Questioning Medicine

Clinicians should refer patients for liver transplant evaluation after any decompensation event—such as ascites or variceal bleeding—regardless of MELD score. After a first decompensation, 5-year mortality is 20–30%; after a second, it rises to 80–90%. Refractory ascites carries a 50% 1-year mortality, and overt hepatic encephalopathy has a 25–40% 1-year mortality. After an initial variceal bleed, the 1-year rebleeding risk is 60% without prophylaxis. There are no strict BMI or age cutoffs, and frailty has minimal effect on post-transplant outcomes. Substance use, including alcohol, is not a contraindication to referral—current guidelines no longer require a 6-month abstinence period. CitationsKing LY et al. Guidance for timely referral to liver transplantation. Clin Gastroenterol Hepatol 2025 Aug 5; [e-pub]. (https://doi.org/10.1016/j.cgh.2025.07.032)