Non-invasive Risk Stratification for NAFLD Among Living Liver Donor Candidates: A Proposed Algorithm

To reduce waitlist mortality, living donor liver transplantation (LDLT) has increased over the past decade in US, however, not at a rate sufficient to completely mitigate organ shortage. As a result, there are ongoing efforts to expand the living liver donor pool. Simultaneously, the prevalence of Non-alcoholic Fatty Liver Disease (NAFLD) in the general population has increased, which has significant implications on the pool of potential living liver donors. As such, a clinical assessment algorithm that exhaustively evaluates for NAFLD and fibrosis is critical to the safe expansion of LDLT. An ideal algorithm would employ safe and non-invasive methods, relying on liver biopsy only when necessary. While exclusion of NAFLD and fibrosis by non-invasive means is widely studied within the general population, there are no well-accepted guidelines for evaluation of living donors using these modalities. Here we review the current literature regarding non-invasive NALFD and fibrosis evaluation and propose a potential algorithm to apply these modalities for the selection of living liver donors.