Appropriate timing of the initial referral for transplant evaluation is critical for optimal care of patient with cirrhosis.

Key concepts

• There are 2 phases of cirrhosis: compensated and decompensated
• Decompensated cirrhosis carries a poor prognosis with few options for improvement of the underlying liver failure other than transplant
• Median survival of patients with compensated cirrhosis is >12 years
• Median survival of patients with decompensated cirrhosis is 2 years
• Transition from the compensated phase to the decompensated phase occurs at a rate of 5-7 percent per year
• Patients may be eligible for liver transplant if they have advanced decompensated cirrhosis, or compensated cirrhosis with certain conditions such as liver cancer (hepatocellular carcinoma, HCC)

Key recommendations

• Long-term management of patients with cirrhosis should include regular, repeated calculation of the MELD-sodium score to continually assess appropriate time for transplant referral
• Comprehensive care of patients with cirrhosis should include:
  • Discussions with patients to remain mindful of the potential eventual need for a liver transplant
  • Efforts to optimize medical, social, and behavioral factors relevant to liver transplant

Criteria for transplantation referral

• Child-Turcotte-Pugh score ≥7
• MELD-sodium score: optimal timing for first referral is MELD ≥10, and definitely by MELD ≥15
• First development of any decompensation event: ascites, variceal bleeding, or hepatic encephalopathy
• HCC without metastasis or macrovascular invasion; patients with HCC and cirrhosis (either compensated or decompensated) should be referred for transplant evaluation

Conditions warranting expedited transplantation referral

• Fulminant hepatic failure (critical care management)
• Hepatopulmonary syndrome
• Hepatorenal syndrome type 1

Some contraindications to liver transplant

• Severe cardiac or pulmonary disease
• Ongoing alcohol or illicit substance abuse
• Persistent noncompliance
• Lack of adequate social support system

Some areas a referring physician can help patients to manage prior to transplant evaluations

• Alcohol
• Smoking
• Obesity
• Illicit drug use
• Social support
• Osteoporosis
• Coronary artery disease
• Hepatitis C infection
• Hepatitis B infection
• Pulmonary disease
• Depression and anxiety
• Diabetes mellitus
• Chronic opioid use
• Hyperlipidemia
• HIV infection
• Medical adherence

Conditions that do not necessarily make patients ineligible for transplant

• Methadone maintenance
• Older age (>70 years)
• History of extrahepatic malignancy that has received definitive treatment
• Cholangiocarcinoma