“Transplantation is the most dramatic demonstration of what science and compassion can achieve together.”
— Thomas E. Starzl, MD
Liver transplantation remains the most effective “reset button” for people with end-stage liver disease and selected liver cancers, but who needs a transplant—and when—has changed. Today, fatty liver disease (MASLD) and alcohol-related liver disease (MetALD/ALD) are the leading indications, while hepatitis C is far less common due to highly effective cures. This shift has placed greater emphasis on metabolic health, alcohol recovery support, and long-term disease management before and after transplant.
Transplant decisions now go beyond diagnosis alone. Centers increasingly consider how quickly disease is progressing, complications of cirrhosis, cancer behavior, and overall fitness for surgery, with a strong focus on timing and equitable access. National allocation policies have also evolved, and ongoing efforts aim to further improve fairness and transparency in how donor livers are distributed.
The hard reality is that organ shortage is pervasive, so the field has focused on safely expanding the donor pool. That’s where the “big plays” are: more use of DCD (donation after circulatory death) livers and better ways to protect them. Machine perfusion is a major advancement, either normothermic machine perfusion (NMP) (keeping the liver functioning warm on a pump) or hypothermic oxygenated perfusion (HOPE/DHOPE) (cool, oxygenated support), which can reduce injury, help teams assess organ quality, and increase utilization of livers that previously might have been declined. Real-world and clinical data show improved outcomes and lower complication rates in DCD settings when machine perfusion strategies are used, including lower ischemic-type bile duct injury.
What this means for patients is genuinely positive: the system is still constrained, but it’s becoming smarter and more capable. There are active clinical trials and ongoing implementation work aimed at getting more transplantable livers safely to more people, including expanding DCD availability and improving preservation/transport (e.g., FDA-cleared platforms for liver perfusion in the U.S.). The near-future direction is a more personalized approach, matching the right organ and preservation strategy to the right recipient, so more patients can reach transplant in time and do well afterward.