Who Qualifies for a Liver Transplant

The short answer

A liver transplant is for people whose liver disease has gone past what medicine can manage. National guidance from the American Association for the Study of Liver Diseases (AASLD) and the American Society of Transplantation puts it this way: a transplant is indicated "when the limits of medical therapy have been reached."

To qualify, two things need to be true. First, you need the transplant: your liver disease is serious enough that a new liver offers a better chance at life than staying on medical treatment. Second, you need to be able to come through it: you are strong enough for major surgery, you can take anti-rejection medicines for life, and you have people to help you. A transplant center's team decides both questions through an evaluation, and each center has its own guidelines on top of the national rules.

The guideline groups the medical reasons for a liver transplant into four types:

• Acute liver failure: sudden liver failure in someone without earlier liver disease, often from an acetaminophen overdose, a drug reaction, or viral hepatitis.
• Complications of cirrhosis: by far the most common reason. Leading causes are alcohol-associated liver disease, fatty liver disease, and hepatitis C.
• Liver-based metabolic diseases: such as Wilson disease, alpha-1 antitrypsin deficiency, or certain inherited conditions.
• Body-wide complications of liver disease: such as hepatopulmonary syndrome, a lung problem caused by liver disease.

Liver cancer (hepatocellular carcinoma) that stays within set size limits is also a common reason, often together with cirrhosis.

Who should be referred for a liver transplant evaluation

Referral is the first step, and it should happen earlier than many people expect. For people with cirrhosis, the guidance says to refer when either of these happens:

• The first major complication of cirrhosis, such as fluid in the belly (ascites), bleeding from swollen veins (variceal bleeding), or confusion from toxins (hepatic encephalopathy). These mark the move to decompensated cirrhosis.
• A MELD score of 15 or higher. The MELD score measures how sick the liver is from routine blood tests.

Some people need an urgent referral: anyone with acute liver failure, anyone whose kidneys fail because of liver disease (hepatorenal syndrome), and anyone getting worse quickly. If you have end-stage liver disease and have not been referred, ask your doctor why.

Why early? The evaluation itself can take weeks to months, and the first major complication is a turning point. In one study, more than 90% of people with compensated cirrhosis were alive at 5 years, compared with about half of those who had a decompensating event.

The liver transplant evaluation, step by step

Once you are referred, the transplant center runs a full evaluation. You may visit several times over a few weeks or months. You will meet a team that usually includes a transplant coordinator, transplant surgeons, a hepatologist, a social worker, a financial coordinator, a psychiatrist or psychologist, and a dietitian.

After testing, the center's selection committee reviews your results and decides whether to approve you. If approved and you do not have a living donor, the center adds you to the national liver transplant waiting list. You can still choose not to have a transplant after you are approved.

A strong caregiver plan matters. Centers need to know you have a reliable support system, and a lack of adequate social support is one of the reasons a center may not list someone. If you are worried about this part, tell the social worker early. They can often help you build a plan.

Common reasons a center may say no

Doctors call these contraindications. They vary from center to center, and many are not permanent. A "not now" can become a "yes" after treatment. The conditions most often listed include:

• Severe heart or lung disease that makes surgery too risky
• Cancer that has spread outside the liver, or certain other cancers
• An uncontrolled, severe infection
• Ongoing alcohol or drug use
• Repeatedly not following medical care plans
• No adequate support system
• Body anatomy that makes the operation impossible
• Liver disease that is not yet severe enough (for example, a MELD score below 15 without other reasons)

Other factors make a transplant harder but do not rule it out. These include heart disease that can be treated, smoking, HIV, a past cancer, blood clots in the portal vein, a body mass index that is very low or very high, and mental health conditions that need to be well controlled. There is no fixed age cutoff, and hepatitis C is not a reason to say no.

Alcohol use and liver transplant eligibility

For years, many programs required six months of sobriety before listing anyone with alcohol-associated liver disease. This "6-month rule" traces back to a 1984 medical paper and became standard at many programs by the mid-1990s.

That is changing. Research found that the length of sobriety before a transplant does a poor job of predicting who will drink again afterward. The American College of Gastroenterology's 2024 guideline now states that selection for a transplant "should not be based solely on an arbitrary duration of sobriety." It also says a transplant should be considered for selected people with severe alcohol-associated hepatitis who do not respond to medical treatment and have a low risk of returning to alcohol.

In a landmark French study of carefully chosen patients with severe alcohol-associated hepatitis, 77% of those who received an early transplant were alive at 6 months, compared with 23% of similar patients who did not.

What centers look for now is a full picture: honesty about drinking, treatment for alcohol use disorder, family support, and a commitment to lifelong sobriety. Policies still differ, so ask each center directly what it requires. Ongoing drinking remains a reason most centers will not list someone.

MELD and getting listed

Once you are on the list, your place in line for a deceased-donor liver depends mainly on your MELD score, which runs from 6 to 40. Since July 2023, the national system has used MELD 3.0, which adds albumin and sex to bilirubin, INR, creatinine, and sodium. Your team updates the score as your lab results change. You can estimate your own with our MELD calculator.

Qualifying for the list and getting a liver are two different things. How sick patients are when they receive a liver varies by transplant center and region. Our page on median MELD at transplant explains this, and you can compare programs on our list of liver transplant centers.

A note about children

Children are scored differently. Under national policy, children younger than 12 receive a PELD (Pediatric End-Stage Liver Disease) score instead of MELD, and candidates 12 and older receive MELD. The most common reason children need a liver transplant is biliary atresia, a bile duct disease of infancy. Surgeons can sometimes split a deceased donor's liver so that the smaller part goes to a child.

If you are turned down: second opinions and other centers

Each transplant center has its own guidelines, so a "no" at one center is not always a "no" everywhere. You have options:

• Ask why. Request the specific reasons in writing and ask what would need to change.
• Get a second opinion. Ask your hepatologist or insurer for a referral to another program. Each center usually does its own evaluation.
• Consider listing at more than one center. National rules let you register at more than one transplant center. This is called dual listing.
• Compare programs. The Scientific Registry of Transplant Recipients (SRTR) publishes waiting-list and outcome data for every U.S. program.

If you need help sorting this out, our support page can connect you with resources.

Questions to bring to your first visit

At your first visit, the center should explain the evaluation, how listing works, the reasons someone can be removed from the list, and what life after a transplant involves. It helps to write your questions down ahead of time:

• What are your center's own requirements beyond the national rules?
• How long does your evaluation usually take, and what can I do to speed it up?
• What do you require for alcohol or drug history, if that applies to me?
• Who should my caregiver be, and what will they need to do?
• Do you consider living donors, and would that be an option for me?
• If you decide not to list me, will you tell me why and what could change?