Liver Transplantation

📋 Key Information Summary

📋

Liver transplantation is the definitive treatment for end-stage liver disease (ESLD), acute liver failure (ALF), selected hepatocellular carcinoma (HCC), inherited metabolic disorders, and hepatopulmonary syndrome, with Australia performing approximately 550–650 liver transplants per year across six designated centres.
MELD-Na score is the primary allocation tool in the US and has been adopted variably in Australia; wait-list priority is determined by disease severity using validated scoring systems, with national waiting times of 3–6 months.
Acute liver failure indications follow King's College criteria — paracetamol (pH < 7.3, or all three of: INR > 6.5, creatinine > 300 µmol/L, grade III–IV encephalopathy) and non-paracetamol (INR > 6.5 regardless of encephalopathy grade, or five of six poor prognostic factors).
HCC patients qualify for transplantation within Milan criteria (single tumour ≤ 5 cm, or up to 3 nodules each ≤ 3 cm, no macrovascular invasion, no extrahepatic spread), with MELD exception points increasing wait-list priority.
Pre-transplant workup is multidisciplinary: cardiac (stress testing ± coronary angiography if risk factors), pulmonary (spirometry, arterial blood gas, hepatopulmonary screening with contrast echocardiography), renal (eGFR, consideration for combined liver–kidney if eGFR < 30), psychosocial assessment.
Absolute contraindications include extrahepatic malignancy (unless disease-free ≥ 2 years), uncontrolled sepsis, severe irreversible cardiopulmonary disease, active harmful alcohol or substance use without adequate abstinence (typically ≥ 6 months), and inability to comply with lifelong immunosuppression.
Living donor liver transplantation (LDLT) uses right or left lobe grafts; donor safety is paramount with extensive medical, anatomical (CT volumetry, MRCP), and psychosocial evaluation; small-for-size syndrome remains a key risk when graft-to-recipient body weight ratio < 0.8%.
Recipient outcomes for LDLT are comparable to deceased donor transplantation, with one-year graft survival approximately 85–90% in Australian centres.
Immunosuppression centres on tacrolimus-based regimens (calcineurin inhibitor + mycophenolate ± corticosteroids), with ongoing post-transplant monitoring for rejection, infection, malignancy, and metabolic complications.
Aboriginal and Torres Strait Islander Australians face barriers to liver transplant referral, higher rates of chronic liver disease (including HBV, HCV, NAFLD), remoteness from transplant centres, and require culturally safe pathways throughout assessment and follow-up.
Psychosocial compliance (alcohol abstinence, medication adherence, social support) is a critical determinant of post-transplant survival and is formally assessed by transplant psychiatrists/psychologists.
Combined liver–kidney transplantation is considered when eGFR < 30 mL/min/1.73 m² or with hepatorenal syndrome type 2 unresponsive to medical therapy, with national allocation via Transplant Australia.
Hepatopulmonary syndrome qualifies for MELD exception points when PaO₂ < 60 mmHg on room air, with intrapulmonary shunting confirmed by contrast-enhanced echocardiography.
Post-transplant long-term survival in Australia reaches approximately 90% at one year, 80% at five years, and 65–70% at ten years for most indications, with quality-of-life improvements typically apparent within 6–12 months.

Introduction & Australian Epidemiology

Liver transplantation is the definitive and potentially curative treatment for patients with end-stage liver disease (ESLD), acute liver failure (ALF), and selected hepatic malignancies. Since the first successful human liver transplant performed by Thomas Starzl in 1967, the procedure has evolved into a standardised, life-saving intervention with excellent long-term outcomes.

Australian context: Australia performs approximately 550–650 liver transplants annually across six designated transplant centres — Royal Prince Alfred Hospital (Sydney), Austin Health (Melbourne), Princess Alexandra Hospital (Brisbane), Sir Charles Gairdner Hospital (Perth), Flinders Medical Centre (Adelaide), and the Australian National Liver Transplant Unit (Sydney Children's Hospital Network for paediatric recipients). The Australian and New Zealand Liver Transplant Registry (ANZLTR) reports one-year patient survival rates of approximately 89–92%, five-year survival of 80–85%, and ten-year survival of 65–70%, reflecting outcomes comparable to leading international centres.

