Evaluation and Selection of Liver Transplant Candidates
What the evaluation is really asking
Transplant evaluation answers three questions: is the liver disease severe enough that transplantation offers a survival benefit, is there a contraindication that cannot be modified, and can the patient survive surgery and adhere to lifelong care?
Indications and timing. Listing in the United States uses MELD 3.0 - bilirubin, INR, creatinine, sodium, albumin, and sex - with a common threshold around 15. Decompensations (refractory ascites, variceal bleeding, hepatic encephalopathy, SBP) and HCC within criteria (Milan: one lesion ≤5 cm, or up to three each ≤3 cm, without vascular invasion or extrahepatic spread) generate exception points. Acute liver failure is listed separately as Status 1 regardless of MELD.
Contraindications. Absolute: uncontrolled sepsis, malignancy outside accepted protocols (HCC or hilar cholangiocarcinoma only within protocol), severe irreversible cardiopulmonary disease, and inability to adhere. Relative: age alone, HIV with controlled disease, BMI >40, frailty, and active psychiatric illness are not automatic exclusions. Six months of abstinence is a program policy, not an evidence-based rule.
Pretransplant management. Treat sarcopenia with nutrition and physical therapy, screen and band varices, surveil for HCC every 6 months, and evaluate for portopulmonary hypertension (right heart catheterization if echo suggests it) and cirrhotic cardiomyopathy. Vaccinate, treat dental disease, and assess psychosocial support.
Rule of thumb: a low MELD does not mean low risk - a patient with MELD 12 and refractory ascites has high waitlist mortality and may need an exception or living-donor evaluation.
Trap: questions often offer age >70 or HIV as absolute contraindications; both are wrong.