Liver transplantation · Who can receive
Told you are too sick, too old or too heavy for a liver transplant?
Many patients are turned away for reasons that the latest international guidelines no longer accept. Here is what the European and American liver societies actually recommend — and what genuinely rules a patient out.
The short answer
- A low MELD score should never stop a referral. Fluid in the abdomen, confusion or bleeding from varices mean you should be referred immediately.
- Being very sick is not a reason to refuse. A MELD score above 40, or acute-on-chronic liver failure, is not a contraindication.
- There is no age limit. Frailty is measured — but it is not, on its own, a reason to say no.
- Weight alone does not exclude you, and neither does a fixed number of months without alcohol.
- What does rule a patient out: heart disease that cannot be treated, severe pulmonary hypertension, or active cancer.
When should you be referred?
Transplant teams use the MELD score — a number calculated from blood tests (bilirubin, INR, creatinine and sodium) — to measure how severe liver disease is. The higher the score, the more urgent the need.
According to the American guideline, patients on the waiting list may begin to benefit from a transplant at a MELD score above 12, and referral at 15 remains reasonable. But the guideline is clear that a lower MELD score should never be a barrier to referral.
- Ascites — fluid building up in the abdomen
- Hepatic encephalopathy — confusion, drowsiness, personality change
- Variceal bleeding — vomiting blood or black stools
These are signs that the liver is failing, whatever the MELD score says.
"You are too sick for a transplant"
This is one of the hardest things a family can hear — and the guidelines do not support it as a blanket rule. The American guideline states that neither a MELD score above 40 nor acute-on-chronic liver failure (ACLF) is a contraindication. The European guideline recommends that patients with the most severe grade of ACLF be evaluated.
Very sick patients carry higher risk, and not every one of them will be suitable. But the decision should come from a full evaluation — not from the score alone.
"You are too old"
Neither guideline sets an upper age limit. Older candidates are assessed carefully for heart and lung fitness, nutrition and frailty.
Frailty — how physically strong and independent a patient is — matters, because frail patients recover more slowly. Both guidelines say it should be measured with standard tests, not judged by eye, and that frailty on its own is not a reason to refuse.
"You weigh too much"
The American guideline states that patients should not be excluded from evaluation based on BMI alone. Patients with a BMI above 40, or below 18.5, need a nutrition assessment — not an automatic no.
The European guideline goes further for patients with a BMI above 35: weight-loss surgery may be done before the transplant if the cirrhosis is still compensated, or at the time of or after the transplant if it is not.
"You must stop drinking for six months first"
For years, many centres required six months without alcohol before a patient could even be listed. The current guidelines have moved away from this.
- The American guideline states that the length of abstinence should not be a criterion for excluding a patient from the list — particularly when the liver is too sick to wait.
- The European guideline sets no fixed abstinence period, and allows early transplantation for selected patients with severe alcohol-related hepatitis who do not respond to medical treatment.
This does not mean alcohol does not matter. Both guidelines expect a multidisciplinary assessment, and patients on the list continue to be monitored for alcohol use. A commitment to stop drinking is part of the agreement.
Every centre does not follow the same rule
Guidelines describe best practice; individual centres still set their own policies. If you have been refused because of a fixed abstinence period, it is reasonable to ask whether that centre's rule reflects the current guidelines — and to seek a second opinion.
Liver cancer (hepatocellular carcinoma)
A liver transplant can cure some patients with liver cancer, because it removes the tumour and the diseased liver together. Selection matters, because cancer can return after transplantation.
- The Milan criteria remain the standard: a single tumour up to 5 cm, or up to three tumours each up to 3 cm, with no spread into blood vessels or outside the liver.
- Patients beyond the Milan criteria may still be considered if treatment first shrinks the cancer back within limits — known as downstaging.
- A tumour marker (AFP) above 1,000 ng/ml is a warning sign: the European guideline advises against transplantation unless treatment brings it down and keeps it down.
Living donor transplantation may offer options to some patients beyond the Milan criteria, but there is no international agreement on how far these limits can be extended.
What genuinely rules a patient out
| Condition | Why |
|---|---|
| Significant coronary artery disease that cannot be treated | The heart cannot safely survive the operation |
| Severe pulmonary hypertension (mean pressure above 45 mmHg despite treatment) | Very high risk of death during and after surgery |
| Active cancer (except selected slow-growing cancers) | Anti-rejection medicines can speed its growth |
| Complete clotting of the portal vein system (grade IV) | A relative contraindication — needs specialist assessment |
| No reliable support at home, or untreated mental illness | Recovery depends on taking medicines and attending follow-up |
Mental health conditions are not an absolute contraindication if they are treated and stable. Every candidate has an ECG and an echocardiogram of the heart.
The living donor option
Because a liver can regrow, part of a healthy person's liver can be transplanted. For patients travelling to Turkey, a transplant means a living donor — usually a family member.
- The donor must keep at least 30% of their own liver.
- The part given must be large enough for the recipient — generally more than 40% of the recipient's expected liver volume, or more than 0.8% of their body weight.
- Living donor transplantation is beneficial even at lower MELD scores, because it can be done before complications develop.
Who can legally be your donor in Turkey, and what to check before choosing a centre, is explained in Liver transplant in Turkey: the facts and what to check.
"If they said no once, the answer is no."
A refusal based on age, weight, a MELD score or a fixed number of sober months may not reflect current international guidelines. Ask what the specific medical reason was — and get a second opinion.
Medically reviewed by Prof. Dr. Murat Tuncer
Nephrologist and transplant physician. This guide was prepared by the BookingHospital medical team from the current European (EASL) and American (AASLD/AST) liver transplantation guidelines.
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Medical disclaimer. This article is general information based on published international guidelines. It is not personal medical advice, it does not establish a doctor–patient relationship, and it cannot replace assessment by the physician treating you. Eligibility for liver transplantation is decided by a transplant team after detailed testing. Always consult a transplant centre before making decisions about your treatment.
References
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines on liver transplantation. J Hepatol 2024;81(6):1040–1086.
- Dove L, Chadha RM, Lai JC, et al. AASLD AST Practice Guideline on Adult Liver Transplantation: Candidate Evaluation. Hepatology 2025;83(6):1609–1645.
- Miller CM, Quintini C, Dhawan A, et al. The International Liver Transplantation Society Living Donor Liver Transplant Recipient Guideline. Transplantation 2017;101(5):938–944.