The national wait-list is managed by Transplant Australia, with donor organs allocated through DonateLife (organ procurement) and the Australian Organ Donor Allocation System (AODAS). Living donor liver transplantation (LDLT) has expanded the donor pool, now accounting for 15–20% of all liver transplants performed in Australia. The predominant indications in Australia are chronic liver disease (alcoholic liver disease, hepatitis C–related cirrhosis [declining with direct-acting antiviral availability], NAFLD/NASH [increasing]), HCC, ALF (paracetamol-induced and idiosyncratic drug reactions), and increasingly, inherited metabolic liver disease in the paediatric population.

ℹ️

Key Australian resource: The Australian and New Zealand Liver Transplant Registry (ANZLTR) provides outcome data and is managed by the Australian National Liver Transplant Unit. All transplant centres contribute mandatory data for quality assurance and research.

Indications & Assessment

General Indications for Liver Transplantation

Liver transplantation is indicated when the predicted survival without transplant is lower than expected survival with transplant, or when the quality of life is unacceptable and transplantation offers a meaningful improvement. The following conditions represent established indications.

Decompensated Cirrhosis (Child-Turcotte-Pugh / MELD-Na / UKELD)

Decompensation events — ascites, hepatic encephalopathy, variceal haemorrhage, hepatorenal syndrome, or spontaneous bacterial peritonitis — mark the transition from compensated to decompensated cirrhosis, with one-year mortality rising from 1–5% to 20–50%. Referral for transplant assessment is recommended at the first decompensation event.

Scoring systems for prioritisation:

Score	Components	Threshold for Listing	Notes
MELD-Na	Bilirubin, INR, creatinine, sodium (range 6–40)	≥ 15 (3-month mortality ~ 10–20%)	Primary allocation metric in US; used in Australian triage; incorporated into AODAS
MELD 3.0	Adds albumin and female sex modifier to MELD-Na	≥ 15	Implemented in US from 2023; reduces sex disparity; under evaluation in Australia
UKELD	Bilirubin, INR, creatinine, sodium	≥ 49 (5-year mortality ≥ 50% without transplant)	UK-based; used historically in some Australian centres; regression model
Child-Turcotte-Pugh (CTP)	Encephalopathy grade, ascites, bilirubin, albumin, INR (Class A/B/C)	CTP Class C (score 10–15)	Older system; subjectivity in ascites/encephalopathy grading; still widely referenced

Australian note: In Australia, MELD-Na is used alongside clinical assessment by multidisciplinary transplant teams. Patients with MELD-Na < 15 but recurrent decompensation, refractory ascites, or hepatopulmonary syndrome may still be considered for listing based on clinical judgement and MELD exception pathways.

Hepatocellular Carcinoma (HCC)

Liver transplantation remains the optimal treatment for HCC in the setting of cirrhosis, as it simultaneously removes the tumour and the underlying cirrhotic liver with its field effect for recurrence.

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Milan Criteria (primary selection standard): Single tumour ≤ 5 cm, OR up to 3 tumours each ≤ 3 cm; no macrovascular invasion; no extrahepatic disease. Within Milan, five-year recurrence-free survival exceeds 70%.

MELD exception for HCC: HCC patients within Milan criteria are eligible for MELD exception points (currently 28 points in the US system, with escalation to 29 at 3-month intervals if not transplanted). In Australia, allocation follows national guidelines through Transplant Australia with AODAS oversight. Expanded criteria (UCSF, Up-to-7) are used at some centres for selected patients with excellent response to locoregional therapy.

Acute Liver Failure (ALF)

ALF is defined as severe acute liver injury with encephalopathy and impaired synthetic function (INR ≥ 1.5) in the absence of pre-existing liver disease, occurring within 26 weeks of symptom onset. It carries high mortality without transplantation.

