INTERNAL MEDICINE ROUNDS · VANCOUVER GENERAL HOSPITAL
From Decompensation to Transplant
An overview of inpatient cirrhosis care and transplant assessment
Dr. Daljeet Chahal MD
Transplant Hepatology & Gastroenterology, VGH
Clinical Assistant Professor, University of British Columbia
Daljeet.chahal3@vch.ca
Outline & Objectives
1
Demonstrate the transfer, manage and assessment workflow
2
Highlight aspects of inpatient cirrhosis care and transplant assessment
3
Introduce clinical registries aimed at addressing care gaps
THE PREMISE
One Patient, Two Teams, Disjointed Workflows
Internal Medicine
Hepatology
The problem: The two workflows operate almost independently which results in a lack of effective communication and unnecessary “silos”.
DAY 1 · PRESENTATION
Overview of case and timeline
Mrs. R, 52
Alcohol-related cirrhosis diagnosed three years ago. Brought to UHNBC with two days of confusion.�
Tense ascites. Creatinine 172 (baseline 78). Sodium 128. Bilirubin 190. INR 2.1. Afebrile, white count 8.9.
Last drink twelve weeks ago. No paracentesis in six months. Partner works away two weeks in three.
Day 1: Admit with confusion, ascites, AKI, last drink 12 weeks ago.
Days 2–4: SBP, HRS-AKI. Grade 3 HE and vasopressor – ACLF.
Day 5: Referral and transfer criteria, transfer call conference.
Day 6: Transfer to VGH, and the pre-transfer workup is complete.
Days 6–12: Inpatient assessment then listing rounds decision.
Day 12: Activated for transplant as status 2 in hospital.
Days 12–20: Waiting as an inpatient. Candidacy reassessed daily.
Context
VGH is the only liver transplant centre in British Columbia. 112 liver transplants in 2023.
One-year survival after transplant is above 90%, five-year above 75%.
1
2
3
Timeline of case
DAY 1 · WHY THIS ADMISSION MATTERS
Where a patient is admitted predicts whether they survive
Independent of age, MELD-Na, etiology and hospital course:
2.5×
Odds of hospital death in low/lower-middle income countries. Difference due to access in ICU beds, ER endoscopy, albumin, rifaximin, terlipressin and transplant.
One may extrapolate that similar differences may exist in rural vs urban centers, or non-transplant and transplant centers – although this has not been investigated in BC.
Bajaj JS, et al., CLEARED Consortium. Lancet Gastroenterol Hepatol 2023;8:611–622. 3,884 inpatients, 90 centres, 25 countries.
DAY 1–4 · INITIAL MANAGEMENT
Cirrhosis is four prognostic stages, not two
1
Compensated
No current or past decompensation. Split by presence of clinically significant portal hypertension.
2
Decompensated
Ascites or hydrothorax, variceal bleeding, or overt HE (West Haven ≥ II). Mortality rises sharply.
3
Further Decompensation
A second event, or recurrence of the first. A distinct, more advanced stage with higher mortality.
4
Recompensated
Back to a compensated stage after the aetiology is removed, controlled or suppressed.
Baveno VIII Consensus, J Hepatol 2026 (statements 3.1–3.3, 4.1, 7.1–7.4).
Mr. K arrives already at further decompensation: Ascites, encephalopathy and AKI in one admission.
DAY 1–4 · INITIAL MANAGEMENT
Infections: Highest yield admission assessment
Nearly a third of patients admitted with cirrhosis have an infection at presentation. It roughly doubles the risk of dying in hospital.
32%
of admitted patients had an infection on arrival or within 48 hours
29%
of those infections were spontaneous bacterial peritonitis — the single most common
1.75×
adjusted relative risk of in-hospital death or hospice transfer
Cao Z, et al., CLEARED Consortium. Lancet Gastroenterol Hepatol 2024;9:997–1009. 4,238 patients, 98 centres, 26 countries.
