Preparing for a Liver Transplant: A Checklist for Indian Patients and Families

Liver transplant preparation starts the day you are told you may need one, not the day a donor is found. In a nine-centre study of 1,044 people on the waiting list, one in four was frail, and frailty nearly doubled the risk of dying before a liver arrived. Eat, walk, stop alcohol completely, finish the evaluation, and keep your phone on.
— Dr Chetan Kalal, DM Hepatology, Gleneagles Hospital Mumbai

Think of a composite of a family I meet most weeks: a 48-year-old schoolteacher from Thane with cirrhosis from hepatitis B, a MELD of 19, two episodes of ascites behind him, and a wife and brother on either side of him in my clinic. He has been told he “may need a transplant.” Nobody has told him what to do on Monday morning.

That gap is what this article fills. Over the 1,000-plus transplants I have been part of (around 300 of them complex), with 92% survival, the patients who did best were rarely the ones with the lowest MELD. They were the ones who arrived at surgery fed, mobile, sober, vaccinated, with a caregiver beside them and their paperwork done. What follows is the checklist I would hand that schoolteacher: the evaluation, the two donor routes, how deceased-donor registration works in Maharashtra, the physical preparation only you can do, and the honest conversation about work and money. The surgery itself is covered elsewhere on this site.

The evaluation: what we test, and why

Being “listed” means a multidisciplinary team has examined you and agreed that a transplant will help and that your body can withstand it. Maharashtra’s state guidelines require this assessment before registration, so the evaluation is both medical and administrative. We follow the AASLD and American Society of Transplantation framework for evaluating adults, adapted to Indian realities.

Heart and lungs. Cirrhosis strains the circulation, and the operation lasts many hours. Everyone has an echocardiogram; older patients, diabetics and smokers usually need a stress test or cardiology opinion, some an angiogram. Two liver-specific lung problems, hepatopulmonary syndrome and portopulmonary hypertension, are looked for: one improves after transplant, the other can make it dangerous.

Infection screening. After transplant your immune system is deliberately suppressed, so any infection that can hide must be found now: hepatitis B and C, HIV, tuberculosis (a particular concern in India), and the teeth. An abscessed tooth is trivial today and serious on immunosuppression, which is why dental clearance is on the list.

Imaging and cancer screening. A contrast CT or MRI maps the vessels the surgeon will join and looks for liver cancer, which changes priority and sometimes eligibility. Age-appropriate screening for other cancers is completed too; an active cancer elsewhere is a listed exclusion.

Psychosocial assessment. A psychiatrist or counsellor meets you and your family, not to judge character but because lifelong tablets and follow-up are what keep the new liver alive; “lack of social or family support” and “high risk of non-compliance with long-term immunosuppression” are listed exclusions in the state guidelines. Alcohol abstinence is documented here too.

Two roads to a new liver: living donor or deceased donor

Most liver transplants in India use a living donor: a healthy adult, usually a close relative, who gives part of their liver, which regrows in both of you over the following weeks. The advantage is control: the operation is scheduled once you and the donor are ready, so many of my patients with a willing relative never join the deceased-donor list.

Living donation is governed by the Transplantation of Human Organs Act. A near relative can donate once an authorisation committee is satisfied that the donor is healthy, properly informed and under no pressure; donors outside the near-relative circle face a stricter process, and any hint of payment ends the matter. Expect identity and relationship documents, affidavits and a separate interview of the donor; the coordinator walks families through it, and it is routine for us even when it feels daunting.

The deceased-donor route depends on an organ from a brain-dead donor. In Maharashtra, allocation runs through four Zonal Transplant Coordination Centres (Mumbai, Pune, Nagpur, Aurangabad) under the state body SOTTO and the national body NOTTO. Three facts matter to you:

First, your hospital registers you; ZTCC Mumbai states plainly that patients cannot register directly, and listing is allowed through only one centre at a time. Second, the application needs a NOTTO ID, identity proof showing date of birth (Aadhaar or passport), signed patient guidelines, a declaration that you are not listed elsewhere in the state, and reports under a month old from an accredited laboratory; charges follow ZTCC norms and are waived in public-sector hospitals. Third, routine listing needs a MELD of 15 or more or a Child-Pugh score of 8 or more, and offers begin only after a short minimum listing period, except for super-urgent cases such as acute liver failure.

Livers are then allocated by a MELD-based score, sickest first, with preference for patients registered at the donor’s hospital. Updates on your position come only through your hospital, never by calling the ZTCC. More on the mechanics in my article on the liver transplant waiting list in India.

Prehabilitation: the part only you can do

Here is the number I want every waiting patient to remember. Among 1,044 adults listed at nine American centres, 25% were frail on a simple three-part test of grip strength, chair stands and balance, and the frail were 1.82 times as likely to die or be removed from the list after adjusting for liver disease severity. Among patients with ascites, 29% of the frail died waiting, against 17% of the non-frail. Frailty, not just the blood tests, decides who reaches the operating theatre.

Frailty is modifiable, and the tools are unglamorous.

