Liver Transplant Criteria and Needs for Donor & Recipient

Medically Reviewed by Dr. Aman Priya Khanna
Written by Dr Sania Datta, last updated on 17 July 2023
Liver Transplant Criteria and Needs for Donor & Recipient

Medical technology has reached a point where a person with a diseased liver can actually get a whole new liver by undergoing liver transplantation. A liver transplant is a surgical procedure in which a damaged liver is replaced with a healthy one. A liver patient can get a whole liver transplant from a deceased person (deceased donor) or a part of a liver from a living person (living donor). 

A liver transplant is a life-saving procedure that has saved many lives. Many are waiting for their turn to get a liver transplant. But how to opt for a liver transplantation procedure? Is there  a waiting list? Where to register? There are many criteria that you must fulfil before your turn. First, you must know all the processes you might go through to get a liver transplant.

Why is there a Need for a Liver Transplant?

The liver is a vital organ as it performs more than 500 functions for properly working the human body. The liver functioning may get altered due to several reasons, such as acute (immediate) causes like poisoning or chronic (long-term) causes like hepatic cirrhosis. A person may need a liver transplant if there is improper liver functioning in conditions such as:

  1. Hepatitis (B or C)
  2. Liver failure
  3. Primary liver cancer 
  4. Biliary atresia (a rare condition of the bile ducts and liver in newborns)
  5. Acute hepatic necrosis (liver tissue dies)
  6. Autoimmune hepatitis

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Who are the Candidates for a Liver Transplant?

The right candidate for receiving a liver transplant is a patient who is:

  1. Healthy enough to recover after the transplant surgery.
  2. Showing clinical signs of primary liver cancer or liver failure.
  3. Not considered at risk of future drug or alcohol abuse.

The candidates who are not appropriate for a liver transplant are patients with:

  1. Cancer, that has spread to other parts of the body.
  2. Chronic or current infection that limits short-term life expectancy.
  3. Heart condition.
  4. Another serious disease besides liver condition that will not get better after a liver transplant.
  5. A history of non-compliance and being unable to follow a treatment plan.
  6. A habit of Active drug and/or alcohol abuse

Selection Criteria of the Candidates for a Liver Transplant

  1. King’s College Criteria for Liver Transplant: Various factors are used to diagnose patients with AHF (acute hepatic failure). Many predictive models have been established to check when a liver transplant is suggested for a person. The most widely accepted one is the King’s College criteria. The King’s College criteria for liver transplant include:
    APAP (acetaminophen)-associated AHF All other AHF causes
    pH < 7.3 INR > 6.5
    Or Or
    1. International normalised ratio (INR) >6.5,
    2. Serum creatinine > 3.4 mg/dl,
    3. Grade III-IV encephalopathy

    Three of the following variables:

    1. INR > 3.5
    2. Age < 10 or > 40 years
    3. Serum bilirubin > 17.5 mg/dl
    4. Duration of jaundice before encephalopathy > 7 days
    5. The cause is non-A, non-B hepatitis or idiosyncratic drug reaction
  2. Milan criteria for Liver Transplant: The Milan criteria help determine whether a patient with hepatocellular carcinoma (HCC) can opt for liver transplantation. These criteria have been adopted by several transplant societies worldwide. The following table elaborates on the Milan criteria.
    Criteria Description Tissue/biopsy needed?
    Milan criteria

    1 lesion ≥ 2 cm and ≤ 5 cm OR up to 3 lesions, Each ≥ 1 cm and ≤ 3 cm, No evidence of extrahepatic metastases or vascular invasion

