01Purpose and principlesWhat the treatment does and how it fits into care.
Liver transplantation replaces a failing or cancer-bearing liver when expected survival or quality-of-life benefit outweighs operative, immunological and donor-organ risks. Referral should occur after first major decompensation, progressive cholestatic or metabolic disease, qualifying HCC, or acute liver failure—well before multi-organ failure removes the opportunity. Assessment defines diagnosis and prognosis, tests cardiovascular and respiratory reserve, evaluates frailty and nutrition, excludes uncontrolled infection or malignancy, and considers alcohol or drug dependence, mental health, adherence, social support and informed consent. These are individual clinical domains, not moral judgements.
After implantation, patterns of abnormality matter. Very poor early graft function may reflect primary dysfunction, preservation injury, shock or vascular compromise. Hepatic-artery thrombosis can rapidly cause graft loss or biliary ischaemia; portal-vein and hepatic-vein obstruction have different haemodynamic consequences. Biliary leak, anastomotic or non-anastomotic strictures, collections and infection often need imaging and endoscopic or radiological intervention. Rejection is diagnosed through clinical context, blood tests, imaging exclusion and sometimes biopsy; empirical alteration of immunosuppression outside the transplant service risks both graft loss and infection.
Long-term survival depends on consistent immunosuppression and preventive care. Calcineurin inhibitors such as tacrolimus are highly interaction-prone and can cause kidney injury, tremor, neurotoxicity, hypertension, hyperglycaemia and electrolyte disturbance. Immunosuppression increases infection and malignancy risk, while the original liver disease or cancer may recur. Shared care therefore needs explicit ownership of trough testing, renal and metabolic surveillance, vaccination, dermatological protection, cancer screening, contraception or pregnancy planning, adherence and emergency contact. The transplant centre remains part of care for life even when routine bloods occur locally.
Key points
- Early transplant referral creates time to assess reversibility, frailty, infection, cancer, cardiopulmonary risk, adherence and the patient's goals before crisis occurs.
- UK listing and allocation follow current NHSBT policies; UKELD, super-urgent status and disease-specific criteria support but do not replace transplant-centre judgement.
- Indications include decompensated chronic liver disease, acute liver failure, selected HCC and certain metabolic, cholestatic or symptom-dominant disorders.
- Immediate graft threats include primary non-function, hepatic-artery thrombosis, portal or hepatic venous problems, biliary leak or obstruction, infection and acute rejection.
- A normal or mildly abnormal liver panel cannot exclude a serious vascular or biliary complication when symptoms or Doppler findings are concerning.
- Tacrolimus exposure is managed by the transplant team using trough concentrations, formulation, time after transplant, graft function, renal function and interacting medicines.
- Macrolides, azole antifungals, rifamycins, some anticonvulsants, grapefruit and St John's wort can cause dangerous tacrolimus changes; check before prescribing.
- Long-term care addresses kidney disease, hypertension, diabetes, dyslipidaemia, bone loss, infection, skin and other cancers, vaccination, recurrence and psychological health.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Ascites, variceal bleeding, encephalopathy, jaundice, declining synthetic function or repeated admissions should prompt specialist transplant consideration rather than waiting for irreversible renal or functional collapse.
Coagulopathy with encephalopathy in a patient without known cirrhosis can deteriorate within hours. Contact a transplant centre early while pursuing cause-specific emergency management.
Rising aminotransferases, lactate, INR or bilirubin, haemodynamic instability, hypoglycaemia and low bile output after surgery require coordinated Doppler, laboratory and surgical assessment.
New abdominal pain, fever, jaundice, pale stools, dark urine or a cholestatic liver profile can signal arterial, portal or biliary complications and needs same-day transplant advice.
Fever may be muted; rigors, lethargy, cough, diarrhoea, urinary symptoms, rash or graft discomfort can represent bacterial, viral, fungal or opportunistic infection.
New tremor, headache, confusion, rising creatinine, hyperkalaemia, hypertension or hyperglycaemia after another prescription, herbal product or diarrhoeal illness can reflect altered immunosuppressant exposure.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Transplant referral assessment panelFirst step - Why
- Define liver prognosis, comorbidity, technical feasibility and expected net transplant benefit.
- Interpretation and limitations
- Combine diagnosis, decompensation history, liver and renal tests, imaging, cancer stage, cardiopulmonary work-up, nutrition, frailty and psychosocial assessment. A single score cannot resolve every indication.
- 02
Liver profile, INR, glucose, lactate and renal profile - Why
- Identify graft dysfunction, synthetic failure, metabolic instability and medicine toxicity.
- Interpretation and limitations
- Interpret trends and injury pattern with time from transplant. Disproportionate cholestasis suggests biliary or vascular causes, while rising creatinine may reflect sepsis, volume loss, calcineurin toxicity or intrinsic renal disease.
- 03
Urgent liver Doppler ultrasound - Why
- Assess hepatic artery, portal vein, hepatic veins, graft parenchyma and biliary dilatation.
- Interpretation and limitations
- Absent or abnormal arterial flow is an emergency but technical artefact exists; escalate equivocal findings for immediate transplant-radiology review and further angiographic imaging when required.
- 04
Tacrolimus or ciclosporin trough level - Why
- Estimate immunosuppressant exposure and guide specialist dose adjustment.
- Interpretation and limitations
- A valid trough is taken immediately before the next dose with formulation, last dose time and interacting medicines recorded. Target ranges vary by regimen and time after transplant; never invent a universal target.
