Liver Transplant Indications, Contraindications and Referral

The core liver transplant indications in cirrhosis are the signs of decompensation: refractory ascites, more than one episode of upper gastrointestinal bleeding, hepatic encephalopathy or failing kidneys. Any of them should prompt referral. Without those signs, a MELD score above 15 and a Child-Pugh score above 8 is the trigger. The referral then has to clear a second test: no contraindication that would make the transplant futile.

That two-step logic, first who qualifies and then who will genuinely benefit, framed the clinical core of Dr. Sandeep Jha's masterclass for referring doctors. Dr. Sandeep Jha, Consultant, Liver Transplantation, Shalby Sanar International Hospital, Gurugram, India, called the indications and contraindications a very important part of his talk, because every later decision in a living donor liver transplant rests on choosing the right recipient at the right time.

How cirrhosis progresses, and what it costs in survival

Cirrhosis is the end stage of repeated liver injury, whatever the cause: hepatitis B, hepatitis C, alcohol or metabolic disease. The liver shrinks, hardens and becomes nodular, and blood can no longer flow through it. The consequences are what patients present with: an abdomen distended by ascites that is tapped again and again despite diuretics, dilated veins on the abdominal wall, bleeding from varices (dilated veins in the oesophagus or stomach), and jaundice that lingers for three or six months instead of clearing.

Dr. Jha divided the course of the disease into stages:

• Compensated cirrhosis: the patient may have varices but no ascites.
• Stage 3: ascites develops, with or without varices.
• Stage 4: upper gastrointestinal bleeding occurs together with ascites.

The probability of death rises steeply across those stages. In his figures, 20% of patients with ascites (with or without varices) die within one year, and 57% of those with bleeding plus ascites die within one year. "This is what drives transplant," he said. Once a patient is bleeding and accumulating ascites, the suspicion that the patient is a transplant candidate must rise, because long-term survival at that point is possible only with a transplant.

Child-Pugh score: the first test

The Child-Turcotte-Pugh (CTP) score, usually called the Child-Pugh score, grades the severity of cirrhosis from five parameters: serum albumin, serum bilirubin, prothrombin time (expressed as INR), ascites and encephalopathy. Each is scored and the total runs up to 15. Dr. Jha's reading of the classes:

Class B (7 to 9 points) is therefore assessed case by case, and the decision at a score of 8 rests on the clinical picture rather than the number alone.

MELD score: the second test

The MELD (Model for End-Stage Liver Disease) score has become the more widely used of the two, because developed countries use it to decide when a patient is placed on the waiting list for a deceased donor organ. It is calculated from serum creatinine, serum bilirubin and INR using a formula that is complicated by hand, but both MELD and Child-Pugh calculators are freely available online: enter the patient's results and the tool returns the score and a prognosis.

Dr. Jha described a MELD score of 15 as the point at which patients are listed on organ-sharing networks, which makes it, in his words, a surrogate marker that the patient requires a liver transplant.

When to refer for liver transplant: the indications

Dr. Jha combined symptoms and scores into a rule a referring clinician can apply at the bedside:

1. Refer at once if the patient has clear-cut ascites, upper gastrointestinal bleeding, encephalopathy, or kidneys that are beginning to fail.
2. Refer on the scores if those features are absent but the MELD score is above 15 and the Child-Pugh score above 8.

The specific indications he listed for cirrhosis were:

• Refractory ascites: fluid that has to be drained again and again, with diuretics no longer working.
• Upper gastrointestinal bleeding or haematemesis on more than one occasion.
• Hepatic encephalopathy, the confusion and altered consciousness caused by the failing liver.
• Hepatorenal syndrome, kidney failure driven by advanced liver disease.
• Hepatopulmonary syndrome, low blood oxygen caused by dilated blood vessels in the lungs in liver disease.

Beyond cirrhosis, the indications include acute liver failure and acute-on-chronic liver failure, biliary atresia in children, primary sclerosing cholangitis, autoimmune hepatitis and metabolic liver disease.

