Hepatic encephalopathy as an indication or contraindication to liver transplant?

Hepatic encephalopathy (HE) presents a significant challenge in liver transplantation (LT). On the one hand, LT can provide a curative treatment for HE by addressing its underlying cause, suggesting HE should be a strong indication for LT. Conversely, the severity of HE may reflect advanced liver disease and significant neurocognitive impairment, potentially complicating post-transplant outcomes and raising concerns about its suitability as an indication. This review will provide helpful insight to the hepatologist deciding whether HE should be considered an indication or a contraindication to liver transplantation in their patient. It gives an overview of the burden of HE pretransplant, HE's current status in the transplant listing process, and pre- and post-transplant cognitive issues to be mindful of. The main take-away messages are that pre-transplant HE should be managed aggressively, that neurodegenerative disorders and other differential diagnoses to HE should be thoroughly excluded, and that immunosuppressants can cause new onset cognitive issues post-transplant and should be monitored closely. In the future, objective measures of HE severity should be included in the MELD score to enhance the fairness and efficacy of transplant listings, ensuring those with cirrhosis complicated by HE receive timely and appropriate treatment.