End-Stage Liver Disease and Indications for Liver Transplantation

  • Aparna Goel
  • Osama Siddique
  • Aijaz AhmedEmail author


Cirrhosis is a leading cause of morbidity and mortality in the United States. Once a patient develops complications from cirrhosis such as hepatic encephalopathy, ascites, esophageal variceal bleeding, or hepatocellular carcinoma, a liver transplantation should be considered. Patients with fulminant hepatic failure, systemic complications of liver disease, and liver-specific metabolic defects should also be considered for transplant. The evaluation for liver transplant is extensive and rigorous and involves numerous members from the transplant team to determine if transplantation is medically and psychosocially appropriate and technically feasible and is in the best interests of the patient.


Liver transplantation Indications for liver transplant Liver failure End-stage liver disease Evaluation for liver transplant 


  1. 1.
    Kochanek KD, Murphy SL, Xu J, Tejada-Vera B. National vital statisitcs reports. 65(4), (06/30/2016). 2014 [cited 2017 Sep 20]; Available from:
  2. 2.
    Rastogi A, Maiwall R, Bihari C, Ahuja A, Kumar A, Singh T, et al. Cirrhosis histology and Laennec staging system correlate with high portal pressure. Histopathology [Internet]. 2013 [cited 2017 Sep 20];62(5):731–41. Available from: Scholar
  3. 3.
    Westbrook RH, Dusheiko G. Natural history of hepatitis C. J Hepatol [Internet]. 2014 [cited 2015 Apr 28];61(1 Suppl):S58–68. Available from:
  4. 4.
    Galbraith JW, Franco RA, Donnelly JP, Rodgers JB, Morgan JM, Viles AF, et al. Unrecognized chronic hepatitis C virus infection among baby boomers in the emergency department. Hepatology [Internet]. 2015 Mar 28 [cited 2015 Oct 5];61(3):776–82. Available from:
  5. 5.
    Goel A, Sanchez J, Paulino L, Feuille C, Arend J, Shah B, et al. A systematic model improves hepatitis C virus birth cohort screening in hospital-based primary care. J Viral Hepat [Internet]. 2016 [cited 2017 Mar 8]; Available from:
  6. 6.
    Turner BJ, Taylor BS, Hanson JT, Perez ME, Hernandez L, Villarreal R, et al. Implementing hospital-based baby boomer hepatitis C virus screening and linkage to care: Strategies, results, and costs. J Hosp Med [Internet]. 2015 [cited 2016 Jan 21];10(8):510–6. Available from: Scholar
  7. 7.
    Alcohol-Attributable Deaths and Years of Potential Life Lost — 11 States, 2006–2010 [Internet]. [cited 2018 Feb 14]. Available from:
  8. 8.
    Mittal S, Sada YH, El-Serag HB, Kanwal F, Duan Z, Temple S, et al. Temporal trends of nonalcoholic fatty liver disease–related hepatocellular carcinoma in the veteran affairs population. Clin Gastroenterol Hepatol [Internet]. 2015 [cited 2017 Apr 11];13(3):594–601.e1. Available from: Scholar
  9. 9.
    van der Meer AJ, Veldt BJ, Feld JJ, Wedemeyer H, Dufour J-F, Lammert F, et al. Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis. JAMA [Internet]. 2012 [cited 2017 Mar 8];308(24):2584–93. Available from: Scholar
  10. 10.
    Goldberg D, Ditah IC, Saeian K, Lalehzari M, Aronsohn A, Gorospe EC, et al. Changes in the prevalence of hepatitis C virus infection, nonalcoholic steatohepatitis, and alcoholic liver disease among patients with cirrhosis or liver failure on the waitlist for liver transplantation. Gastroenterology [Internet]. 2017 [cited 2017 Apr 17];152(5):1090–1099.e1. Available from: Scholar
  11. 11.
