:
Recurrent MASLD
Recurrent means you had MASLD before the procedure and it came back after surgery. Up to half of people develop recurrent MASLD following their transplant.
De novo MASLD
De novo means you have fatty liver disease for the first time after transplant surgery. Up to 20% of people who have a liver transplant develop de novo MASLD within a year after their surgery. De novo MASLD tends to start later and is less severe than recurrent MASLD.
Metabolic syndrome increases the risk for both de novo and recurrent fatty liver disease after a liver transplant. Having MASLD could cause problems with your new liver.
Life Expectancy After a Liver Transplant
The outlook is good after a liver transplant. About 75 out of every 100 people who have this surgery live for at least five years afterward. Almost 65% are still alive after 10 years. Your outcome will depend on factors like your age and health. Taking your medicines, eating a nutritious diet, managing other health conditions, and seeing your doctor for regular checkups can improve your life expectancy after a transplant.
Takeaways
MASH and MASLD can cause permanent scarring in your liver. If your liver stops working, you will need a liver transplant. The liver can come from a donor who has died or from a living donor. Transplant surgery comes with risks like infection, bleeding, and organ rejection. Taking your medicine and following your doctor's advice will give you the best outcome after a liver transplant.
Liver Transplantation for MASLD and MASH FAQs
Who cannot get a liver transplant?
You may not be able to get a liver transplant if you have cancer in your liver, severe heart or lung disease, alcohol use disorder, or an active infection. Having a BMI of 40 or higher and not being able to follow your doctor's recommendations are other things that could prevent you from having this surgery.
Can fatty liver be cured with a liver transplant?
A liver transplant replaces your damaged liver with a healthy one from a donor. Sometimes fatty liver comes back after a transplant.
When do doctors recommend liver transplant for cirrhosis?
Your doctor might recommend a liver transplant if other treatments haven't helped MASLD/MASH and your liver has stopped working.