Only 41% were culture-positive
DAY 1–4 · INITIAL MANAGEMENT
Treatment for infections in decompensation and ACLF
AASLD ACLF Practice Guidance, Hepatology 2024 (statements 30–34). Baveno VIII (4.12, 6.21–6.23). Bajaj JS et al, EASL 2025 (FRI-185); Bajaj JS et al, rifaximin and drug-resistant infections, CLEARED.
General Approach
DAY 1–4 · INITIAL MANAGEMENT
AKI and hepatorenal syndrome
1
Stop and treat: Withdraw diuretics. Hold or reduce carvedilol/NSBB.
Treat infection. Stop nephrotoxins.
2
Volume challenge: IV albumin 1 g/kg (max 100 g/day) for 48 hours.
3
HRS-AKI, stage ≥ 2: Vasoconstrictor plus albumin 20–40 g/day.
No vasoconstrictor indication at stage 1.
4
Vasoconstrictor: Terlipressin plus albumin is preferred.
Norepinephrine is best alternative.
5
RRT for those who fail pharmacotherapy and are being considered for transplant. Transplant is the definitive treatment.
Not all renal dysfunction is HRS: Stage CKD by eGFR, ensure no other causes.
AASLD ACLF Practice Guidance, Hepatology 2024 (statements 24–29). Baveno VIII (6.9, 6.18–6.20). Wong F, et al., CLEARED. Chronic kidney disease in cirrhosis, 2026.
DAY 1–4 · INITIAL MANAGEMENT
Encephalopathy and Ascites
1
Consider intubation for grade 3–4 encephalopathy.
2
Assess for withdrawal, Wernicke, sepsis, structural injury.
3
Assess for precipitants such as infection and bleeding.
4
Lactulose orally or rectally; PEG if ileus is a risk.
AASLD ACLF Practice Guidance, Hepatology 2024 (statements 5–12). EASL CPG on hepatic encephalopathy, J Hepatol 2022. BC Transplant Clinical Guidelines, rev. 17 Nov 2025.
1
Diuretics, albumin, therapeutic paracentesis; review PPI.
2
Consider TIPS and/or transplant for refractory cases.
3
Long term albumin for those who are not TIPS candidates.
4
Tunneled peritoneal catheter or low-flow ascites pump instead of repeated taps for non-TIPS/transplant candidates.
Encephalopathy
Ascites
DAY 1–4 · INITIAL MANAGEMENT
If she had bled instead: the first twelve hours
Acute variceal bleeding
Pre-emptive TIPS — decide within 72 hours
Baveno VIII, J Hepatol 2026 (statements 5.3–5.14, 5.18, 5.22–5.25, 5.31–5.33, 5.36, 5.37).
DAY 1–4 · INITIAL MANAGEMENT
The ones that get missed
1
Hepatic hydrothorax
Thoracentesis — not a chest tube.
A tube drains protein and volume continuously, is difficult to remove, and invites infection and renal failure. If it is refractory to medical therapy, consider TIPS — and discuss TIPS and transplant together, not in sequence.
2
Rebalanced haemostasis
Do not correct the INR before the tap.
INR does not gauge bleeding risk in cirrhosis. Bleeding rates are 0–3.3% for paracentesis and around 2% for thoracentesis. Plasma does not correct the coagulopathy and can worsen portal pressure; platelet count and fibrinogen do not predict failure to control variceal bleeding.
3
Cirrhotic cardiomyopathy
A normal ejection fraction is not reassurance.
Low afterload flatters the LVEF. The 2019 consortium criteria add global longitudinal strain (absolute value < 18%) alongside LVEF ≤ 50%. The deficit is contractile reserve, so it is unmasked by sepsis, bleeding, TIPS and transplant — which is the argument for early bedside echo rather than more fluid.
4
Relative adrenal insufficiency
Common, and it predicts death.
Found in 49% of non-critically-ill patients admitted with acute decompensation, with 90-day mortality of 26% versus 10%. Associated with new infection, sepsis, septic shock and circulatory dysfunction — but not with HE or AKI.
Baveno VIII (6.4, 6.7). AASLD ACLF Practice Guidance, Hepatology 2024 (statements 13–14, 19, 35–37, and the adrenal section). Izzy M, et al., Cirrhotic Cardiomyopathy Consortium. Hepatology 2020;71:334–345.