Nutrition. Cirrhosis burns muscle for fuel, especially overnight. The European and American guidelines both ask for a high-protein, high-energy diet with no long fasts: small frequent meals, protein at each, and a late-evening snack. In a randomised trial I led at ILBS, 104 malnourished men with alcohol-related cirrhosis received intensive nutrition with a supplement or diet alone. Over three months the intensive group ate more, gained weight and more often cleared their ascites (53% versus 44%); one-year survival did not differ between arms, but patients in either arm who managed more than 25 kcal and 0.8 g of protein per kilogram a day lived longer. It is the eating, not the brand of supplement, that counts. My Indian-diet guide to protein and sarcopenia in cirrhosis gives the specifics.

Movement. Walk daily and add resistance work, even with a filled water bottle, under a physiotherapist’s guidance. Ask your team to measure your handgrip and Liver Frailty Index at each visit so progress is visible.

Alcohol. Zero, permanently. For alcohol-related liver disease the Maharashtra guidelines require three months of abstinence before deceased-donor listing, certified by you, a psychiatrist, the surgeon and the hepatologist; resumption on the list obliges the team to report you for delisting. Treat this as a prescription, not a sermon, and take the help offered.

Vaccinations and teeth. Vaccines work best before immunosuppression, and live vaccines cannot be given afterwards, so hepatitis A and B, pneumonia and influenza vaccines are usually completed during the evaluation; ask your team which apply to you. Finish dental work now, while healing is uncomplicated.

The people and the logistics

A transplant is a family event. You need one named caregiver, preferably two, committed to being with you in hospital, at every follow-up in the first three months, and at home managing medicines, wounds, temperatures and transport. The transplant team asks because the guidelines treat missing support as a reason not to list. Decide who, and tell their employer early.

On the deceased-donor list, distance matters. A donor liver tolerates only a few hours outside the body, and the offer may come at 2 a.m. The state guidelines count “patient not contactable” as a logistic refusal; three such refusals put you on hold for three months, and an offer that has passed to the next patient is not reversed. Keep two phones charged, give the coordinator two relatives’ numbers, and if you live far away, arrange to stay within a couple of hours of the centre when your turn is near. Living-donor logistics are kinder: a planned date, a planned admission.

Working and money while you wait

Should you keep working? Usually yes, if the work is safe and you can manage it; routine, income and dignity all matter during a wait that can stretch to months. Two conditions apply.

The first is safety. Hepatic encephalopathy, even in its mild form, slows reaction time and judgement before you or your family notice anything. If you have had an episode, or your psychometric tests are abnormal, do not drive, operate machinery, work at heights or take on tasks where a lapse harms someone else. Ask your hepatologist specifically about driving rather than assuming.

The second is fatigue. Cirrhosis tires you, and the evaluation itself eats days. Tell your employer the truth in outline: a serious but treatable liver condition, intermittent leave for tests, and at some point weeks or months of continuous leave at short notice. Employers respond better to a plan than to a surprise. Ask HR about medical leave and insurance cover, and get the hospital’s estimate letter early.

Which brings us to cost. A liver transplant is expensive in India, and the figure should come from your own hospital, not the internet. Insurance, employer schemes, government health schemes, charitable trusts and community fundraising are all used, often together. The coordinator and social worker exist to help; the mistake I see is families waiting for the donor call to begin. Start the funding conversation the week you are told you may need a transplant.

Decompensation can accelerate; the patient fit and funded today may be too sick in six months. If a willing, healthy relative exists, do not let indecision about living donation cost you the window. If you are in Mumbai, my cirrhosis clinic is where that conversation starts.

References

1. Martin P, DiMartini A, Feng S, Brown R, Fallon M. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014;59(3):1144–1165. PMID 24716201. doi:10.1002/hep.26972
2. Lai JC, Covinsky KE, Dodge JL, et al. Development of a novel frailty index to predict mortality in patients with end-stage liver disease. Hepatology. 2017;66(2):564–574. PMID 28422306. doi:10.1002/hep.29219
3. Lai JC, Rahimi RS, Verna EC, et al. Frailty associated with waitlist mortality independent of ascites and hepatic encephalopathy in a multicenter study. Gastroenterology. 2019;156(6):1675–1682. PMID 30668935. doi:10.1053/j.gastro.2019.01.028
4. Lai JC, Tandon P, Bernal W, et al. Malnutrition, frailty, and sarcopenia in patients with cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74(3):1611–1644. PMID 34233031. doi:10.1002/hep.32049
5. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol. 2019;70(1):172–193. PMID 30144956. doi:10.1016/j.jhep.2018.06.024
6. Kalal C, Benjamin J, Shasthry V, et al. Effect of long-term aggressive nutrition therapy on survival in patients with alcohol-related cirrhosis: a randomized controlled trial. Indian J Gastroenterol. 2022;41(1):52–62. PMID 35235198. doi:10.1007/s12664-021-01187-3
7. State Appropriate Authority, Government of Maharashtra. Maharashtra State Appropriate Authority Guidelines for Cadaver Transplant Program (with SOTTO Maharashtra). Hosted by ZTCC Mumbai: ztccmumbai.org/MaharashtraStateGuidelines.pdf. Accessed 8 October 2026.
8. Zonal Transplant Co-ordination Centre, Mumbai. Registration and liver allocation information. ztccmumbai.org. Accessed 8 October 2026.