Table 4.

Transplant Ineligibility Factors

Factor	Rationale
Obstructive coronary artery disease not amenable to revascularization	Patients with medically-managed obstructive coronary artery disease without revascularization have nearly 100% intra-operative and post-operative morbidity and mortality.[82]
Systolic heart failure	Profound hemodynamic changes during LT require adequate compensatory cardiac function.[83]
Pulmonary hypertension (mPAP ≥ 35 mmHg) not correctable with medical therapy	Perioperative mortality associated with mPAP ≥ 50 mmHg is 100%; mortality for mPAP 35–50 mmHg is 50%.[84]
Severe intrinsic pulmonary disease	Impaired pulmonary function is associated with increased post-transplant length of stay and ventilator time.[85]
Class 3 obesity (BMI ≥ 40 kg/m2)	Obesity is associated with increased transplant operative time, wound infections and dehiscence, overall infections, postoperative respiratory failure, and hospital length of stay.[86]
Inability to maintain abstinence from alcohol or illicit substances	A short duration of abstinence before transplant is associated with post-transplant recidivism, which results in decreased survival.[87,88]
Persistent nonadherence to medical recommendations	Pre-transplant nonadherence predicts post-transplant nonadherence, which results in organ rejection and graft loss.[89,90]
Lack of adequate social support	Social support is necessary to aid the transplant recipient in maintaining their health through assisting with appointments, necessary testing, and medications.
Hepatocellular carcinoma with extrahepatic spread	Patients with advanced HCC have a limited life expectancy that cannot be corrected with LT.
Intrahepatic cholangiocarcinoma	Following LT with intrahepatic cholangiocarcinoma, recurrence was found in 57%, and 5-year survival was 51%.[91]
Active extrahepatic malignancy	Post-transplant cancer recurrence rates are associated with the duration of remission and vary based on the type of cancer. Cancers treated after transplant are associated with very high recurrence rates.[92]
Poorly-controlled HIV infection	Patients with poorly-controlled HIV (CD4+ T-cell count < 200 cells/mm3 and/or detectable HIV viral load) have a high incidence of HIV-related complications following LT, and 3/11 patients in one report died rapidly of HIV.[93]
Uncontrolled sepsis	Patients with active sepsis are generally too unstable to safely undergo LT.
Anatomic abnormality that precludes transplant	Anatomic features may prohibit the ability to perform LT (e.g. extensive mesenteric thrombosis).
Patient preference to decline transplant	Autonomy is a central principle of biomedical ethics, and fully informed patients may wish to decline LT in favor of hospice.[94]

Abbreviations: LT, liver transplantation; mPAP, mean pulmonary arterial pressure; BMI, body mass index; HCC, hepatocellular carcinoma; HIV, human immunodeficiency virus