Background and aims
Recently, the term metabolic dysfunction-associated fatty liver disease (MAFLD) was proposed to replace non-alcoholic fatty liver disease (NAFLD), enabling the diagnosis of MAFLD in the co-existence of alcohol-related liver disease (ALD). ALD is the most frequent indication for liver transplantation (LTx). We assessed the prevalence of MAFLD in ALD patients undergoing LTx and its prognostic value on post-LTx outcome compared to traditional individual risk factors.

Methods
We retrospectively analyzed all ALD patients transplanted between 1990 and August 2020 at the University Hospitals Leuven. MAFLD was diagnosed based on the presence or history of steatosis and a BMI >25, type II diabetes, or two or more metabolic risk abnormalities at LTx. Overall survival and risk factors of recurrent liver and cardiovascular disease were analyzed by Cox regression.

Results
371 ALD patients were included in the analysis, of which 255 (68.73%) had concomitant MAFLD at LTx. Mean follow-up after LTx was 86.24 months (Std. 3.433) for the total group. Patients with ALD-MAFLD were significantly older (61.00 years (56.00-76.00) vs. 58.00 years (52.50-64.00), P = 0.001), more often male (86.3% vs. 66.4%, P < .001) and more frequently had hepatocellular carcinoma (44.31% vs. 25.00%), P < .001) at LTx compared to ALD-non-MAFLD patients. No differences in perioperative mortality and overall post-LTx survival were found. The presence of MAFLD at LTx was an independent risk factor for recurrent hepatic steatosis (HR: 1.573 (1.084-2.282); p = .017), irrespective of alcohol relapse. MAFLD, in contrast to traditional individual risk factors, was no independent risk factor for cardiovascular events, heart failure, or de novo atrial fibrillation after LTx.

Conclusions
The presence of MAFLD in ALD patients at LTx is associated with a distinct patient profile and is an independent risk factor for recurrent hepatic steatosis but not for cardiovascular morbidity and overall mortality.