King's College Criteria for transplant listing:

Aetiology	Criteria for "Poor Prognosis" (Transplant Listing)
Paracetamol-induced ALF	Arterial pH < 7.3 (after fluid resuscitation, regardless of encephalopathy grade), OR all three of: INR > 6.5 Creatinine > 300 µmol/L Grade III–IV hepatic encephalopathy
Non-paracetamol ALF	INR > 6.5 (regardless of encephalopathy grade), OR any three of the following five factors: Age < 10 or > 40 years Aetiology: non-A non-B hepatitis, halothane hepatitis, or idiosyncratic drug reaction Jaundice-to-encephalopathy interval > 7 days INR > 3.5 Serum bilirubin > 300 µmol/L

⚠️

Time-critical: ALF patients meeting King's College Criteria require urgent listing and may be transferred to a transplant centre for management while awaiting organ availability. Use of N-acetylcysteine (NAC) in non-paracetamol ALF may provide modest survival benefit and should be initiated early.

Inherited Metabolic Disease

Liver transplantation is curative for several inherited metabolic diseases where the primary enzymatic defect resides within hepatocytes. These include:

Wilson's disease — Fulminant presentation or decompensated cirrhosis unresponsive to chelation therapy (penicillamine, trientine)
Alpha-1 antitrypsin deficiency (PiZZ) — With decompensated cirrhosis; does not reverse pulmonary disease
Urea cycle defects (OTC deficiency, CPS1 deficiency, citrullinaemia) — When dietary/medical management fails; restores hepatic urea cycle function
Glycogen storage disease type I/IV — Progressive liver failure or refractory metabolic complications
Crigler-Najjar syndrome type I — Unconjugated hyperbilirubinaemia unresponsive to phototherapy; risk of kernicterus
Familial amyloid polyneuropathy (FAP) — Liver produces mutant transthyretin; transplantation halts systemic amyloid deposition (combined with cardiac transplant if cardiac involvement)
Primary hyperoxaluria type 1 — Combined liver–kidney transplant corrects hepatic enzyme deficiency and replaces damaged kidneys

Hepatopulmonary Syndrome (HPS) — MELD Exception

HPS is characterised by the triad of liver disease, intrapulmonary vascular dilatation, and impaired oxygenation. Transplantation is the only effective treatment.

Diagnostic criteria:

Intrapulmonary shunting confirmed by contrast-enhanced echocardiography (bubbles appearing in left atrium 3–6 cardiac cycles after injection) or Tc-99m macroaggregated albumin lung perfusion scan (brain uptake > 6%)
Alveolar-arterial (A-a) gradient ≥ 15 mmHg (or ≥ 20 mmHg if age > 64 years)
PaO₂ < 80 mmHg on arterial blood gas in room air (severe HPS: PaO₂ < 60 mmHg)

MELD exception: Patients with documented HPS and PaO₂ < 60 mmHg qualify for MELD exception points (22 points with automatic upgrade), providing priority access to transplantation given the progressive and fatal natural history of HPS.

Pre-Transplant Workup

Comprehensive multidisciplinary assessment is mandatory and typically requires 2–6 months. The evaluation is designed to confirm the indication, exclude contraindications, and optimise comorbidities before surgery.

1

Cardiac Assessment

Transthoracic echocardiography (resting) — assess ventricular function, valvular disease, portopulmonary hypertension
Stress testing — dobutamine stress echocardiography (preferred in cirrhosis, avoids exercise limitation) or myocardial perfusion scintigraphy
Coronary angiography if stress test positive or significant cardiovascular risk factors (age > 50, diabetes, smoking, hypertension, family history)
Portopulmonary hypertension screening: right heart catheteration if echo suggests pulmonary hypertension (mPAP > 25 mmHg at rest); severe PoPH (mPAP > 35 mmHg or PVR > 3 Wood units) is a relative contraindication without treatment response
Cirrhotic cardiomyopathy screening (diastolic dysfunction, chronotropic incompetence, QTc prolongation)