  3. MELD/PELD system: The Model for End-Stage Liver Disease (MELD) and Paediatric End-Stage Liver Disease (PELD) system was set up to predict risk of death in patients with chronic liver disease. It is good at predicting outcomes in both children and adults with AHF. It is a scoring system for chronic liver diseases and is calculated using blood test results.The test measures:
    1. Bilirubin: an elevated level of bilirubin shows that the bile is leaking into the bloodstream
    2. Creatinine: shows the proper functioning of the liver and kidney
    3. Albumin: measures the functioning of the kidney
    4. Prothrombin time: the time taken by the blood to clot which indicates the production of blood clotting factors by the liver. The MELD and PELD characteristics used in calculating the scores for determining prognoses are:​​​​​
      Bilirubin (mg/dl) Bilirubin (mg/dl)
      Serum creatinine (mg/dl) * Albumin (g/dl)
      INR INR
        Age at listing
        Growth failure (based on height, gender, and weight)
      * Patients who had dialysis twice in the past week are automatically set to a creatine level of 4 mg/dl3The patients are rated on a scale of 6 (least severe) to 40 (most severe). Further, the MELD scores are paired with other factors, such as the chance of survival and the patient’s distance from the donor hospital, to decide the priority.The MELD score is continuously measured to ensure accuracy. The frequency of testing depends on how high the scores are:
      1. 6 to 10: remeasured once a year

      2. 11 to 18: remeasured every three months

      3. 19 to 24: remeasured once a month

      4. 25 to 40: remeasured every week

What is the registration process for a liver transplant?

Registration and listing of recipients:

  1. The patient should register with the hospital where they want to do the surgery by registering online at "". 
  2. The liver advisory committee will approve the registration and urgency criteria.
  3. At the time of listing, the patient should be less than 65 years of age.
  4. The patient with liver cirrhosis should meet the standard criteria for liver transplant with a MELD score of more than 15 in patients aged 12 and above. 
  5. A super-urgent listing is done in the following situations:
    1. Early hepatic artery failure (HAT) needs re-transplant.
    2. Primary non-function (PNF) of liver allograft
    3. Fulminant hepatic failure (FHF) meeting the king’s college criteria
    4. A living liver donor who develops life-threatening liver failure
  6. Patients with metabolic disorders who do not have the minimum required MELD score, including intractable pruritus, polycystic liver disease, and chronic hepatic encephalopathy, will not be considered for listing disease donor liver transplant (DDLT) for now.
  7. Contraindications to listing for liver transplantation:
    1. AIDS
    2. MELD score < 15
    3. Uncontrolled sepsis
    4. Severe pulmonary or cardiac disease, and who are not fit for general anaesthesia
    5. Intrahepatic cholangiocarcinoma
    6. Hepatocellular carcinoma more than UCSF (University of California, San Francisco) criteria
    7. Extra-hepatic cancer
  8. The patient should only be registered in one hospital, which is registered under the Transplantation of Human Organ and Tissue Act (THOTA)
  9. The patient should be registered for a deceased donor even when waiting for a living donor.
  10. The hospital should update the status each month for the listed patients; for the super-urgent patient, the status should be updated more regularly.

What are allocation principles for recipients?

  1. The liver allocation is done according to the waiting list. Firstly, it is done based on the state waiting list. Suppose there is no recipient eligible for the state waiting list, in that case, the allocation is done according to the Army hospital Research And Referral (R&R) to a nearby state in the regional organ and tissue transplant organisation (ROTTO), and then to other ROTTO nationally. 
  2. The liver from a paediatric donor (< 16 years) will first go to a paediatric recipient. If no paediatric recipient is eligible, it will go to an adult patient.
  3. Liver from a donor of blood group O will be allocated to group O recipient and then to any other blood group if no one is eligible.
  4. The other blood groups A, B, and AB will be allocated to the same blood group recipient, except AB, which can be donated to all blood groups.

What is the Allocation algorithm?

Once consent is received for a donation from a deceased person, the following steps are followed:

  1. Step 1: Check the age and blood group of the available deceased donor and follow the allocation principles.
  2. Step 2: If a recipient is on the super-urgent list (according to the accepted criteria and registration), the available liver will go to that recipient. If more than two patients are in similar situations, the allocation depends on how long the waiting period has been.
  3. Step 3: If there is no super-urgent patient, the liver goes to the recipient who needs a simultaneous multi-organ transplant. In case two patients have a similar situation, the liver goes to the patient who has waited longer.
  4. Step 4: If there are no multi-organ recipients and no super-urgent patient, then the allocation depends on the status of the hospital doing the liver retrieval. Status means whether it is a transplant hospital or a Non-Transplant Organ Retrieval Centre (NTORC).
    1. In the case of a transplant hospital: The liver will be given to the local transplant hospital, and the hospital will not lose its turn.
    2. In the case of NTORC: The liver will go to a common pool, and from there, the liver will be allocated to the transplant hospital according to the ROTTO (list).

