Steatotic liver disease is the dominant indication for liver transplantation in both Europe and the United States: Trends and outcomes in the past 2 decades.

Regional differences in liver transplantation (LT) may exist. We described liver transplant populations in the US and European transplant centers over 2 decades. Data from 2 large LT registries: the US Scientific Registry of Transplant Recipients (SRTR) and the European Liver Transplant Registry (ELTR), years 2000-2022, were compared. There were 109,048 recipients of transplant from ELTR (30 countries), 128,765 from SRTR, and a higher proportion of HCC in ELTR (29% vs. 20%). Chronic hepatitis B (9% vs. 3%) and alcohol-associated liver disease (ALD) (30% vs. 23%) occurred more frequently among European recipients of transplant; chronic hepatitis C (18% vs. 27%) and NASH/metabolic dysfunction-associated steatohepatitis (MASH) (7% vs. 19%) for the United States (all p <0.0001). The HCC proportion for both increased (SRTR peak 30% in 2015, SLTR 35% in 2016), then decreased. The most prominent trends for both were increases in ALD and decreases in chronic hepatitis C (trend p <0.0001). NASH/MASH also increased: SRTR 9%-28%, ELTR 5%-12%. From SRTR, NASH/MASH was the common etiology by 2022; ALD was the most common and fastest-growing in ELTR. In patients without HCC, the 3 most common etiologies were identical: ALD, NASH/MASH, and primary sclerosing cholangitis. Predictors of higher post-transplant mortality included earlier calendar year, older recipient's age, male, higher MELD, grade III/IV encephalopathy, having chronic hepatitis C-HCC, older donor's age, small transplant center (all adjusted HR>1.0, p <0.01), similar between ELTR and SRTR, in patients without and with HCC. ALD and NASH/MASH are now leading indications for liver transplantation in 2 large global regions.