All right, so I have a few other things to add. Number one, why not? We've done liver biopsy protocol, liver biopsy on a patient with hepatitis C for a long time, and now that we have effective treatment, hepatitis C is probably not a big deal. I mean, why not do the same for patients with NAFLD and study this disease? Because like Dr. Watt indicated, there are a lot of questions unanswered. And if you don't like to do liver biopsy, you could use non-invasive tools to assess fibrosis and, you know, and I use this cautiously because I understand those tests have a lot of limitations. NAFLD fibrosis score, ALF blood test, the transient elastography or the shear wave elastography and the MR elastography. Of course, those tests have been studied extensively pre-transplant and has not been well validated post-transplant. And not to mention, like I said, they have their own limitations. In a meta-analysis of a lot of studies that have been done post-transplant, it seems like transient elastography, believe it or not, works fairly well. I was kind of pleasantly surprised to see that. Works way better than the APRI score or the FIP4 with odds ratio of 21. This is what I use in my patients with NAFLD outside transplant. And I feel like, you know, we could probably use the same post-transplant, particularly if we are talking about people with normal LFTs, like indicated by other speakers. If you have abnormal LFTs after transplant, probably going for a liver biopsy. But if you have normal LFT after transplant and evidence of steatosis on the allograft, which can happen with normal LFT, what I would do, I would do the NAFLD fibrosis score and a fibroscan. And if I get two negative results, you know, those tests have high negative predictive value. And if both of them are negative, probably I'm okay to keep monitoring. If I get two positive values, maybe I need to do liver biopsy. And the same if I get values in between, maybe I need to do something more sophisticated such as MR elastography or liver biopsy. This is something I do pre-transplant. Whether it's true post-transplant, I think yet to be studied. There is no pharmacological treatment license for fatty liver. And someone may argue, it's like, okay, well, those guys need to lose weight and get their diabetes under control no matter what. Whether they have steatosis or they don't, because there is nothing else to add. Well, that's true. But as you know, treatment for NAFLD is on the horizon. There are a lot of advanced agents, if you will. This is something, opticoric acid, as you know, has been studied pre-transplant and it's not approved yet. This is off-label and has been somewhat promising in resolution of NASH with no worsening fibrosis achieved primary outcome. I think in a few years, maybe we will be debating here whether to use pharmacological treatment for fatty liver after transplant or not. And lastly, I think this mentioned already earlier in this course, pyroglytosone improves fibrosis in patient with NASH and has been studied post-transplant and apparently it's safe thing to use. So I would say if you do have somebody with diabetes post-transplant, it's not a bad idea to use pyroglytosone. This meta-analysis has been shown to be promising to improve fibrosis. So with that, I'll stop and I'll turn it to Dr. Wang. Thank you.

liver health

NAFLD

transplant

fibrosis assessment

non-invasive tools