Who is eligible for a liver transplant?

Who Will Match for Liver Transplant

Patients with end-stage liver disease (ESLD) and a MELD score ≥15, or those with hepatocellular carcinoma (HCC) meeting Milan criteria, are eligible for liver transplantation. 1, 2

Primary Eligibility Categories

End-Stage Liver Disease Without HCC

MELD Score ≥15 is the minimum threshold for transplant listing, as this corresponds to a 5-year transplant benefit of at least 12 months of life gained. 1, 2

The MELD score is calculated using:

• Serum creatinine
• Serum bilirubin
• INR (International Normalized Ratio) 2

Patients with MELD scores >15 derive maximal transplant benefit, with higher scores indicating greater urgency and priority for organ allocation. 2

Common indications include:

• Chronic noncholestatic disorders: Chronic hepatitis B/C, autoimmune hepatitis, alcoholic liver disease 2
• Cholestatic disorders: Primary biliary cirrhosis, primary sclerosing cholangitis, biliary atresia 2
• Metabolic disorders: Alpha-1-antitrypsin deficiency, Wilson disease, nonalcoholic steatohepatitis 2

Hepatocellular Carcinoma (HCC)

The Milan criteria remain the gold standard for HCC transplant eligibility: single tumor ≤5 cm OR up to 3 nodules each ≤3 cm, with NO macrovascular invasion. 1

These criteria achieve 4-year overall survival of 85% and recurrence-free survival of 92%, matching outcomes of patients transplanted for cirrhosis alone. 1

UNOS criteria for HCC transplant eligibility require:

• AFP level <1,000 ng/mL 1
• Single lesion 2-5 cm in diameter, OR 2-3 lesions 1-3 cm in diameter 1
• No macrovascular involvement 1
• No extrahepatic disease 1

Expanded UCSF criteria may be considered at some centers: single tumor ≤6.5 cm OR up to 3 tumors with none >4.5 cm and cumulative size <8 cm. 1

Critical exclusion: Patients with AFP >1,000 ng/mL should NOT be considered for transplantation regardless of tumor size, unless liver-directed therapy produces significant sustained AFP decline. 1

Downstaging for HCC

Patients initially beyond Milan criteria may become eligible if successfully downstaged to within Milan criteria through bridge therapy (ablation, transarterial chemoembolization, or radioembolization). 1

Downstaging must demonstrate: tumor currently meeting Milan criteria with no macrovascular invasion or extrahepatic spread. 1

Combined Liver-Kidney Transplantation

Combined liver-kidney transplantation is indicated for:

• End-stage renal disease: Patients on dialysis OR GFR/creatinine clearance <30 ml/min 1
• Sustained acute kidney injury: GFR <25 ml/min and/or hemodialysis for ≥6 weeks 1
• Chronic kidney disease with uncertain reversibility: Either simultaneous or sequential transplantation 1

In compensated cirrhosis candidates for kidney transplant alone: Kidney transplant alone is only appropriate in the ABSENCE of clinically significant portal hypertension. 1

Special Populations and Considerations

Pulmonary Complications

Porto-pulmonary hypertension: Mean pulmonary arterial pressure >45 mmHg despite vasomodulator therapy is an absolute contraindication. 1

Adequate hemodynamic response required: Mean pulmonary arterial pressure <35 mmHg and portal vascular resistance <5 Wood units, OR mean pulmonary arterial pressure 35-45 mmHg with portal vascular resistance <3 Wood units. 1

Other Malignancies (Highly Selected Cases)

Unresectable liver-only colorectal metastases: May be considered within clinical trials in well-selected patients. 1

Neuroendocrine tumor metastases: Selected patients with G1-2 tumors, resected primary, and disease stability may be considered at experienced centers. 1

Small intrahepatic cholangiocarcinoma: Patients with cirrhosis and tumors <2-3 cm may be considered, ideally within clinical trials with bridge therapy. 1

Functional Status

All patients must be assessed for frailty, though frailty alone is not a contraindication. 1

Frail patients require: Evaluation for rehabilitation and nutritional support before transplantation. 1

Evaluation Process

Multidisciplinary evaluation is mandatory, involving transplant hepatologist, transplant surgeon, and other specialists as needed. 2

Assessment must include:

• Comorbidities that could compromise post-transplant outcomes 2
• Ability to comply with complex post-transplant immunosuppression regimen 2
• Psychosocial evaluation 2

Contraindications are dynamic and include limited life expectancy from non-liver-related comorbidities, with final decisions made by the multidisciplinary team. 2

Common Pitfalls

Do not list patients with Child-Pugh class A cirrhosis and resectable HCC meeting UNOS criteria without multidisciplinary discussion, as controversy exists whether resection or transplantation is preferable. 1

Avoid transplanting HCC patients on immunotherapy without adequate washout period to reduce rejection risk, though optimal interval is unknown. 1

Portal vein thrombosis is NOT a contraindication: Anticoagulation is recommended for newly diagnosed bland thrombosis, and TIPS may be considered in selected candidates. 1