Liver Transplantation Candidate Evaluation and Waitlist Management
When to refer and list
Transplant evaluation begins when chronic liver disease complications or progressive synthetic failure predict poor 1-year survival without transplant. Indications include intractable cholestasis or pruritus, growth failure, recurrent variceal bleeding, refractory ascites or SBP, encephalopathy, hepatopulmonary syndrome, HCC within criteria, and selected metabolic disease. Contraindications are uncontrolled infection, extrahepatic malignancy, irreversible severe neurologic impairment, active nonadherence without support, and inadequate psychosocial resources. Evaluate cardiac, pulmonary, renal, nutritional, dental, and infectious status.
Allocation
Pediatric chronic candidates use PELD, incorporating bilirubin, INR, albumin, growth failure, and age under 1 year; exceptions capture complications such as variceal bleeding, hepatopulmonary syndrome, or metabolic disease. Acute liver failure may qualify for status 1A or 1B. Scores are population-based; they do not replace clinical judgment. Waitlist management includes frequent lab updates, growth measurement, nutrition support, variceal surveillance, and timely exception petitions.
Traps
A low PELD can still hide urgent complications. Do not list a child with active uncontrolled infection. Obesity and malnutrition both affect outcomes. Nonadherence is dynamic; assess support, not a single missed visit.
Worked example
A 3-year-old with biliary atresia has bilirubin 12 mg/dL, INR 1.8, albumin 2.4 g/dL, and height z-score -2.5. PELD components are all abnormal; calculate and update, refer for transplant evaluation, and address nutrition and variceal screening. If refractory ascites or SBP occurs, consider an exception pathway.
Rule of thumb: refer when expected waitlist mortality exceeds transplant risk, not when the child is sick enough.