DAY 4 · INITIAL MANAGEMENT
From cirrhosis to ACLF
EASL–CLIF
Organ failure across six systems, graded 1–3 by the number of failures.
DAY 4 · INITIAL MANAGEMENT
Prognosis: MELD is the wrong tool here
30–50%
28-day mortality once ACLF is established, across definitions and regions
48%
of ACLF worldwide is precipitated by infection — the commonest trigger
day 3–7
the window in which the trajectory becomes clear
Two practical consequences
AASLD ACLF Practice Guidance, Hepatology 2024 (statements 3–4, and prognosis section).
DAY 4 · INITIAL MANAGEMENT
Management triaging based on severity
AASLD ACLF Practice Guidance, Hepatology 2024 (statements 5–23, 30–47).
DAY 4 · INITIAL MANAGEMENT
Bridging therapies - TIPS
Established indications
No longer absolute contraindications
ACLF, overt HE, hyperbilirubinaemia or high MELD, and severe alcohol-related hepatitis. Prior overt HE requires assessment, not exclusion.
Baveno VIII, J Hepatol 2026 — statements 3.20, 4.10, 4.13, 4.15, 4.19, 5.31–5.34, 5.36, 5.37, 5.41, 5.42, 6.3, 6.4, 6.7, 6.8, 6.14, 6.15, and research agenda items RA4.16, RA5.14, RA6.7, RA6.21, RA6.24.
Emerging and expanding
DAY 4 · INITIAL MANAGEMENT
Bridging therapies – PLEX
DAY 5 · THE PIVOT
This is now a transplant conversation
Patient’s trajectory is consistent with ACLF and warrants conversation around transplant assessment.
Where she is on day 5 — SBP treated. HRS-AKI on terlipressin equivalent and albumin. Grade 3 HE improving. Two organ failures. MELD 3.0 is 31.
What that means — ACLF-2. Without transplant her 28-day mortality is in the range that makes this the only definitive treatment.
Potential issues — Eight hours from Vancouver. Twelve weeks of abstinence. No consistent support person. None of the transplant workup done.
The question the team asks — “Should we wait until she is more stable, and refer next week?”
The answer is no. No absolute contraindications. Referral is not listing, and assessment takes time.
Crucially, she is a candidate for assessment, but not yet a candidate for transplantation. These are NOT the same.
DAY 5 · THE CALL
How the referral actually happens
IN PRINCE GEORGE
The admitting physician
Recognises that referral criteria are met and makes the call.
AT VGH
Transplant hepatologist on call
Assesses plausibility of candidacy and decides whether transfer is warranted.
AT VGH
Internal Medicine
Confirms space availability, management on arrival, and what she needs on day one.
1
Prince George — “She has SBP, HRS-AKI and grade 3 encephalopathy. MELD 3.0 is 31. She meets referral criteria, and I do not think she has weeks.”
2
VGH hepatology — What is the aetiology and the abstinence history; what has been excluded; how stable is she right now; and what workup is already done?
3
PTN — A three-way call through the Patient Transfer Network: referring physician, on-call hepatologist, accepting physician. Outstanding items agreed on the call.
Agreed on the call: transfer once CT, echo, gastroscopy and TB testing are done at UHNBC — two days, because they were started that afternoon.
BC Transplant Clinical Guidelines, rev. 17 Nov 2025, section 3.2. Urgent referrals: transplant gastroenterologist on call via VGH switchboard, 604-875-4111.
DAYS 5–6 · REFERRAL AND TRANSFER
When to refer: the threshold is lower than you think
Child-Pugh ≥ 8 or MELD 3.0 ≥ 12
The BC Transplant referral threshold for chronic liver disease
Refer (or discuss) regardless of score if these are present
What this means in practice
BC Transplant, Clinical Guidelines for Liver Transplantation, rev. 17 Nov 2025, section 2.1.
DAYS 6–12 · INPATIENT ASSESSMENT AT VGH
The inpatient assessment at VGH
Investigations
Consultations
DAYS 6–12 · INPATIENT ASSESSMENT AT VGH
The transplantation window in severe decompensation & ACLF
Without transplant, ACLF-3 carries 28-day mortality of 68–89%
against 18–25% for ACLF-1. One-year survival after transplant is around 90%.