- 05
Microbiology and viral monitoring - Why
- Identify bacterial sepsis and protocol-defined CMV, EBV or other opportunistic infection.
- Interpretation and limitations
- Obtain cultures from likely sites before antimicrobials where safe, but do not delay sepsis care. Viral nucleic-acid results are interpreted against donor-recipient risk, prophylaxis and immunosuppression.
- 06
MRCP, ERCP, angiography or graft biopsy - Why
- Resolve suspected biliary, vascular or rejection pathology after initial assessment.
- Interpretation and limitations
- Choose the test with the transplant MDT. Biopsy can support rejection but only after vascular and biliary obstruction have been considered; invasive tests require coagulation and infection planning.
04Treatment approachPreparation, options, escalation and aftercare.
01ReferCreate a transplant windowFirst stepLiver disease has decompensated, progressed despite treatment, produced qualifying HCC or caused acute liver failure.+
- 1Contact regional hepatology or the transplant centre early, supplying diagnosis, decompensation episodes, current physiology, infection status, renal trajectory, imaging and relevant alcohol or substance history.
- 2Optimise nutrition, frailty, ascites, encephalopathy, infection control and disease-specific treatment while assessment proceeds, avoiding a passive wait for a score to cross a threshold.
- 3Use current NHSBT selection policy and centre review for standard, non-standard and super-urgent indications, and give the patient balanced information about waiting-list, donor and post-transplant risks.
02RespondAssess the unwell recipientA liver-transplant recipient develops fever, jaundice, abdominal pain, abnormal liver tests, oliguria or neurological change.+
- 1Stabilise using ABCDE, obtain cultures and urgent blood tests, establish exact immunosuppressant formulation and last doses, and call the transplant centre at the beginning of management.
- 2Arrange Doppler ultrasound or other urgent imaging appropriate to timing and phenotype while treating sepsis, obstruction or physiological compromise through local emergency pathways.
- 3Do not stop, double or switch immunosuppression empirically; agree dose timing, trough sampling and any temporary route or adjustment directly with the transplant service.
03ProtectDeliver lifelong shared careThe recipient is clinically stable after the early transplant period and routine care is shared locally.+
- 1Maintain an up-to-date medication and interaction record, planned trough and renal monitoring, and a clear process for contacting the transplant pharmacist before new prescriptions or supplements.
- 2Review blood pressure, diabetes, lipids, kidney function, bone health, weight, vaccination, skin protection and standard cancer screening, tailoring frequency to regimen and risk.
- 3Support adherence, mental health, employment, alcohol or substance recovery, contraception and planned pregnancy, and investigate recurrent liver disease or graft dysfunction through specialist follow-up.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Tacrolimus
Use the exact immediate- or prolonged-release product and individual dose prescribed by the transplant team; adjust only against valid trough concentrations, graft status, adverse effects and interactions.Formulations are not freely interchangeable. Monitor nephrotoxicity, neurotoxicity, potassium, magnesium, glucose, blood pressure and QT risk; strong CYP3A inhibitors or inducers, grapefruit and St John's wort can produce dangerous exposure changes.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Follow the transplant centre's schedule for liver tests, INR, renal function, electrolytes, glucose, blood pressure and correctly timed immunosuppressant trough concentrations.
- At every medicine change, screen for CYP3A and P-glycoprotein interactions and arrange extra levels or laboratory checks at the interval specified by the transplant pharmacist.
- Monitor weight, cardiovascular risk, diabetes, kidney disease, bone health and neurological adverse effects rather than focusing exclusively on graft enzymes.
- Review infection symptoms, vaccination status and prophylaxis, remembering that live attenuated vaccines are generally contraindicated during clinically significant immunosuppression.
- Provide sun-protection advice, dermatological review according to risk and age-appropriate cancer screening because cumulative immunosuppression increases malignancy risk.
- Track recurrence of the original liver disease, alcohol or substance-related risk, adherence, mental health and social function through coordinated local and transplant follow-up.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Referral precedes listing
A referral begins a multidimensional assessment and optimisation process; it does not promise a graft, and deferring referral can remove options that earlier work could preserve.
Artery supplies bile ducts
After transplantation the biliary tree depends heavily on hepatic arterial perfusion, explaining why arterial thrombosis can present with biliary necrosis, leak or later strictures.
Trough needs metadata
A tacrolimus number without dose time, sampling time, formulation and interacting medicines may be uninterpretable and can provoke a harmful adjustment.
Rejection is treatable
Abnormal liver tests can reflect rejection, but vascular, biliary, infectious, toxic and recurrent-disease causes overlap; structured exclusion protects both graft and patient.
Primary care remains central
Long-term morbidity often comes from renal, metabolic, skeletal and malignant complications, making reliable shared preventive care as important as transplant-centre surveillance.
08Common pitfallsFrequent interpretation and management errors.
- 01
Waiting for repeated intensive-care admissions before discussing transplantation in a patient with clear decompensation.
- 02
Treating UKELD or another score as the sole selection decision and ignoring disease-specific NHSBT criteria.
- 03
Assuming rejection whenever liver tests rise without urgent vascular and biliary assessment.
- 04
Stopping tacrolimus during infection or AKI without a transplant-directed alternative and monitoring plan.
- 05
Prescribing clarithromycin, an azole, rifampicin, anticonvulsants or herbal remedies without checking calcineurin-inhibitor interactions.
- 06
Giving a live vaccine to a clinically immunosuppressed recipient without specialist immunisation advice.