Aug. 23, 2025
Referral timing is essential to ensure patients with advanced liver disease experience optimal transplant results. It is important to avoid referring a patient early, before transplant evaluation and services are necessary. However, a late referral can cause the patient to miss the transplant window of opportunity. The disease could be too advanced for transplant eligibility, or the patient's stamina may be too poor to proceed with surgery.
When evaluating patients who may need liver transplants, it is crucial to consider the rapid changeability of advanced liver disease, says Julie K. Heimbach, M.D., a liver transplant surgeon at Mayo Clinic in Rochester, Minnesota. Stringent disease status monitoring is essential, including regular hepatocellular carcinoma (HCC) screening. "We perform this screening via a liver ultrasound or other imaging and an alpha-fetoprotein level blood test measurement every six months," Dr. Heimbach says.
"Patients with advanced liver disease can see their condition worsen very quickly," says Bashar A. Aqel, M.D., transplant hepatologist at Mayo Clinic in Pheonix, Arizona. "Our team is dedicated to improving access to liver transplant and ensuring that physicians refer their patients at the appropriate time."
Indications your patient is ready for transplant referral
The Mayo Clinic transplant team says the following six key signs can indicate that it's time to send a patient to a transplant center for evaluation:
- Symptom progression despite low MELD scores. "At times, patients with advanced liver disease may present with significant symptoms, yet have low Model for End-Stage Liver Disease (MELD) scores," explains Liu Yang, M.B.B.S., a transplant hepatologist at Mayo Clinic in Jacksonville, Florida. Despite this contradictory situation, worsening ascites, encephalopathy or sarcopenia requires referral.
- Decompensated liver signs. If ascites, edema, pleural effusions, encephalopathy, gastrointestinal bleeding, disabling itching or muscle wasting appear, refer the patient for a transplant consult. Unexplained dyspnea with low oxygen levels also can represent liver-related pulmonary complications.
- HCC. Patients with cirrhosis require biannual screening for HCC, which is a common liver transplant indication. Dr. Aqel suggests referral immediately after identification of a concerning lesion because it could indicate an adjacent tumor that can grow too large for liver transplant eligibility.
- Bacterial cholangitis. Repeated episodes of bacterial cholangitis in patients with biliary disease also should prompt transplant referral.
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Poor function in daily life. If a patient has trouble with everyday tasks and can no longer work, these are signs that referral for a transplant discussion is appropriate.
"A patient can mow the lawn in May and by June have a complication and become bedridden and fatigued with muscle wasting," says Dr. Heimbach, illustrating how drastically and rapidly patients with advanced liver disease can decompensate.
- Repeated admissions. Multiple hospital stays are indicators that a patient's may benefit from transplant surgery.
Mayo Clinic's liver transplant team urges physicians to err on the side of referral for transplant sooner rather than later. If patients are eligible for transplant, earlier surgery may offer them greater odds of full function post-transplant.
"At Mayo Clinic, transplant patients benefit from a team approach to care and treatment," says Dr. Yang. "After liver transplant surgery, most patients return to their normal daily lives."
Physicians caring for patients with advanced liver disease should contact Mayo Clinic's liver transplant specialists with any questions about a given patient's status, even when it appears the patient may not have viable treatment options. At Mayo Clinic Gastroenterology and Hepatology, rotating hepatologists take external physician calls all day.
"Please reach out and ask," says Dr. Aqel. "We'd be happy to discuss with you or see the patient in person or by telemedicine."
Mayo Clinic liver transplant surgeons perform more than 600 liver transplants each year across Mayo Clinic's three campuses. The transplant team has the skills to successfully treat challenging diagnoses using innovative treatment options.
For more information
Refer a patient to Mayo Clinic.