What are the criteria for a liver transplant?

Criteria for Liver Transplantation

Liver transplantation is indicated for patients with end-stage liver disease who have a MELD score ≥15, acute liver failure, hepatocellular carcinoma meeting Milan criteria (single tumor ≤5 cm or up to 3 tumors ≤3 cm without vascular invasion), or specific MELD exceptions including severe complications of cirrhosis. 1

Primary Disease Indications

Liver transplantation is recommended for the following conditions 1:

• Chronic noncholestatic liver disorders: Chronic hepatitis B/C, autoimmune hepatitis, and alcoholic liver disease 1
• Cholestatic liver disorders: Primary biliary cirrhosis, primary sclerosing cholangitis, and biliary atresia 1
• Metabolic disorders causing cirrhosis: Alpha-1-antitrypsin deficiency, Wilson disease, and nonalcoholic steatohepatitis 1
• Hepatocellular carcinoma within specific tumor criteria 1

MELD Score-Based Criteria

The Model for End-Stage Liver Disease (MELD) score serves as the primary allocation tool, calculated from serum creatinine, bilirubin, and INR 1:

• MELD ≥15 is the threshold for listing patients with end-stage liver disease, as this represents the point where transplant benefit exceeds waitlist mortality risk 2, 1
• MELD >30 receives urgent priority with allocation at the macro-area level 2
• MELD 15-29 receives standard priority with regional allocation 2

A critical caveat: approximately half of patients listed with low MELD scores (≤15) will die from liver-related complications, and current evidence demonstrates a 40% mortality reduction with transplantation even in low MELD patients 3. This underscores that MELD alone inadequately captures mortality risk in decompensated cirrhosis.

Hepatocellular Carcinoma Criteria

For HCC, the Milan criteria remain the gold standard: single tumor ≤5 cm or 2-3 tumors each ≤3 cm, without major vessel invasion or extrahepatic spread 2:

• 4-year survival of 75% with recurrence-free survival of 83% when Milan criteria are met 2
• 5-year survival of 61-78% in deceased donor transplantation under Milan criteria 2
• Tumors >5 cm or >3 in number should only be considered within novel management strategies or downstaging protocols 2
• Extrahepatic disease is an absolute contraindication 2
• Fibrolamellar variant of HCC is not constrained by size/volume criteria 2

For living donor liver transplantation, expanded criteria such as the "5-5-500 rule" (tumor ≤5 cm, ≤5 tumors, AFP ≤500 ng/mL) have been adopted in some centers without significantly higher recurrence rates 2.

MELD Exception Categories

Patients with specific conditions receive standardized MELD exception points 2:

Priority 1 (30 points, macro-area allocation):

• Rendu-Osler-Weber syndrome
• Young adult hepatoblastoma
• Kasabach-Merritt syndrome
• Late "acute" retransplantation 2

Priority 2 (25 points + 1/month, regional allocation):

• Hepatopulmonary syndrome
• Portopulmonary hypertension
• Late "chronic" retransplantation
• Refractory hydrothorax
• Hepatorenal syndrome
• Previous severe infections 2

Priority 3 (20 points + 1 every 2 months, regional allocation):

• Refractory ascites
• Familial amyloidotic polyneuropathy
• Wilson's disease with initial neurological symptoms and well-compensated cirrhosis
• Neuroendocrine tumor metastases
• Hemangioendothelioma 2

Priority 4 (15 points + 1 every 2 months, regional allocation):

• Complicated adenomatosis
• Polycystic disease
• PSC or PBC with intractable pruritus 2

Super-Urgent Priority (Nationwide Allocation)

Fulminant hepatic failure and early retransplantation receive highest priority on a first-come, first-served basis with nationwide organ sharing 2.

Disease-Specific Considerations

Alcoholic Liver Disease:

• Transplantation in selected patients with advanced ALD improves outcomes 2
• Six months of supervised community abstinence is desirable but not mandatory 2
• Young patients on first presentation with life-threatening illness may not need stringent evaluation 2
• Multidisciplinary psychosocial assessment is required, differentiating alcohol dependence from non-dependent misuse 2

Hepatitis B:

• Patients must be HBV DNA negative before transplantation (based on commercial non-PCR assays) 2
• HBV DNA positive patients can be rendered negative with antiviral treatment and should not be excluded from assessment 2
• Precore mutant HBV or HDV co-infection are not contraindications 2

Wilson's Disease:

• Good indication for transplantation 2

Budd-Chiari Syndrome:

• Optimally managed in centers offering decompressive surgery, transplantation, TIPS, and radiological intervention 2

Genetic Hemochromatosis:

• Viable option but considered higher risk than other elective indications 2

Absolute Contraindications

The following are contraindications to transplantation 2, 1:

• Cholangiocarcinoma (unless within novel management strategy) 2
• Extrahepatic metastatic disease from neuroendocrine tumors 2
• Local or systemic extrahepatic HCC disease 2
• Limited life expectancy due to non-liver-related comorbidities 1

Evaluation Requirements

Multidisciplinary assessment involving transplant hepatologist, transplant surgeon, and other specialists is mandatory 1:

• Assessment of comorbidities that could compromise post-transplant outcomes 1
• Evaluation of ability to comply with complex post-transplant medical regimen 1
• Exclusion of significant comorbid disease is essential 2

Special Clinical Scenarios

Decompensated cirrhosis with low MELD: Patients with grade 3 ascites or overt hepatic encephalopathy have significant mortality and should be considered for transplantation despite low MELD scores 3. The MELD score inadequately captures quality of life impairment and mortality risk in these patients.

Hepatic myelopathy: Liver transplantation should be considered as soon as possible 1.

Hepatitis C with decompensated cirrhosis: Patients with MELD ≥18-20 and expected waiting time >6 months can be treated for hepatitis C before transplantation 1.