This chapter sets out to discuss metabolic liver diseases and their pre-transplant management by primary care providers, internal medicine physicians, and gastroenterologists. Assessment of metabolic liver disease starts with laboratory testing. When elevated liver chemistries are observed, further evaluation includes viral serology, serum ferritin, transferrin saturation, ceruloplasmin, antimitochondrial antibodies, antinuclear antibodies, anti-smooth muscle antibodies, immunoglobulin G level, alpha-1 antitrypsin genotype, and alcohol use history. Next, initial primary risk assessment with a Fibrosis-4 (FIB-4) Index for Liver Fibrosis can categorize individuals into low risk (< 1.3), intermediate risk (1.3–2.67), and high risk (> 2.67) of advanced hepatic fibrosis (i.e., hepatic fibrosis stage ≥3). Patients who are determined to have an intermediate or high risk of advanced liver disease (FIB-4 > 1.3) should undergo secondary risk assessment with non-invasive testing. Management of the cause of chronic liver disease is critical to prevent progression and increase the probability of regression of fibrosis (as long as advanced cirrhosis has not ensued). Finally, liver transplantation is curative, and evaluation for transplant candidacy should be considered, irrespective of liver disease etiology, when patients have decompensated cirrhosis, liver disease with MELD score >15, or early hepatocellular carcinoma.