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Liver disease severe enough to require a liver transplant can come from many causes. Doctors have developed various systems to determine the need for the surgery. Two commonly used methods are by specific disease process or a combination of laboratory abnormalities and clinical conditions that arise from the liver disease. Ultimately, the transplantation team takes into account the type of liver disease, the person's blood test results, and the person's health problems in order to determine who is a suitable candidate for transplantation.

In adults, chronic active hepatitis and cirrhosis (from alcoholism, unknown cause, or biliary) are the most common diseases requiring transplantation. In children, and in adolescents younger than 18 years, the most common reason for liver transplantation is biliary atresia, which is an incomplete development of the bile duct.

Laboratory test values and clinical or health problems are used to determine a person's eligibility for a liver transplant.

• For certain clinical reasons, doctors may decide that a person needs a liver transplant. These reasons may be health problems that the person reports, or they may be signs that the doctor notices while examining the potential recipient. These signs usually occur when the liver becomes severely damaged and forms scar tissue, a condition known as cirrhosis. The most common clinical and quality-of-life indication for a liver transplant is ascites, or fluid in the belly due to liver failure. In the early stage of this problem, ascites may be controlled with medicines (diuretics) to increase urine output and with dietary modifications (limiting salt intake). Another serious consequence of liver disease is hepatic encephalopathy. This is mental confusion, drowsiness, and inappropriate behavior due to liver damage. Both ascites and encephalopathy are used in the current classification system to determine the severity of liver disease.
• Several other clinical problems may arise from liver disease. Infection in the abdomen, known as bacterial peritonitis, is a life-threatening problem. It occurs when bacteria or other organisms grow in the ascites fluid. Liver disease causes scarring, which makes blood flow through the liver difficult and may increase the blood pressure in one of the major blood vessels that supply it. This process may result in serious bleeding. Blood may also back up into the spleen and cause it to increase in size and to destroy blood cells. Blood may also go to the stomach and esophagus (swallowing tube). The veins in those areas may grow and are known as varices. Sometimes, the veins bleed and may require a gastroenterologist to pass a scope down a person's throat to evaluate them and to stop them from bleeding. These problems may become very difficult to control with medicines and can be a serious threat to life. A liver transplant may be the next step recommended by the doctor.

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