The American Association for the Study of Liver Diseases (AASLD), American Society of Transplantation (AST), and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) just released a clinical practice guideline on candidate evaluation for pediatric liver transplantation (LT). The 2026 guideline, Pediatric Liver Transplantation: Candidate Evaluation, replaces the AASLD’s 2014 guideline on the same topic.

This 2026 AASLD/AST/NASPGHAN practice guideline provides clinicians with best practices and evidence-based guidelines on the evaluation process, outlining indications, contraindications, and barriers to transplantation. Below, we have highlighted some key recommendations for your convenience. Consult the full-text version for the complete look at all 90 recommendations and provided rationale.

Pre-Transplant Assessment of the Pediatric LT Candidate
  • All pediatric LT candidates should undergo testing to assess renal function using CKiD U25 to estimate the glomerular filtration rate.
  • All pediatric patients undergoing LT evaluation should be screened for hepatopulmonary syndrome using pulse oximetry to assess oxygen saturation in both upright and supine positions.
  • All age-appropriate inactivated and live vaccinations should be administered to LT candidates and household contacts before transplantation using the accelerated vaccine schedule, when necessary, except in cases of pediatric acute liver failure.
  • LT candidates should receive Measles-Mumps-Rubella and Varicella Vaccines starting at 6 months of age.
Referral for Liver Transplantation in Children
  • All pediatric patients with acute liver failure should be referred to a LT center for urgent evaluation.
  • Pediatric patients with a severe urea cycle disorder presenting in the first year of life, as well as those with Crigler-Najjar Type I, should be considered for LT before brain injury occurs.
  • LT should be considered for pediatric patients with inborn errors of metabolism or coagulation disorders who continue to experience severe clinical complications despite optimal medical management.
  • Pediatric patients with primary hyperoxaluria type 1 should be considered for LT evaluation at diagnosis to allow multidisciplinary assessment regarding combined liver-kidney transplant or sequential LT followed by kidney transplant based on current or expected renal function, and response to RNA interference therapy.
  • Pediatric patients and families of children with methylmalonic acidemia and propionic acidemia should be informed about the potential risk of neurologic deterioration, cardiomyopathy, and progressive kidney injury even after LT.
Liver Tumors
  • Pediatric patients with unresectable hepatoblastoma should be referred for LT evaluation at diagnosis or no later than after 2 rounds of chemotherapy.
  • Pediatric patients with hepatoblastoma and pulmonary metastases should be considered for LT if the metastases are no longer visualized on imaging following chemotherapy or surgical resection.
  • Pediatric patients with unresectable hepatocellular carcinoma without extrahepatic disease should be referred for LT evaluation, even if outside the Milan criteria.
  • Extrahepatic disease in children with hepatocellular carcinoma should be considered a contraindication for LT.
Disease-Specific Conditions in Pediatric Liver Transplantation
  • Infants with biliary atresia should undergo hepatoportoenterostomy as initial management. Primary LT evaluation is indicated for infants with signs of decompensated liver disease at presentation. 
  • Pediatric patients with cholestatic liver diseases should receive aggressive nutritional support prior to LT to improve outcomes.
  • Pediatric patients with inborn errors of metabolism and structural liver damage who develop complications of end-stage liver disease should be referred for LT evaluation.
  • Pediatric patients presenting with acute liver failure due to Wilson disease should be promptly referred for LT evaluation.
  • Surveillance for inflammatory bowel disease with colonoscopy and biopsies should be a part of pre- and post-transplant care in patients with primary sclerosing cholangitis.
  • Pediatric patients experiencing progressive graft failure due to recurrent autoimmune hepatitis and/or primary sclerosing cholangitis should be evaluated for re-transplant.
Special Situations
  • Closure of portosystemic shunts should be considered an alternative to LT when technically possible.
  • Pediatric liver re-transplantation should be considered for all causes of graft failure not amenable to medical or non-transplant surgical treatment.
Organ Allocation
  • Nonstandard exception requests should remain available to ensure pediatric patients have fair access to transplantation, thereby avoiding waitlist mortality, while prioritization is improved.
  • All efforts should be made to ensure equitable access for pediatric patients to technical variant grafts, including living donor LT, deceased donor split grafts, and reduced-size grafts.
  • The PELD-Creatinine and MELD 3.0 scores should be used to determine initial liver allocation priority for pediatric patients on the transplant waitlist.

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