    Kim WR, Lake JR, Smith JM, Skeans MA, Schladt DP, Edwards EB, et al. OPTN/SRTR 2015 Annual data report: liver. Am J Transplant [Internet]. 2017 [cited 2017 Apr 11];17(S1):174–251. Available from: Scholar
  12. 12.
    Charlton MR, Burns JM, Pedersen RA, Watt KD, Heimbach JK, Dierkhising RA. Frequency and outcomes of liver transplantation for nonalcoholic steatohepatitis in the United States. Gastroenterology [Internet]. 2011 [cited 2017 Sep 20];141(4):1249–53. Available from: Scholar
  13. 13.
    Stepanova M, Wai H, Saab S, Mishra A, Venkatesan C, Younossi ZM. The portrait of an adult liver transplant recipient in the United States from 1987 to 2013. JAMA Intern Med [Internet]. 2014 [cited 2017 Oct 11];174(8):1407–9. Available from: Scholar
  14. 14.
    Grant BF, Chou SP, Saha TD, Pickering RP, Kerridge BT, Ruan WJ, et al. Prevalence of 12-month alcohol use, high-risk drinking, and DSM-IV alcohol use disorder in the United States, 2001–2002 to 2012–2013. JAMA Psychiatry [Internet]. 2017 [cited 2017 Oct 11];74(9):911. Available from: Scholar
  15. 15.
    D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol [Internet]. 2006 [cited 2017 Oct 11];44(1):217–31. Available from: Scholar
  16. 16.
    García-Pagán J, Gracia-Sancho J, Bosch J. Functional aspects on the pathophysiology of portal hypertension in cirrhosis. J Hepatol [Internet]. 2012 [cited 2017 Oct 11];57(2):458–61. Available from: Scholar
  17. 17.
    Ginès P, Cárdenas A, Arroyo V, Rodés J. Management of cirrhosis and ascites. N Engl J Med [Internet]. 2004 [cited 2017 Oct 11];350(16):1646–54. Available from: Scholar
  18. 18.
    Bosch J, Arroyo V, Betriu A, Mas A, Carrilho F, Rivera F, et al. Hepatic hemodynamics and the renin-angiotensin-aldosterone system in cirrhosis. Gastroenterology [Internet]. 1980 [cited 2017 Oct 11];78(1):92–9. Available from:
  19. 19.
    Runyon BA. Introduction to the revised American association for the study of liver diseases practice guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology [Internet]. 2013;57(4):1651–3. Available from: Scholar
  20. 20.
    Runyon BA. Care of patients with ascites. N Engl J Med [Internet]. 1994 [cited 2017 Oct 11];330(5):337–42. Available from: Scholar
  21. 21.
    Veldt BJ, Lainé F, Guillygomarc’h A, Lauvin L, Boudjema K, Messner M, et al. Indication of liver transplantation in severe alcoholic liver cirrhosis: quantitative evaluation and optimal timing. J Hepatol [Internet]. 2002 [cited 2017 Oct 11];36(1):93–8. Available from: Scholar
  22. 22.
    Casadaban LC, Parvinian A, Minocha J, Lakhoo J, Grant CW, Ray CE, et al. Clearing the confusion over hepatic encephalopathy after TIPS creation: incidence, prognostic factors, and clinical outcomes. Dig Dis Sci [Internet]. 2015 [cited 2018 Feb 14];60(4):1059–66. Available from: Scholar
  23. 23.
    Wiest R, Krag A, Gerbes A. Spontaneous bacterial peritonitis: recent guidelines and beyond. Gut [Internet]. 2012;61(2):297–310. Available from: Scholar
  24. 24.
    Rimola A, García-Tsao G, Navasa M, Piddock LJV, Planas R, Bernard B, et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. J Hepatol [Internet]. 2000 [cited 2014 Oct 28];32(1):142–53. Available from: Scholar
  25. 25.
    Thuluvath PJ, Morss S, Thompson R. Spontaneous bacterial peritonitis--in-hospital mortality, predictors of survival, and health care costs from 1988 to 1998. Am J Gastroenterol [Internet]. 2001 [cited 2015 May 14];96(4):1232–6. Available from: Scholar
  26. 26.
    EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol [Internet]. 2010 [cited 2014 Oct 18];53(3):397–417. Available from:
  27. 27.
    Ginès P, Schrier RW. Renal failure in cirrhosis. N Engl J Med [Internet]. 2009 [cited 2017 Oct 16];361(13):1279–90. Available from: Scholar
  28. 28.
    Arroyo V, Ginès P, Gerbes AL, Dudley FJ, Gentilini P, Laffi G, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology [Internet]. 1996 [cited 2017 Oct 16];23(1):164–76. Available from: Scholar
  29. 29.
    Angeli P, Ginès P, Wong F, Bernardi M, Boyer TD, Gerbes A, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the international club of ascites. J Hepatol [Internet]. 2015 [cited 2015 Apr 23];62(4):968–74. Available from: Scholar
  30. 30.
    Salerno F, Gerbes A, Gines P, Wong F, Arroyo V. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Postgrad Med J [Internet]. 2008 [cited 2017 Oct 16];84(998):662–70. Available from: Scholar
  31. 31.
    Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med [Internet]. 2010 [cited 2017 Oct 11];362(9):823–32. Available from: Scholar
  32. 32.
    Kovalak M, Lake J, Mattek N, Eisen G, Lieberman D, Zaman A. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. Gastrointest Endosc [Internet]. 2007 [cited 2017 Oct 11];65(1):82–8. Available from: Scholar
  33. 33.
    Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American association for the study of liver diseases. [cited 2017 Oct 11]; Available from:
  34. 34.
    Carbonell N, Pauwels A, Serfaty L, Fourdan O, Lévy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology [Internet]. 2004 [cited 2017 Oct 11];40(3):652–9. Available from: Scholar
  35. 35.
    Fernández J, Ruiz del Arbol L, Gómez C, Durandez R, Serradilla R, Guarner C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology [Internet]. 2006 [cited 2017 Oct 11];131(4):1049–56; quiz 1285. Available from:
  36. 36.
    Wijdicks EFM. Hepatic encephalopathy. Longo DL, editor. N Engl J Med [Internet]. 2016 [cited 2017 Oct 11];375(17):1660–70. Available from:
  37. 37.
    Bajaj JS, Cordoba J, Mullen KD, Amodio P, Shawcross DL, Butterworth RF, et al. Review article: the design of clinical trials in hepatic encephalopathy--an International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) consensus statement. Aliment Pharmacol Ther [Internet]. 2011 [cited 2017 Oct 16];33(7):739–47. Available from: Scholar
  38. 38.
    Bajaj JS. Review article: potential mechanisms of action of rifaximin in the management of hepatic encephalopathy and other complications of cirrhosis. Aliment Pharmacol Ther [Internet]. 2016 [cited 2017 Apr 18];43:11–26. Available from: Scholar
  39. 39.
    Bass NM, Mullen KD, Sanyal A, Poordad F, Neff G, Leevy CB, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med [Internet]. 2010 [cited 2017 Oct 16];362(12):1071–81. Available from: Scholar
  40. 40.
    Tumgor G. Cirrhosis and hepatopulmonary syndrome. World J Gastroenterol [Internet]. 2014 [cited 2017 Oct 16];20(10):2586. Available from: Scholar
  41. 41.
    Aller R, Moya JL, Moreira V, Boixeda D, Cano A, Picher J, et al. Diagnosis of hepatopulmonary syndrome with contrast transesophageal echocardiography: advantages over contrast transthoracic echocardiography. Dig Dis Sci [Internet]. 1999 [cited 2017 Oct 16];44(6):1243–8. Available from:
  42. 42.
    Saleemi S. Portopulmonary hypertension. Ann Thorac Med [Internet]. 2010 [cited 2017 Oct 16];5(1):5–9. Available from: Scholar
  43. 43.
