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International Liver Transplantation Consensus Statement on End-stage Liver Disease Due to Nonalcoholic Steatohepatitis and Liver Transplantation

Tsochatzis, Emmanuel, MD, PhD1; Coilly, Audrey, MD2,3; Nadalin, Silvio, MD, FEBS4; Levistky, Josh, MD, MS5; Tokat, Yaman, MD6; Ghobrial, Mark, MD, PhD7; Klinck, John, MD, FRCA, FRCPC8; Berenguer, Marina, MD9,10

doi: 10.1097/TP.0000000000002433

Nonalcoholic steatohepatitis (NASH)-related cirrhosis has become one of the most common indications for liver transplantation (LT), particularly in candidates older than 65 years. Typically, NASH candidates have concurrent obesity, metabolic, and cardiovascular risks, which directly impact patient evaluation and selection, waitlist morbidity and mortality, and eventually posttransplant outcomes. The purpose of these guidelines is to highlight specific features commonly observed in NASH candidates and strategies to optimize pretransplant evaluation and waitlist survival. More specifically, the working group addressed the following clinically relevant questions providing recommendations based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system supported by rigorous systematic reviews and consensus: (1) Is the outcome after LT similar to that of other etiologies of liver disease? (2) Is the natural history of NASH-related cirrhosis different from other etiologies of end-stage liver disease? (3) How should cardiovascular risk be assessed in the candidate for LT? Should the assessment differ from that done in other etiologies? (4) How should comorbidities (hypertension, diabetes, dyslipidemia, obesity, renal dysfunction, etc.) be treated in the candidate for LT? Should treatment and monitoring of these comorbidities differ from that applied in other etiologies? (5) What are the therapeutic strategies recommended to improve the cardiovascular and nutritional status of a NASH patient in the waiting list for LT? (6) Is there any circumstance where obesity should contraindicate LT? (7) What is the optimal time for bariatric surgery: before, during, or after LT? (8) How relevant is donor steatosis for LT in NASH patients?

1 UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom.

2 Department of Hepatology and Hepatinov, Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, Villejuif, France.

3 Université Paris-Sud, Université Paris-Saclay, INSERM, Unité 1193; Villejuif, France.

4 Transplant and HBP Surgery Program, University Hospital Tuebingen, Tuebingen, Germany.

5 Northwestern University Feinberg School of Medicine Chicago, Chicago, IL.

6 Department of Liver Transplantation, Florence Nightingale Hospital, Sisli, Istanbul, Turkey.

7 Sherrie and Alan Conover Center for Liver Disease and Transplantation, Weill Cornell Medical College, Houston, TX.

8 Anaesthesia, Division of Perioperative Care, Cambridge University Hospitals, Cambridge, United Kingdom.

9 Liver Transplantation and Hepatology Unit, Ciberehd, IISLaFe, La Fe University Hospital, Valencia, Spain.

10 Department of Medicine, University of Valencia, Valencia, Spain.

Received 8 May 2018. Revision received 26 July 2018.

Accepted 22 August 2018.

All authors drafted sections of the article and revised the final article for important intellectual content. In addition, M.B. and E.T. also drafted some of the sections, combined all the sections in a single article, and revised the final before submission.

E.T., S.N., Y.T., M.G., and J.K. declare no conflicts of interest. Y.L. is the speaker for Gilead and grants and Speaker for Novartis. M.B. is the speaker for Novartis, Astellas, Gilead, and received a grant from Gilead.

Ciberehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas) is partially funded by the Instituto de Salud Carlos III.

Correspondence: Marina Berenguer, MD, La Fe University Hospital, Avenida Fernando Abril Martorell, 106 (Torre F5), 46026 Valencia, Spain. (

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