What are the indications for referring a patient with PSC to a specialist for liver transplantation?

Indications for referring a patient with primary sclerosing cholangitis (PSC) to a specialist for liver transplantation include:

• Development of decompensated liver disease, such as ascites, hepatic encephalopathy, or gastrointestinal bleeding, indicating liver failure or end-stage liver disease.
• Evidence of cirrhosis diagnosed by imaging or transient elastography, especially if complications or decompensation occur.
• High risk of serious complications as assessed by specialist evaluation, including use of prognostic scores like the Model for End-stage Liver Disease (MELD) to predict mortality and transplant eligibility.
• Presence of portal hypertension or related complications such as variceal bleeding or splenomegaly.
• Recurrent or severe episodes of cholangitis or biliary complications that are not manageable by other treatments.
• Development of hepatocellular carcinoma (HCC) in the context of PSC and cirrhosis, where transplantation may be considered.

Referral should be made to a hepatologist or gastroenterologist with an interest in hepatology for specialist assessment and consideration of liver transplantation listing. Early referral is important to optimize timing and management of transplantation candidacy.

These indications align with general guidance for referral in cirrhosis and end-stage liver disease, as PSC is a chronic cholestatic liver disease that can progress to cirrhosis and liver failure requiring transplantation ¹,⁴.