Unifying Concepts

Indications and Contraindications for Liver Transplantation

Survival rates after liver transplantation have improved steadily because of earlier referral and timely evaluation, judicious patient selection, improved surgical techniques, superior immunosuppressive regimens, and effective prevention of perioperative opportunistic infections. Indications and contraindications for liver transplantation are undergoing constant modifications with the goal of improving survival and functional status of patients who have end-stage liver disease or acute liver failure. Potential candidates for liver transplantation should meet minimal listing criteria and not have contraindications to liver transplantation.

Indications for liver transplantation
1- Acute liver failure

  • Acute hepatitis A
  • Acute hepatitis B
  • Drug/toxin hepatotoxicity

2- Cirrhosis from chronic liver diseases

  • Chronic hepatitis B virus and chronic hepatitis C virus infection
  • Alcoholic liver disease
  • Autoimmune hepatitis
  • Cryptogenic liver disease
  • Primary biliary cirrhosis and primary sclerosing cholangitis
  • Secondary biliary cirrhosis

3- Metabolic disorders

  • Alpha-1 antitrypsin deficiency
  • Hereditary hemochromatosis
  • Wilson’s disease
  • Glycogen-storage disorders
  • Type 1 hyperoxaluria
  • Familial homozygous hypercholesterolemia

4- Malignancy

  • Primary hepatic cancer: hepatocellular carcinoma and cholangiocarcinoma
  • Metastatic: carcinoid tumors and islet cell tumors

5- Miscellaneous

  • Polycystic liver disease
  • Budd-Chiari syndrome

Contraindications to liver transplantation
1- Absolute contraindications

  • Brain death
  • Extrahepatic malignancy
  • Active uncontrolled infection
  • Active alcoholism and substance abuse
  • AIDS
  • Severe cardiopulmonary disease
  • Uncontrolled sepsis
  • Inability to comply with medical regimen
  • Lack of psychosocial support
  • Anatomic abnormalities precluding liver transplantation
  • Compensated cirrhosis without complications (Child-Turcotte-Pugh score, 5–6)

2- Relative contraindications

  • Advanced age
  • Cholangiocarcinomaa
  • HIV infectiona
  • Portal vein thrombosis
  • Psychologic instability

a Transplantation for cholangiocarcinoma is undergoing study using protocols with strict selection criteria and use of chemotherapy and radiation. Transplantation for HIV infection without AIDS also is undergoing study as part of a National Institutes of Health protocol


  1. Yu AS, Keeffe EB. Liver transplantation. In: Zakim D, Boyer TD, editors. Hepatology: a textbook of liver disease. 4th edition. Philadelphia: Elsevier; 2003. p. 1617–56.
  2. Ahmed A, Keeffe EB. Current indications and contraindications for liver transplantation. Clin Liver Dis. 2007 May;11(2):227-47. [Medline]


Created: Nov 01, 2008

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