What are the criteria for a liver donor?

An individual must fulfil the following criteria to be able to donate a small part of their liver to someone in need.

  1. Age between 18 to 60 years
  2. Blood type compatibility with the recipient
  3. Sound mental and physical health
  4. BMI (body mass index) less than 35
  5. Free from the following conditions:
    1. Hepatitis 
    2. Ongoing cancer
    3. Active or chronic infection
    4. Significant organ diseases such as kidney or heart diseases
    5. Active substance abuse


All the information you need regarding a liver transplant, various criteria and the registration process for a liver transplant are shared above. If you still have some queries, feel free to visit the HexaHealth website or you can get in touch with our assistant team to resolve all your queries.

Frequently Asked Questions

Who gets priority for liver transplants?

Recipients on the super-urgent list are prioritised for a liver transplant.
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What are the criteria to qualify for a liver transplant?

The patient must satisfy the minimum criteria for a liver transplant, including:

  1. Have clinical signs of primary liver cancer or liver failure.
  2. Be healthy enough to undergo surgery and recovery.
  3. Not be considered at risk of future drug or alcohol abuse.
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Who Is Not a Candidate for a Liver transplant?

A liver transplant is not recommended for individuals who have:

  1. Lung or heart disease or other life-threatening diseases
  2. Cancer history
  3. Hepatitis
  4. Certain infections (osteomyelitis or tuberculosis)
  5. Drug abuse, alcohol, or smoking
  6. Difficulty taking medicines many times a day for their entire lives.
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What happens if two suitable recipients are in line to receive a liver that has been donated?

If there are more than two recipients in similar situations, then the allocation depends on the waiting period that has been longer.
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How is the liver transplant waiting list ranked?

The liver transplant waiting list is ranked according to the MELD score.
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How are donor livers matched with transplant recipients?

The donor’s liver matches the recipient according to the blood group.
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How much liver is needed for a liver transplant?

For a child, 15-20% of the liver is enough for a liver transplant. In the case of adults, either the right lobe (2/3rd part of the liver) or left lobe (1/3rd part of the liver) is used. For an adolescent, mostly the left lobe is sufficient.
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Where do donated livers come from?

The donated livers either come from a deceased donor or a living donor.
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How does living liver donation work?

A piece of the liver is taken from a living donor and transplanted into the recipient. As the liver is a unique organ, the piece inside both the recipient and the donor grows back to its full size.
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What are the next steps once the patient is accepted for a liver transplant?

Once the patient is accepted for a liver transplant, they will be listed with the United network for organ sharing (UNOS). They maintain and administer the computerized national organ transplant waiting list. The patient will enter a list of people waiting for a liver donation from a deceased person.
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Updated on : 17 July 2023


Dr. Aman Priya Khanna

Dr. Aman Priya Khanna

MBBS, DNB General Surgery, Fellowship in Minimal Access Surgery, FIAGES

12 Years Experience

Dr Aman Priya Khanna is a well-known General Surgeon, Proctologist and Bariatric Surgeon currently associated with HealthFort Clinic, Health First Multispecialty Clinic in Delhi. He has 12 years of experience in General Surgery and worke...View More


Dr Sania Datta

Dr Sania Datta

BDS (Panjab University) I MBA Hospital & Health Management (IIHMR Jaipur)

8 Years Experience

She is a high-impact healthcare management and medical content professional with enriching work experience in Parexel, HexaHealth Technologies, Apollo Munich, Credihealth and Fortis Hospital. Armed with deep and c...View More

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