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Liver transplantation

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of liver transplantation are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2025), the European Association for the Study of the Liver (EASL 2024,2023), the European Society of Anaesthesiology and Intensive Care (ESAIC 2023), the American Society of Transplantation (AST 2019), the American College of ...
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Diagnostic investigations

Evaluation of transplant recipients, eligibility: as per EASL 2024 guidelines, do not disqualify a potential candidate for LT based on age alone.
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  • Evaluation of transplant recipients (frailty assessment)

  • Evaluation of liver donors

Medical management

Post-transplant immunosuppression, initiation: as per EASL 2024 guidelines, maintain tacrolimus trough levels at 6-10 ng/mL during the first month, followed by 4-8 ng/mL thereafter.
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  • Post-transplant immunosuppression (monitoring)

  • Post-transplant immunosuppression (de-escalation)

Nonpharmacologic interventions

Dietary modifications: as per AASLD/AST 2013 guidelines, provide ongoing dietary counseling to avoid obesity.
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  • Smoking cessation

  • Alcohol use cessation

  • Environmental exposures

  • Protective habits

Therapeutic procedures

Perfusion preservation strategies
As per EASL 2024 guidelines:
Consider using perfusion preservation strategies at various stages of the donation and transplantation process to reduce adverse post-transplant outcomes, including biliary complications, particularly when using extended criteria and donation after circulatory death grafts.
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Use machine perfusion strategies to increase the donor organ pool and enhance organ utilization.
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Perioperative care

Management of perioperative bleeding: as per ESAIC 2023 guidelines, recognize that higher intraoperative blood loss and transfusion requirements are associated with decreased survival after LT.
B
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Surgical interventions

Considerations for graft use, donors with viral infections: as per EASL 2024 guidelines, consider using HCV RNA-positive grafts in HCV-positive or HCV-negative recipients, provided informed consent is obtained, organ quality is appropriate, and rapid initiation of effective antiviral therapy is ensured.
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  • Considerations for graft use (donors with cancer)

  • Considerations for graft use (donors with familial amyloidotic polyneuropathy)

  • Surgical techniques

Specific circumstances

Pregnant patients, preconception counseling
As per EASL 2024 guidelines:
Provide preconception counseling for liver transplant recipients to assess graft function, rule out the risk of drug-related teratogenic effects, and obtain genetic tests if needed. Ensure a combined, strict follow-up by obstetricians and transplant hepatologists during pregnancy and immediately after delivery.
B
Advise female liver transplant recipients that delaying pregnancy for ≥ 1 year after transplant is associated with improved maternal and fetal outcomes.
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  • Pregnant patients (immunosuppressive therapy)

  • Pregnant patients (surveillance)

  • Patients with obesity

  • Patients with CMV infection

  • Patients with CKD

  • Patients with HIV infection

  • Patients with acute-on-chronic liver failure

  • Patients with portopulmonary hypertension

  • Patients with portal vein thrombosis

  • Patients with coronary artery disease

  • Patients with MASLD or MASH

  • Patients with ALD

  • Patients with viral hepatitis (HBV)

  • Patients with viral hepatitis (HCV)

  • Patients with AIH

  • Patients with primary biliary cirrhosis

  • Patients with primary biliary cholangitis

  • Patients with PSC

  • Patients with liver malignancy (HCC)

  • Patients with liver malignancy (cholangiocarcinoma)

  • Patients with liver malignancy (metastasis)

  • Patients with non-liver malignancy

  • Patients with Wilson's disease

  • Patients with AAT deficiency (LT)

  • Patients with AAT deficiency (liver donation)

Patient education

General counseling: as per AASLD/AST 2013 guidelines, educate all LT recipients about the importance of sun avoidance and sun protection through the use of a sun block with a sun protection factor of at least 15 and protective clothing. Encourage them to examine their skin on a regular basis and report any suspicious or concerning lesions to their physicians.
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Preventative measures

Routine immunizations, general principles: as per AST 2019 guidelines, review vaccination status and develop a vaccination plan in all transplant candidates and recipients.
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  • Routine immunizations (influenza)

  • Routine immunizations (HBV)

  • Routine immunizations (pneumococcal)

  • Routine immunizations (meningococcal)

  • Routine immunizations (herpes zoster)

  • Routine immunizations (HPV)

  • Routine immunizations (measles, mumps, rubella, and varicella)

Follow-up and surveillance

Post-transplant monitoring, liver function: as per AASLD/AST 2013 guidelines, individualize the frequency of follow-up laboratory tests according to the time elapsed since LT, prior complications of LT, the stability of serial test results, and the underlying cause of hepatic disease.
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  • Post-transplant monitoring (renal function)

  • Post-transplant monitoring (BP)

  • Post-transplant monitoring (blood glucose)

  • Post-transplant monitoring (lipid profile)

  • Post-transplant monitoring (bone mineral density)

  • Post-transplant monitoring (QoL)

  • Management of post-transplant complications (hepatic artery thrombosis or stenosis)

  • Management of post-transplant complications (bilomas and biliary cast syndrome)

  • Management of post-transplant complications (opportunistic infections)

  • Management of post-transplant complications (incisional hernia)

  • Management of post-transplant complications (sexual dysfunction)

  • Management of transplant rejection

  • Surveillance for malignancy

Quality improvement

Liver donor programs: as per EASL 2024 guidelines, optimize the allocation of deceased donor livers for transplantation to reduce mortality on the LT waiting list. Consider implementing or expanding living donor LT programs if there is ongoing avoidable waiting list mortality.
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