Emphasis on waiting list management towards better prognosis of all potential liver transplant recipients

The post-operative prognosis has been continuously improved in experienced centers for actual liver transplant (LT) recipients with the development of surgical techniques and perioperative management (1). The bird-view of all potential LT recipients, however, is far beyond satisfaction according to the recent waiting list mortality statistics (2). Combating organ shortage with split and domino LT (3) are critical measures to increase graft accessibility, and waiting list management should be renovated to benefit the potential LT recipients as well.

Firstly, the pre-LT indication/contraindication evaluation should be considered earlier than the current practice. In cases including pediatric acute liver failure, timely evaluation and enlistment for LT is pivotal for life-saving LT instead of death during waiting or after LT (4). Since the usual severity scoring system, model for end-stage liver disease (MELD), might underestimate the short-term death risk in a great number of cases such as acute-on-chronic liver failure (5), it should be appropriate to include those cases into the waiting list of organ allocation systems earlier to compensate for their MELD disadvantages.

Secondly, the treatment of primary diseases and comorbidities should be optimized in order to minimize acute decompensation and/or infectious events. The carriage of multi-drug resistance organisms, for instance, was demonstrated as independent predictor for liver-related complications in potential LT recipients (6), which set an alarm for long-term usage of wide-spectrum antibiotics. Also, comorbidities like diabetes could add to the risk of variceal bleeding on the waiting list, suggesting the value of comprehensive medical optimization (7).

Thirdly, the pre-habilitation should be universally introduced to potential LT recipients. Frailty and myopenia are prevalent in patients with end-stage liver disease due to a low-protein diet, motionless daily routine, and other factors. It was confirmed that physical activity (8) and muscle mass (9) positively correlated with post-LT prognosis. Pre-habilitation, including nutritional counseling and assisted exercise, could help avoid or delay the development of these complications and consequently improve the prognosis of LT recipients.

Last but not least, psychosocial support should be maximized for potential LT recipients. A positive correlation was clearly displayed between the level of psychosocial support and the possibility of enlistment (10). These non-medical issues play important roles as the aforementioned medical issues do, and healthcare professionals should cooperate with family members as well as social workers towards a better prognosis of all potential LT recipients.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-310/coif). The author has no conflicts of interest to declare.

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