2

Pulmonary Assessment

Pulmonary function tests (spirometry, DLCO)
Arterial blood gas on room air — assess for HPS (A-a gradient, PaO₂)
Contrast-enhanced agitated saline echocardiography — gold standard for intrapulmonary shunt detection (HPS)
Chest CT if indicated (tobacco history, suspected interstitial lung disease)
Exclusion of intrinsic pulmonary disease that would preclude safe surgery and mechanical ventilation

3

Renal Assessment

Serum creatinine, eGFR (CKD-EPI formula), urine protein-to-creatinine ratio, urinalysis
Hepatorenal syndrome (HRS) classification — type 1 (acute) vs type 2 (chronic); response to terlipressin/albumin or midodrine/octreotide
Combined liver–kidney transplant considered if: eGFR < 30 mL/min/1.73 m² sustained ≥ 90 days, or HRS type 2 with eGFR < 20, or need for dialysis ≥ 6 weeks
Renal biopsy if aetiology of kidney disease is unclear (e.g., IgA nephropathy, diabetic nephropathy vs hepatorenal)

4

Psychosocial Assessment

Formal evaluation by transplant psychiatrist or psychologist
Substance use history — alcohol, tobacco, illicit drugs; urine drug screening
Abstinence documentation — most Australian centres require ≥ 6 months demonstrated abstinence for alcohol-related liver disease (ALD) before listing, supported by counselling and/or Alcoholics Anonymous engagement
Social support assessment — primary caregiver, accommodation, transportation to transplant centre
Cognitive capacity assessment — ability to understand and comply with lifelong immunosuppression, clinic appointments, medication management
Mental health screening (PHQ-9, GAD-7) — depression and anxiety must be optimised before listing
Financial counselling — PBS medications, ongoing specialist costs, travel for regional/remote patients

5

Additional Workup Components

Viral hepatitis serology (HBV, HCV, HIV) — HCV treatment with direct-acting antivirals (DAAs) is PBS-listed and should be initiated pre-transplant if feasible
CMV, EBV, VZV serology (IgG) — guides post-transplant prophylaxis
Blood group and HLA typing, panel reactive antibody (PRA)
Cross-sectional imaging (CT abdomen with contrast, MRI/MRCP if indicated) — vascular anatomy, portal vein patency, HCC staging
Age-appropriate cancer screening — colonoscopy (age > 50 or symptomatic), mammography, cervical screening, PSA (individualised)
Bone densitometry (DEXA) — hepatic osteodystrophy common, especially with cholestatic disease
Dental assessment — optimise oral health to reduce post-transplant infection risk
Nutritional assessment — sarcopenia is common and associated with worse post-transplant outcomes; dietitian involvement

Allocation & Contraindications

Liver Organ Allocation

Organ allocation aims to balance urgency (who will die soonest without a transplant) with utility (who will benefit most from the available organ). Allocation systems vary by jurisdiction.

MELD-Na — Primary Allocation Metric

MELD-Na has been the dominant allocation metric in the United States since 2016 and is used in modified form in Australia. It integrates objective laboratory values — bilirubin, INR, creatinine, and serum sodium — to predict 90-day mortality on the waiting list. The score ranges from 6 to 40.

MELD-Na 6–14: Low wait-list mortality; transplantation may not provide survival benefit
MELD-Na 15–20: Moderate urgency; transplantation generally provides survival benefit
MELD-Na 21–29: High urgency; shorter expected wait time
MELD-Na 30–40: Very high urgency; perioperative risk also increases; some centres may favour lower-MELD patients with living donor options

MELD 3.0

Introduced in the United States in January 2023, MELD 3.0 modifies MELD-Na by adding a serum albumin coefficient and applying a female sex adjustment (additional points for women, correcting for lower creatinine due to reduced muscle mass). It has reduced sex-based disparities in transplant access. MELD 3.0 is under evaluation for adoption in the Australian allocation framework through Transplant Australia.

