Liver disease is the twelfth commonest cause of mortality in adults in the United States, resulting in 34,000 deaths annually from cirrhosis. 7 In addition, the rising incidence of HCC in the United States is reflected in an increasing number of deaths from HCC. Access to LT, however, has profoundly altered the management of advanced liver disease. Management of decompensated cirrhosis and acute liver failure before the advent of LT was limited to attempts to ameliorate complications. In contrast, successful LT extends life expectancy and enhances quality of life. 6 The term orthotopic liver transplantation (OLT) refers to placement of the new organ in the same location as the explanted liver. Although most LTrecipients receive a whole organ from a deceased donor, an organ can be “split,” with a pediatric recipient receiving a left lateral segment and an adult recipient the larger right lobe. Live donor transplant using the left hepatic lobe initially introduced for pediatric recipients has been extended into adult recipients using the donor’s right lobe. Although live donor transplant is widely employed, it remains controversial, with continuing concern about potential risks to the donor, especially when right lobe resection is required for an adult recipient. 8-10 Recipients of live donor transplant have reduced waiting list mortality compared to potential recipients of deceased donor organs. 11 Live donor transplant should only be contemplated when LT with a deceased donor is unlikely to occur within a reasonable time frame given the severity of the potential candidate’s liver disease. Irrespective of the source of the graft, deceased or live, LT is a surgically challenging procedure with dissection and removal of a diseased liver from an abdominal cavity with extensive venous collaterals due to portal hypertension with subsequent implantation of the graft and creation of vascular and biliary anastomoses. Reflecting the complexity of surgery in recipients who are often debilitated because of their advanced liver disease, a number of technical complications can occur as well as a variety of adverse effects from therapeutic immunosuppression. Despite these concerns, however, LT has revolutionized the management of severe liver disease. The United Network for Organ Sharing (UNOS) facilitates organ allocation in the United States and also records graft and recipient outcomes. The UNOS database allows critical evaluation of center-and disease-specific recipient outcomes with LT as well as guiding organ allocation policies. Analogous organizations are involved in organ allocation and data collection in other regions of the world. The greatest challenge in LT remains the inadequate supply of donor organs, limiting access to LT for many potential recipients.

Indications for Liver Transplant LT is indicated for severe acute or advanced chronic liver disease when the limits of medical therapy have been reached (see Table 2). Recognition of cirrhosis per se does not imply a need for LT. Many patients with cirrhosis in the absence of an index complication such as ascites or variceal hemorrhage will not develop hepatic decompensation, although patients with cirrhosis have diminished survival compared to the population as a whole. 12, 13 Occurrence of a major complication is an important predictor of decreased survival and should