The Changing Indications for Adult Liver Transplantation in Australia: A Narrative Review

Adult liver transplantation practice in Australia and New Zealand has changed substantially over the past decade in response to shifting liver disease epidemiology and advances in donor organ preservation. Alcohol-related liver disease and metabolic dysfunction-associated steatotic liver disease have become leading indications for adult liver transplantation in Australia and New Zealand. Transplant recipients are increasingly older and medically complex, necessitating multi-disciplinary assessment including evaluation of frailty. Indications for liver transplantation have expanded to include selected patients with severe alcohol-related hepatitis, acute-on-chronic liver failure, extended-criteria hepatocellular carcinoma and other highly selected non-resectable liver malignancies including colorectal liver metastases and cholangiocarcinoma. In parallel, donor utilisation has evolved, with increasing use of expanded-criteria donors and donation after circulatory determination of death. Machine perfusion technologies are increasingly used in Australia to optimise marginal liver grafts and minimise waitlist mortality. Having an awareness of these evolving indications, recipient complexity and donor optimisation strategies is essential to support timely liver transplantation referral, improve inter-disciplinary understanding, allow equitable access and provide appropriate stewardship of limited donor organs.