MELD Exception Points

Not all patients with high mortality risk are captured by laboratory-based MELD scores. Exception points provide standardised priority for specific conditions:

Condition	Exception Points	Criteria
HCC (within Milan)	28 points (initial), +1 every 3 months to max 34	Single ≤ 5 cm or up to 3 each ≤ 3 cm; AFP < 1,000 ng/mL; no vascular invasion
Hepatopulmonary syndrome	22 points (automatic upgrade)	PaO₂ < 60 mmHg on ABG room air; confirmed shunt on contrast echo
Hilar cholangiocarcinoma	28 points (after neoadjuvant protocol)	Selected centres only; neoadjuvant chemoRT + brachytherapy; tumour ≤ 3 cm; no intrahepatic/extrahepatic metastases
Cholestatic liver disease	May qualify for increased points	PBC/PSC with intractable pruritus, recurrent cholangitis, or refractory metabolic bone disease
Familial amyloid polyneuropathy	Varies by centre	Documented TTR mutation; progressive neuropathy; Australian centre evaluation

Australian allocation: In Australia, the Australian Organ Donor Allocation System (AODAS) manages deceased donor liver allocation. Priority is based on clinical urgency, predicted benefit, blood group compatibility, donor-recipient size matching, and logistical factors (distance from donor hospital). Living donor transplantation bypasses the deceased donor wait-list entirely. Transplant Australia coordinates the national framework with input from the six liver transplant centres.

Contraindications to Liver Transplantation

Absolute Contraindications

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Extrahepatic malignancy — active or recently treated cancer (unless disease-free for ≥ 2 years; non-melanoma skin cancers and certain low-risk cancers excepted)
Uncontrolled sepsis — active systemic infection not responsive to appropriate antimicrobial therapy
Severe irreversible cardiopulmonary disease — severe coronary artery disease not amenable to revascularisation, severe irreversible pulmonary hypertension (mPAP > 35 mmHg, PVR > 3 Wood units despite therapy), severe left ventricular dysfunction (LVEF < 30%)
Ongoing harmful alcohol or substance use — active alcohol use disorder without demonstrated abstinence (typically ≥ 6 months with engagement in addiction treatment); active illicit substance use (methamphetamine, opioids without supervised substitution therapy)
Inability to comply with immunosuppression — severe psychiatric illness, cognitive impairment, or lack of social support precluding reliable medication adherence and follow-up
Cholangiocarcinoma with metastases — outside the highly selected neoadjuvant protocol
HIV with uncontrolled viraemia — though well-controlled HIV on ART with undetectable viral load is no longer an absolute contraindication at experienced centres

Relative Contraindications

Age > 70 years — physiologic age more important than chronological; outcomes in carefully selected elderly recipients are acceptable
Portal vein thrombosis — may require portal vein reconstruction; extensive thrombosis (cavernoma) increases surgical complexity but is no longer an absolute barrier at experienced centres
Body mass index > 40 kg/m² — increased perioperative risk, wound complications, metabolic syndrome
Prior abdominal surgery — increases operative complexity but is manageable
Non-adherence to prior medical care — raises concern for post-transplant non-compliance; requires intensive psychosocial intervention and clear behavioural contracts
Recurrent HCC beyond Milan — downstaging with locoregional therapy (TACE, ablation) may permit listing at selected centres
Severe malnutrition/sarcopenia — nutritional optimisation before listing improves outcomes

Living Donor Liver Transplantation

Living donor liver transplantation (LDLT) involves the transplantation of a hepatic lobe from a healthy living donor to a recipient. It offers the advantage of elective timing, shorter ischaemia times, and expansion of the donor pool beyond deceased organ availability. LDLT now accounts for 15–20% of liver transplants in Australia and is the predominant form of liver transplantation in parts of Asia (Japan, Korea, India).

Donor Evaluation

The evaluation of potential living donors is rigorous and designed to protect donor safety above all else. It is conducted by an independent donor advocate team separate from the recipient's transplant team.