1
ACLF-3, CLIF-C ACLF ≤ 64 — Evaluate for transplant. 100% panel agreement.
2
> 3 organ failures, or CLIF-C ACLF > 64 — Re-evaluate daily. List only once organ failures or grade improve to ≤ 3 (or score ≤ 64).
3
ARDS or high lactate — Proceed cautiously — both carry higher postoperative mortality.
The type of organ failure and direction of travel matter more than raw count. ACLF-3 is a dynamic contraindication, not a permanent one.
EASL CPG on liver transplantation, J Hepatol 2024;81:1040–1086.
DAYS 6–12 · INPATIENT ASSESSMENT AT VGH
Contraindications, and what is not one
General contraindications
Not automatic contraindications
BC Transplant Clinical Guidelines, rev. 17 Nov 2025, sections 2.2.5–2.2.14.
Reversibility or change in status of contraindications: Even absolute contraindications can be reversible (e.g., active infection) or they can achieve a change in status later point (e.g., active alcohol use that is stopped after discharge and temporary recovery). However, some of course are not reversible (e.g., metastatic malignancy).
DAYS 6–12 · INPATIENT ASSESSMENT AT VGH
The six-month rule is not a rule
Severe alcohol-related hepatitis not responding to therapy
The honest caveat
Many patients with active alcohol use at presentation have a history of established alcohol related disease and have not followed medical advice around alcohol
Unfortunately, this often becomes an issue and results in a decline for transplant assessment until some insight and sobriety is documented
EASL CPG on liver transplantation, J Hepatol 2024;81:1040–1086. BC Transplant Clinical Guidelines, rev. 17 Nov 2025. ALD was the leading aetiology (40%) in the CLEARED 90-day cohort.
DAYS 6–20 · THE INPATIENT CLOCK
Two weeks from arrival to theatre, day by day
Day 6
Arrives at VGH. Bloods repeated, MELD 3.0 recalculated. Transplant hepatology reviews. Internal Medicine continues to manage the ACLF.
Day 7
Hepatobiliary surgery and anaesthesia. Vascular anatomy reviewed on the CT that Prince George did.
Day 8
Social work, dietitian, addiction medicine. The support-person problem is identified here.
Days 9–10
Outstanding items and investigations are completed. Infection screen repeated.
Day 11
Multidisciplinary liver transplant rounds. The listing decision.
Day 12
Activated. Status 2, because she is in hospital. MELD 3.0 recaptured at activation.
Days 12–20
Waiting on ward. Score recaptured at least every 7 days above MELD 30. Candidacy reviewed continuously.
Day 20
An offer. Re-assessed on the day for any new contraindication, bloods repeated.
What can undo it
Illustrative timeline, not a service standard. Lab capture intervals and status definitions: BC Transplant Clinical Guidelines, rev. 17 Nov 2025, Tables 9 and 10.
DAYS 12–20 · LISTED, AND WAITING IN HOSPITAL
What happens between a donor and an operating room
1
A donor becomes available: BC Transplant identifies the donor. The transplant surgeon and hepatologist on call review the active list.
2
Filter by compatibility: Blood group first, then size — graft size is estimated from the recipient's height and weight.
3
Rank: Medical urgency by status, then MELD 3.0 or exception score, then waiting time. Minimum estimated 5-year survival of 60% to allocate.
4
Call the recipient: They (or SDM) must be reachable at all times. Travel to Vancouver is arranged by the coordinator.
5
Final check, and a backup: Recipient re-assessed on arrival for any new contraindication; bloods repeated. A second recipient is sometimes prepared in parallel and stood down if the first proceeds.
Graft types: neurological determination of death, donation after circulatory death, split grafts, extended-criteria donors, and living donation — all are available in BC.
BC Transplant Clinical Guidelines, rev. 17 Nov 2025, sections 4.1–4.2.
