AASLD Releases New Liver Transplantation Practice Guidelines on Candidacy, Management

The American Association for the Study of Liver Diseases (AASLD) and American Society of Transplantation (AST) have released 2 new practice guidelines on evaluating adult liver transplant candidates and managing non-graft complications that drive long-term outcomes following liver transplantation.1

“AASLD’s practice guidelines and guidances are invaluable tools for clinicians worldwide. Together, these guidelines represent a comprehensive, patient-centered roadmap for adult liver transplantation,” Grace Su, MD, President of AASLD, said in a statement.1 “By addressing both who should be considered for transplant and how patients should be cared for long after surgery, we aim to support better outcomes, improved quality of life, and more consistent care for patients worldwide.”

Liver Transplant Candidacy

Across its 69 guideline statements, the document on candidate evaluation lays out a comprehensive, principle-driven framework for who should be referred for liver transplantation, how candidates should be evaluated, and how risks should be mitigated to maximize post-transplant benefit. Broadly, the statements emphasize early and equitable referral for patients with decompensated cirrhosis, acute-on-chronic liver failure, acute liver failure, and selected liver malignancies.2

It emphasizes that MELD score alone should never be a barrier to referral, particularly when portal hypertensive complications or biologically aggressive disease are present. For tumor indications, the statements reinforce careful staging, use of accepted criteria, and selective downstaging or neoadjuvant approaches to identify favorable tumor biology before listing.2

The guidelines strongly recommend that transplant evaluation be multidisciplinary and individualized, integrating medical urgency, likelihood of benefit, and patient goals. Statements address standardized cardiopulmonary assessment, infection screening and vaccination, and age-appropriate cancer screening.2

Nutritional status, bone health, and physical function are also highlighted as modifiable risk factors that should be routinely assessed, with interventions initiated pre-transplant when feasible.2

Many of the statements focus on psychosocial evaluation and substance use, underscoring that transplant candidacy depends on the ability to adhere to care, adequate social support, and access to mental health and addiction treatment rather than arbitrary abstinence thresholds. The document emphasizes that alcohol abstinence duration alone should not determine eligibility, patients on medication-assisted therapy should not be excluded, and ongoing monitoring for substance use is recommended once listed.2

Diagnosis, Post-Transplant Management

Across the guideline statements in this second AASLD/AST adult liver transplantation document, the recommendations again emphasize appropriate candidate selection, rigorous pre-transplant evaluation, and longitudinal management to optimize transplant outcomes and steward scarce organs responsibly. Timely referral, even before advanced decompensation, is repeatedly highlighted as essential to improving waitlist and post-transplant outcomes.3

A central theme is the need for standardized yet individualized evaluation, incorporating medical, surgical, and psychosocial domains. The guideline statements recommend comprehensive cardiopulmonary assessment, malignancy screening, infection surveillance, and immunization, alongside evaluation of nutritional status, frailty, and sarcopenia. Particular attention is paid to identifying reversible risk factors and intervening early through medical optimization, rehabilitation, or specialty referral rather than excluding patients outright.3

The document also devotes substantial attention to psychosocial considerations, adherence, and substance use, recommending structured assessments of social support, psychiatric comorbidities, and ability to engage in complex post-transplant care.3

As in prior guidance, the statements discourage the use of inflexible abstinence rules and instead support individualized, multidisciplinary approaches to alcohol and substance use disorders, including ongoing monitoring and treatment.3

Collectively, the guideline statements advocate for equitable access, transparent decision-making, and consistent application of evidence-based principles to ensure that liver transplantation delivers meaningful, durable benefit to patients most likely to achieve long-term success.3

References

1. AASLD. AASLD and AST Announce Two New Practice Guidelines. December 17, 2025. Accessed December 17, 2025. https://www.aasld.org/aasld-and-ast-announce-two-new-practice-guidelines

2. Dove L, Chadha RM, Lai JC, et al. AASLD AST Practice Guideline on adult liver transplantation: Candidate evaluation. Hepatology. doi:10.1097/HEP.0000000000001644

3. Sharma P, Izzy M, Ghabril M, et al. AASLD AST Practice Guideline on adult liver transplantation: Diagnosis and post-transplant management of non-graft-related complications. Liver Transplantation. doi:10.1097/LVT.0000000000000785