    Sherman M, Bruix J, Porayko M, Tran T. Screening for hepatocellular carcinoma: the rationale for the American association for the study of liver diseases recommendations. Hepatology [Internet]. 2012 [cited 2014 Feb 12];56(3):793–6. Available from:
  44. 44.
    Petrick JL, Kelly SP, Altekruse SF, McGlynn KA, Rosenberg PS. Future of hepatocellular carcinoma incidence in the United States forecast through 2030. J Clin Oncol [Internet]. 2016 [cited 2017 Oct 18];34(15):1787–94. Available from: Scholar
  45. 45.
    Heimbach J, Kulik LM, Finn R, Sirlin CB, Abecassis M, Roberts LR, et al. AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology. 2018 [cited 2017 Oct 18]; 67(1):358–380. Available from: Scholar
  46. 46.
    Forner A, Llovet JM, Bruix J. Hepatocellular carcinoma. Lancet [Internet]. 2012 [cited 2017 Oct 18];379(9822):1245–55. Available from: Scholar
  47. 47.
    Graziadei IW, Sandmueller H, Waldenberger P, Koenigsrainer A, Nachbaur K, Jaschke W, et al. Chemoembolization followed by liver transplantation for hepatocellular carcinoma impedes tumor progression while on the waiting list and leads to excellent outcome. Liver Transpl [Internet]. 2003 [cited 2014 Feb 10];9(6):557–63. Available from:
  48. 48.
    Kim WR, Lake JR, Smith JM, Skeans MA, Schladt DP, Edwards EB, et al. OPTN/SRTR 2015 Annual data report: liver. Am J Transplant [Internet]. 2017 Jan [cited 2017 Jan 25];17(S1):174–251. Available from: Scholar
  49. 49.
    Albers I, Hartmann H, Bircher J, Creutzfeldt W. Superiority of the child-pugh classification to quantitative liver function tests for assessing prognosis of liver cirrhosis. Scand J Gastroenterol [Internet]. 1989 [cited 2017 Oct 18];24(3):269–76. Available from: Scholar
  50. 50.
    Kim WR, Biggins SW, Kremers WK, Wiesner RH, Kamath PS, Benson JT, et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med [Internet]. 2008 [cited 2017 Oct 18];359(10):1018–26. Available from: Scholar
  51. 51.
    Bernardi M, Gitto S, Biselli M. The MELD score in patients awaiting liver transplant: strengths and weaknesses. J Hepatol [Internet]. 2011 [cited 2016 Apr 28];54(6):1297–306. Available from: Scholar
  52. 52.
    Merion RM, Schaubel DE, Dykstra DM, Freeman RB, Port FK, Wolfe RA. The survival benefit of liver transplantation. Am J Transplant [Internet]. 2005 [cited 2016 Apr 28];5(2):307–13. Available from: Scholar
  53. 53.
    Mathurin P, Moreno C, Samuel D, Dumortier J, Salleron J, Durand F, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med [Internet]. 2011 [cited 2017 Nov 12];365(19):1790–800. Available from: Scholar
  54. 54.
    Im GY, Kim-Schluger L, Shenoy A, Schubert E, Goel A, Friedman SL, et al. Early liver transplantation for severe alcoholic hepatitis in the United States--a single-center experience. Am J Transplant [Internet]. 2016 [cited 2017 Nov 12];16(3):841–9. Available from: Scholar
  55. 55.
    Lee BP, Chen P-H, Haugen C, Hernaez R, Gurakar A, Philosophe B, et al. Three-year results of a pilot program in early liver transplantation for severe alcoholic hepatitis. Ann Surg [Internet]. 2017 [cited 2017 Nov 12];265(1):20–9. Available from: Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Gastroenterology and Hepatology, Department of MedicineStanford University School of MedicineStanfordUSA
  2. 2.Department of MedicineMemorial Hospital of Rhode Island/Alpert Medical School of Brown UniversityProvidenceUSA

Personalised recommendations