CLOSING
If a transplant does not come
Independent predictors of 90-day death
Independent predictors of readmission
Idilman R, et al., CLEARED Investigators. Liver Int 2026;46:e70804. 4,208 patients, 125 centres, 37 countries.
FUTURE COLLABORATIVE WORK
A global registry of exactly the patients you admit
Chronic Liver disease Evolution And Registry for Events and Decompensation — a prospective, consecutive-enrolment cohort of adults admitted non-electively with cirrhosis, followed to 90 days after discharge.
8,143
patients enrolled in the cohort to date
125
participating centres
37
countries, across six continents
clearedconsortium.org · Principal investigators: Jasmohan Bajaj (VCU) and Ashok Choudhury (ILBS).
VGH
VGH has been invited as 3rd Canadian Center – Dependent on IM and Hep collaboration
WHAT WE ARE ASKING FOR
Three things from Internal Medicine
1
Identify Flag patients admitted with known or suspected cirrhosis.
2
Notify One email or text to the study leads or head coordinator.
3
Consent The study team obtains consent and collects the data.
No change to clinical management. No interference with your team's decisions.
Potential benefits
Contacts:
FUTURE COLLABORATION
Potential Future Initiatives
1
Clinic Multi disciplinary clinic for end-stage liver disease
2
Outpatient Expansion of services for advanced decompensation.
3
Inpatient Collaborative service for decompensation and liver failure.
Potential Outcomes
Daljeet Chahal Jayaram Pai And hopefully more collaborators from IM, surgery, radiology!
Benjamin Cox John Staples
Eric Yoshida Iain McCormick
Vladimir Marquez Ian Gan
TAKE HOME
Final Points
1
Infections drive the majority of decompensation and ACLF events.
2
Decompensation is not only an event, but also a prognostic stage.
3
In ACLF, score serially as the direction of travel at day 3 is prognostic.
4
Refer at Child-Pugh 8 or MELD 3.0 of 12, or at any decompensating event.
5
Do not confuse assessment candidacy with transplant candidacy.
Daljeet.chahal3@vch.ca
SOURCES
Reference guidelines, local policy and the CLEARED cohort
Guidelines
Local policy and CLEARED
Appendix
DAY 1–4 · INITIAL MANAGEMENT
Baveno VIII, J Hepatol 2026 (statements 5.3–5.14, 5.18, 5.22–5.25, 5.31–5.33, 5.36, 5.37).
THE ONE SLIDE TO PHOTOGRAPH
Cirrhosis admission bundle
First 6 hours
First 24 hours
Before discharge
Every item on this list is also a CLEARED variable. The care bundle and the registry are the same data.
DAY 1–4 · INITIAL MANAGEMENT
Beta-blockers: what Baveno VIII actually changed
✓
Compensated cirrhosis with CSPH — Carvedilol to prevent decompensation and improve survival.
✗
Compensated cirrhosis without CSPH — Do not use NSBB to prevent decompensation or death.
NEW
Ascites plus varices — Carvedilol/NSBB to prevent first bleeding and to lower ascites-related complications. Carvedilol preferred.
!
Hypotension or HRS-AKI — Dose-reduce or stop if systolic < 90 or MAP < 65, or if HRS-AKI develops.
↺
After recovery — Restart and re-titrate once HRS-AKI resolves and blood pressure recovers.
Baveno VIII, J Hepatol 2026 (statements 3.15, 3.16, 3.18, 4.4, 4.6, 4.7).
DAYS 5–6 · REFERRAL AND TRANSFER
BC moved to MELD 3.0 on 30 November 2025
MELD
Bilirubin, INR, creatinine. Built to predict survival after TIPS, then repurposed for allocation.
MELD-Na
Adds sodium. Adopted across Canada on 1 January 2015. Hyponatraemia independently predicts waitlist death.
MELD 3.0
Adds female sex and albumin, with interaction terms, and caps creatinine. Corrects a measurable disadvantage for women under the older scores.
Why it matters on the ward
BC Transplant Clinical Guidelines, rev. 17 Nov 2025, section 4.1. MELD-Na adopted nationally 1 Jan 2015.