Liver transplant contraindications: who will not benefit

Meeting the criteria is not enough. Some patients, Dr. Jha explained, are candidates on paper but are so advanced, or have such a serious additional problem, that a transplant will not help them. He set out the contraindications a referring doctor must look for before sending the patient.

• Severe cardiac or pulmonary disease. Even after a successful liver transplant, the heart or lung disease will kill the patient.
• Continuing alcohol use without insight. If the patient will not stop drinking, or does not accept the need to stop, there is no point in transplanting: the patient returns to alcohol and the whole effort is wasted.
• Liver cancer that has spread beyond the liver, or a very high alpha-fetoprotein level. Liver cancer is itself a major indication for transplant, but extrahepatic spread or a very high alpha-fetoprotein (a tumour marker) means the cancer is likely to recur, and transplant is of no use.
• Uncontrolled sepsis. This is a relative contraindication. If the infection can be brought under control with appropriate antibiotics, antifungals or antivirals, the patient can then proceed to transplant.
• Anatomical problems that preclude the operation.
• Intrahepatic cholangiocarcinoma, cancer of the bile ducts within the liver, for which little benefit from transplant has been seen. Perihilar cholangiocarcinoma, at the junction of the main bile ducts, is a different matter: it is increasingly amenable to transplant, and Dr. Jha noted that he and his colleagues are performing more and more transplants for it.
• Cancer elsewhere in the body, such as a brain, lung or breast tumour.

The two lists work together. The indications define the pool of patients who need a transplant; within that pool, the contraindications identify those who will not gain from one.

Why early referral changes the result

Dr. Jha returned repeatedly to timing. A patient who remains with decompensated cirrhosis grows weak, becomes vulnerable to infection, and arrives for surgery in worse condition, which in turn reduces the benefit of the transplant itself. His instruction to referring doctors was direct: identify decompensated cirrhosis early and refer early.

Referral does not mean every patient proceeds immediately. Patients with compensated cirrhosis, a Child-Pugh score below 8 and a MELD score of 15 or less can be watched, but once decompensation appears, the window in which a transplant gives the full benefit begins to narrow.

Managing the patient while waiting, and preventing cirrhosis

Asked in the discussion which foods help, Dr. Jha drew a clear line between prevention and management. No diet, drug or medication prevents cirrhosis. Prevention means removing the causes: stopping alcohol, treating hepatitis B and C, and controlling diabetes and obesity.

Once cirrhosis is established, dietary advice does matter, because it helps prevent complications:

• A high-protein diet.
• Low salt intake.
• More frequent meals, with protein snacks every three to four hours.

These general recommendations apply to any patient with cirrhosis, including those awaiting assessment for transplant.

Metabolic liver disease: the rising indication

Asked why metabolic liver disease is becoming a leading reason for transplant, Dr. Jha described a shift in the causes of cirrhosis. Uncontrolled diabetes, obesity, high blood lipids and thyroid problems combine into a metabolic syndrome that is rising in Western countries, especially the United States, and increasingly in India, driven by sedentary lifestyles. At the same time, hepatitis B and C are falling because effective antiviral treatment is available and hepatitis B vaccination is widespread, and alcohol intake is lower because of greater awareness. The condition he described has been renamed: since 2023 the international term for non-alcoholic fatty liver disease is metabolic dysfunction-associated steatotic liver disease (MASLD), and non-alcoholic steatohepatitis is now metabolic dysfunction-associated steatohepatitis (MASH), its progressive form.

Dr. Jha's answers on diet and metabolic liver disease are in the Live Discussion. Once a recipient is accepted, attention turns to the donor; the work-up that makes living donation safe is described in living liver donor evaluation and right lobe surgery. For the cost of the procedure, see the liver transplant cost page. Dr. Jha's separate masterclass on cirrhosis covers the disease itself in more detail in liver cirrhosis: a complete guide, including how MELD and Child-Pugh scores grade cirrhosis.