1

Medical Evaluation

Age 18–60 years (guideline range; individualised)
ABO blood group compatibility (or ABO-incompatible protocol if applicable)
BMI < 30 kg/m² (ideally < 28); liver steatosis assessment (MRI-PDFF or biopsy if > 10% steatosis on imaging)
Liver function tests within normal limits; no chronic liver disease
Hepatitis B surface antigen negative, hepatitis C antibody negative, HIV negative; adequate HBV immunity (anti-HBs > 10 IU/L)
Normal renal function, no diabetes, no significant cardiovascular disease
Haematology, coagulation screen, thyroid function, tumour markers (AFP, CA 19-9)

2

Anatomical Evaluation

CT volumetry with 3D reconstruction — determines total liver volume, graft volume (right or left lobe), graft-to-recipient body weight ratio (GRWR), vascular anatomy
GRWR ≥ 0.8% required (ideal ≥ 1.0%)
Remnant liver volume ≥ 30% of total liver volume for donor safety (≥ 35% if steatosis present)
MRCP (magnetic resonance cholangiopancreatography) — maps biliary anatomy (anatomical variants present in 30–40% of the population)
Portal vein variants, hepatic artery anatomy (Michels classification), hepatic venous drainage pattern
Donor-recipient vascular compatibility assessment

3

Psychosocial Evaluation

Independent assessment by transplant psychiatrist/psychologist — separate from recipient team
Voluntary informed consent — no coercion, no financial inducement (direct or indirect)
Assessment of motivations, understanding of risks, coping strategies
Evaluation of social support during postoperative recovery (typically 6–12 weeks off work)
Right to withdraw at any stage — including on the day of surgery — without disclosure to the recipient (the transplant team may state "medical reasons")
Assessment for undisclosed coercion (family pressure, financial motivation, relationship dynamics)

Right vs Left Lobe Grafts

class="guideline-td">Simpler reconstruction; lower biliary complication rate

Feature	Right Lobe Graft	Left Lobe Graft
Volume	55–65% of total liver volume	35–45% of total liver volume
Recipient	Adults; preferred for large adult recipients (GRWR ≥ 0.8%)	Paediatric recipients, small adults; suitable for adults if GRWR ≥ 0.8%
Donor risk	Greater donor morbidity (larger resection); remnant must be ≥ 30%	Lower donor morbidity (smaller resection); more favourable remnant margin
Complexity	More complex vascular/biliary reconstruction; higher risk of biliary complications
Australian practice	Most commonly used for adult recipients at Australian centres	Used for paediatric recipients and selected adult recipients

Small-for-Size Syndrome (SFSS)

Small-for-size syndrome occurs when the graft volume is insufficient for the recipient's metabolic demands, leading to portal hyperperfusion and graft dysfunction.

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Risk factors for SFSS:

GRWR < 0.8% (critical threshold)
Portal vein flow > 250 mL/min/100 g graft tissue
Persistent portal hypertension in recipient
Steatotic graft (> 30% macrovesicular steatosis)

Clinical features: Prolonged cholestasis (persistent hyperbilirubinaemia), coagulopathy, ascites (> 1 L/day for > 7 days), encephalopathy — appearing within 1–2 weeks post-transplant. Prevention strategies: Splenic artery ligation/embolisation, portocaval shunt, portal flow modulation, appropriate graft selection to ensure GRWR ≥ 0.8–1.0%.

Ethical Principles

LDLT is unique in medicine because a healthy individual undergoes major surgery solely to benefit another. Ethical rigour is paramount.

Donor autonomy: Informed consent must be genuine, voluntary, and free from coercion. Donors must understand that donor hepatectomy carries a mortality risk of approximately 0.2–0.5% (right lobe) and a major morbidity rate of 5–10%.
Non-maleficence (do no harm): The donor must not be placed at undue risk. Independent donor advocates and ethics committee review are standard in Australian centres.
Beneficence: The transplant team must ensure the recipient will derive meaningful benefit (adequate graft function, acceptable survival).
Confidentiality: The donor may withdraw at any time, and the reason is not disclosed to the recipient — the team may cite "medical" or "unsuitability" reasons.
No commercialisation: Australian law (Human Tissue Act, state-based legislation) strictly prohibits payment for organ donation.