DAY 5 · THE CALL
Making an inpatient referral
The inpatient pathway
The outpatient pathway, for contrast
For a patient eight hours from Vancouver who is already decompensating, this route is not realistic. Recognising that is part of the referral decision.
BC Transplant Clinical Guidelines, rev. 17 Nov 2025, sections 2.3, 3.1–3.2.
DAYS 6–12 · INPATIENT ASSESSMENT AT VGH
Referred is not assessed. Assessed is not listed.
1
Referred
The referral has been received. Nothing else has happened yet.
2
Pre-assessment list
Being followed by VGH Pre-Transplant Assessment and worked up. NOT on the transplant list.
3
Active list
Assessment complete, approved at rounds, activated. Now eligible to receive an organ offer.
Two things the guideline is explicit about
BC Transplant Clinical Guidelines, rev. 17 Nov 2025, sections 3.3–3.4.
DAYS 12–20 · LISTED, AND WAITING IN HOSPITAL
A stale score is a low score
Minimum frequency of laboratory capture
MELD 3.0 above 30
every 7 days
MELD 3.0 of 21 to 29
every 30 days
MELD 3.0 below 20
every 90 days
Why the ward should care
A listed patient's priority is only as current as their last set of labs. If a patient is admitted under your team and deteriorates, their score needs to be recaptured — and the transplant coordinator needs to know they are in hospital, because status changes from 1 to 2.
Patients and their supports are asked to notify the coordinator of any admission. In practice they often don't.
The ask: if you admit a patient who is on the liver transplant list, call the transplant clinic coordinator. Their status, their score and their position on the list all depend on someone doing that.
BC Transplant Clinical Guidelines, rev. 17 Nov 2025, Table 10 and section 3.4.
DAYS 12–20 · LISTED, AND WAITING IN HOSPITAL
There is no Canadian exception-points policy
Seven transplant programmes, five provinces, no common standard. A survey of all Canadian centres found that BC and Nova Scotia assign exception points relative to the median MELD-Na with condition-specific modifiers, while Alberta, Ontario and Quebec assign fixed point values by indication, some of which escalate over time to a capped maximum. The same patient with the same disease can hold a materially different priority depending on which province they live in.
1
Provincial by default — Non-urgent patients are allocated within their own province. There is no national MELD-based list.
2
National only when urgent — The Canadian Transplant Registry handles interprovincial sharing for status 4F and 3F, plus urgent re-transplant for primary non-function or hepatic artery thrombosis.
3
Historical context — Canada previously used CanWAIT, a location-based algorithm that leaned heavily on waiting time. MELD outperformed it for predicting waitlist mortality, and MELD-Na was adopted nationally in 2015.
Exception points for liver transplantation: a Canadian review. Canadian Liver Journal 2023. Canadian Blood Services, CTR interprovincial liver sharing policies. Burak KW, et al. Can J Gastroenterol Hepatol 2016.
DAYS 12–20 · LISTED, AND WAITING IN HOSPITAL
Exception points and the MMaT system
Some conditions kill without raising MELD.
BC assigns exception points relative to the Median MELD at Transplant (MMaT) — the median score among everyone transplanted that calendar year. Patients always receive the higher of their natural MELD 3.0 or their exception score.
MMaT + 3
Hepatocellular carcinoma · cholangiocarcinoma · hepatopulmonary syndrome · portopulmonary hypertension · neuroendocrine tumour · hereditary haemorrhagic telangiectasia · cystic fibrosis if lung transplant
MMaT
Refractory hepatic encephalopathy · recurrent cholangitis · polycystic liver disease · familial amyloid polyneuropathy · primary hyperoxaluria · urea cycle disorder
Examples of the criteria
BC Transplant Clinical Guidelines, rev. 17 Nov 2025, section 4.1.
DAYS 12–20 · LISTED, AND WAITING IN HOSPITAL
Where you are still matters
1
At home
2
In hospital
3
In ICU
3F
In ICU, fulminant failure
4
In ICU, intubated
4F
In ICU, intubated, fulminant failure
0
On hold
Reading the table properly
BC Transplant Clinical Guidelines, rev. 17 Nov 2025, Table 9 and section 3.4.1.