fig2

Figure 2. Integrated Pathway Approach to Liver Transplantation in MetALD. This four-stage clinical model spans the transplant trajectory. (1) Early detection and prevention with proactive dual screening for metabolic risk (FIB-4 > 1.30/2.67, LSM ≥ 8 kPa) and alcohol use (AUDIT-C ≥ 3 in women/≥ 4 in men, PEth ≥ 25 ng/mL)^[35]; (2) Double-hit mechanism of metabolic dysfunction and alcohol injury accelerates fibrosis and narrows the window for LT referral; (3) Pre-LT evaluation and waitlist optimization with cardiometabolic workup (CAC score/stress echo, BP target < 130/80 mmHg, HbA1c optimization, frailty assessment) and addiction/psychosocial workup (SIPAT ≥ 12, monthly PEth, AUD treatment)^[41]; (4) Post-LT targets address the three pillars: management of cardiovascular-kidney-metabolic syndrome (GLP-1RA/SGLT2i, early steroid withdrawal), graft monitoring (OGTT at 3 and 12 months, echocardiographic surveillance), and sustained abstinence (systematic PEth, AUD pharmacotherapy plus CBT)^[52]. Created in BioRender. Coronel, C. (2026) https://BioRender.com/z0exxi9. AUD: Alcohol use disorder; AUDIT-C: Alcohol Use Disorders Identification Test-Consumption; BP: blood pressure; CAC: coronary artery calcium; CBT: cognitive behavioral therapy; FIB-4: Fibrosis-4 index; GLP-1RA: glucagon-like peptide-1 receptor agonist; HbA1c: glycated hemoglobin; LSM: liver stiffness measurement; LT: liver transplantation; MetALD: metabolic dysfunction and alcohol-related liver disease; OGTT: oral glucose tolerance test; PEth: phosphatidylethanol; SIPAT: Stanford Integrated Psychosocial Assessment for Transplantation; SGLT2i: sodium-glucose cotransporter-2 inhibitor.