Recipient Outcomes — LDLT vs Deceased Donor

Evidence from international registries and Australian data demonstrates that LDLT recipient outcomes are comparable to, and in some series slightly better than, deceased donor liver transplantation (DDLT), primarily due to shorter cold ischaemia times and elective scheduling.

One-year graft survival: LDLT 85–92% vs DDLT 85–90%
One-year patient survival: LDLT 88–93% vs DDLT 87–92%
Five-year patient survival: LDLT 78–85% vs DDLT 75–82%
Biliary complications: Higher in LDLT (10–30%) vs DDLT (5–15%) — anastomotic strictures and leaks more common due to small duct size and segmental anatomy
Wait-list time: LDLT allows planned surgery, reducing wait-list mortality risk

✅

Australian LDLT experience: Royal Prince Alfred Hospital (Sydney) and Austin Health (Melbourne) are the primary LDLT centres. Australian centres report excellent outcomes with graft and patient survival rates comparable to the best international programmes. Donor safety remains the overriding priority, with a dedicated independent donor assessment process.

Special Populations

🤰 Pregnancy

Pre-transplant

Pregnancy is a contraindication to liver transplantation (immunosuppression teratogenicity, surgical risk). Pregnancy should be deferred until post-transplant stabilisation. Contraception counselling is essential for women of reproductive age on the transplant wait-list.

Post-transplant pregnancy

Pregnancy is generally safe 1–2 years post-transplant with stable graft function. Tacrolimus is compatible with pregnancy (Category C; no evidence of teratogenicity in humans). Mycophenolate must be ceased ≥ 6 weeks before conception (teratogenic — Category D). Sirolimus should be avoided. Specialist obstetric and transplant team co-management is mandatory.

👶 Paediatrics

Indications

Biliary atresia (most common, ~50% of paediatric transplants), metabolic liver disease, ALF, progressive familial intrahepatic cholestasis (PFIC), Alagille syndrome. Australian paediatric transplants performed at Sydney Children's Hospital Network (Westmead) and Royal Children's Hospital (Melbourne).

Technical considerations

Reduced-size, split, and living donor grafts are essential due to limited donor paediatric organs. Split-liver transplantation allows one deceased donor liver to serve two recipients (adult and child). Weight < 6 kg is high risk. ABO-incompatible transplantation is more commonly performed in paediatrics with acceptable outcomes.

Immunosuppression

Tacrolimus-based regimens standard; weight-based dosing with therapeutic drug monitoring. Children have higher rates of post-transplant lymphoproliferative disorder (PTLD) — often EBV-driven — requiring EBV viral load monitoring.

👴 Elderly (≥ 65 years)

Considerations

No absolute age cut-off; physiologic age and frailty (assessed by Fried frailty phenotype or liver frailty index) are more important than chronological age. Pre-transplant sarcopenia assessment (L3 CT cross-sectional area) predicts outcomes. Increased cardiovascular and renal risk. CNI-related nephrotoxicity and diabetes risk amplified.

Outcomes

Carefully selected recipients aged 65–70 have one-year survival of 85–88%, slightly lower than younger cohorts. Frail patients have significantly worse outcomes and may not benefit from transplant.

🫘 Renal Impairment

Hepatorenal syndrome

Type 1 HRS (acute): terlipressin (PBS Authority Required) + albumin; response may permit single-organ liver transplant. Type 2 HRS (chronic): midodrine + octreotide + albumin; combined liver–kidney transplant if eGFR < 20.

Combined liver–kidney transplant

Indicated when eGFR < 30 mL/min/1.73 m² sustained ≥ 90 days, dialysis-dependent acute kidney injury ≥ 6 weeks, or metabolic disease causing both hepatic and renal failure (primary hyperoxaluria type 1). Allocates kidneys from the same donor.

