A liver transplant replaces a failing liver with a healthy one, offering a chance at life for individuals with end-stage liver disease or acute liver failure. Given the scarcity of donor organs, eligibility for this life-saving surgery is determined by strict criteria designed to maximize the chance of long-term success. The evaluation process is rigorous, focusing on whether a patient is physiologically fit enough to survive the operation and recovery. It also assesses whether they can adhere to the demanding post-transplant regimen.
Uncontrolled Systemic Health Conditions
A patient may be disqualified if their body is deemed too frail or compromised to withstand the intense physical stress of the surgery and subsequent recovery. Severe, irreversible cardiopulmonary disease is a primary concern, as conditions like advanced heart failure or uncontrolled pulmonary hypertension can lead to death during or immediately after the lengthy operation. For example, a mean pulmonary arterial pressure of 50 mmHg or higher is often considered an absolute contraindication due to the near 100% post-procedure mortality risk.
Other systemic conditions that are not adequately managed also pose a major barrier to listing. An active, uncontrolled infection, such as sepsis, or an invasive fungal infection, must be cleared entirely before the transplant can be considered. Introducing powerful immunosuppressive drugs after the transplant into a patient with a raging infection would almost certainly lead to uncontrolled spread and patient death. Similarly, severe frailty and sarcopenia, which is the loss of muscle mass common in advanced liver disease, are strong predictors of poor post-transplant outcomes.
Irreversible neurological deficits, such as severe brain damage or cerebral edema associated with acute liver failure, also preclude transplantation. The transplant is deemed futile if the patient cannot recover a meaningful quality of life even with a functioning new liver. These physiological contraindications reflect the reality that the new organ is a scarce resource that must be allocated with the highest possible chance of success.
Active Substance Use and Compliance Failures
Disqualification can also stem from behavioral or adherence concerns, as the long-term success of a transplant depends heavily on the patient’s commitment to their health. Active substance use, including alcohol or illicit drugs, is an absolute contraindication for most transplant centers. This requirement is based on the high risk of continued substance use damaging the new liver or leading to poor outcomes.
For patients with alcohol-associated liver disease, a period of sustained sobriety is typically required before listing, often a minimum of six months. This abstinence period allows for a chance of liver recovery without a transplant and provides time for a thorough psychosocial evaluation. The evaluation assesses the patient’s commitment to lifelong abstinence and their psychological capacity to follow the complex, demanding post-transplant medical regimen.
Compliance failures, such as a documented history of poor adherence to medical appointments, treatments, or medication schedules, can also disqualify a candidate. After a transplant, patients must take immunosuppressive drugs precisely as prescribed for the rest of their lives to prevent organ rejection. A severe, unmanaged mental health disorder that impairs judgment or adherence can indicate a high risk of missing these medications, which would lead to the failure of the transplanted organ.
Extra-Hepatic or Metastatic Malignancy
The presence of cancer that has spread outside the liver represents a major contraindication to liver transplantation. This is known as extra-hepatic or metastatic malignancy, and it includes active, untreated cancers located elsewhere in the body. Transplant centers must avoid allocating a scarce organ to a patient whose underlying cancer would likely recur aggressively, rendering the procedure useless.
This rule is especially important because the powerful immunosuppressive medications required to prevent the body from rejecting the new liver would simultaneously accelerate the growth and spread of any existing cancer cells. The goal is to ensure that the donated liver is not wasted on a patient with a high and unmanageable risk of cancer recurrence.
Hepatocellular carcinoma (HCC), a common liver cancer, is a unique exception. It can be an indication for transplant if the disease is localized and meets specific size and number criteria. Transplant is typically reserved for HCC that meets the Milan criteria, generally defined as one tumor no larger than five centimeters, or up to three tumors, none larger than three centimeters, without evidence of vascular invasion or spread outside the liver. If the cancer exceeds these criteria, or if it has metastasized, it constitutes a clear disqualification because the recurrence risk becomes unacceptably high.
Insufficient Long-Term Support Infrastructure
Beyond medical and psychological fitness, a patient must demonstrate a robust support system and the necessary resources for the demanding post-operative period. The lack of a reliable caregiver or social support system is a serious logistical barrier that can lead to ineligibility. Transplant recovery requires intensive monitoring and assistance, especially during the first few months, which a solo patient is often unable to manage.
Financial toxicity is another significant concern, as the cost of lifelong immunosuppression medication is substantial, and a patient must prove they can afford it or have adequate insurance coverage. Transplant centers require assurance that the patient can manage the frequent, complex logistics of recovery, which include multiple follow-up appointments and laboratory tests. Unstable housing or geographical barriers that prevent regular access to the transplant center can compromise care and therefore lead to a decision of ineligibility.