Post-transplant renal protection

Tacrolimus dose minimisation; mycophenolate-based CNI minimisation protocols; avoid nephrotoxins (NSAIDs, aminoglycosides). Monitor eGFR quarterly. Sirolimus may be considered for CNI-related nephrotoxicity.

🫁 Hepatic (Re-transplantation)

Indications

Primary non-function, hepatic artery thrombosis, chronic rejection, recurrent disease (HCV — now rare with DAA treatment pre/post-transplant). Re-transplantation carries lower survival (~70% at one year vs ~90% primary) and is ethically challenging given organ scarcity.

🛡️ Immunocompromised

HIV-positive recipients

Well-controlled HIV on ART (undetectable viral load, CD4 > 200/µL) is no longer an absolute contraindication. Drug interactions between ART and immunosuppression (especially CNI metabolism via CYP3A4) require specialist pharmacology input. Outcomes comparable to HIV-negative recipients at experienced centres.

Post-transplant immunosuppression

Standard: tacrolimus + mycophenolate mofetil ± corticosteroids (induction with methylprednisolone; prednisolone weaned over 3–6 months). Basiliximab (anti-IL-2R) induction for steroid-sparing or high-risk patients. Target trough tacrolimus: 8–12 ng/mL (early), 5–8 ng/mL (maintenance). Infection prophylaxis: co-trimoxazole (Pneumocystis jirovecii, 12 months), valganciclovir (CMV, 3–6 months), fluconazole (fungal, 1–3 months).

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Disease burden

Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of chronic liver disease, including hepatitis B (endemic in some remote communities), hepatitis C, and increasingly NAFLD/NASH linked to metabolic syndrome. Liver disease mortality is 4–6 times higher in Indigenous Australians compared to non-Indigenous Australians (AIHW, 2022).

Transplant access

Despite higher disease burden, Indigenous Australians are under-represented on transplant wait-lists. Barriers include late presentation, geographic remoteness from transplant centres (all located in major cities), lower GP referral rates for specialist transplant assessment, and health literacy gaps.

Remote & rural challenges

Patients from remote communities (Northern Territory, Far North Queensland, Western Australia) face extreme distances to transplant centres. Post-transplant follow-up requires accommodation near the centre for 3–6 months. Telehealth is used for longer-term follow-up but cannot replace blood test monitoring for immunosuppression levels (tacrolimus trough requires local pathology access). DonateLife participation and organ donation rates in Indigenous communities are lower; culturally appropriate engagement is essential.

Cultural safety

Transplant assessment and care must be culturally safe. This includes Aboriginal Health Worker involvement in pre-transplant counselling, family-centred decision-making (recognising kinship structures), use of interpreter services for communities where English is a second or third language, and respect for cultural practices around death, organ donation, and body integrity. Transplant teams should engage with local Aboriginal Community Controlled Health Organisations (ACCHOs).

Alcohol-related liver disease

ALD is a significant indication for transplant in Indigenous communities. Assessment requires culturally appropriate addiction medicine input. The standard 6-month abstinence rule applies but may need flexibility in the context of social disadvantage, limited local addiction services, and historical trauma. Aboriginal-specific drug and alcohol services should be engaged.

HBV and liver cancer prevention

Universal HBV vaccination of neonates (funded since 2000) has reduced new HBV infections. However, many older Indigenous adults remain unvaccinated or have chronic HBV. Screening for HCC in chronic HBV (6-monthly ultrasound + AFP) must be promoted through primary healthcare, particularly in remote communities. The RHDAustralia guidelines provide specific HBV management protocols for Indigenous settings.

Post-transplant follow-up

Medication adherence (tacrolimus, mycophenolate) is critical and can be challenging in remote settings with limited pharmacy access and complex medication regimens. Simplified dosing schedules, blister packs, and community pharmacist engagement are recommended. Government-funded Patient Assistance Transport Schemes (PATS) may assist with travel costs for transplant follow-up.

📚 References

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