Liver transplantation is now recognised as a highly effective form of treatment for patients with end stage liver disease. Currently, one and five year survival rates are in excess of 80%. As a consequence of many developments in all aspects of transplantation, indications have widened and contraindications become fewer. However, the increase in the number of patients referred for transplantation has not been matched by an increase in donor rates. Despite the innovative use of techniques to make fullest use of the donor pool, such as splitting of livers and increasing use of marginal livers (those livers where there is doubt as to initial graft function), the demand for transplantation is failing to meet the supply. The consequence of this relative shortage of donors is that more patients are on the waiting list for transplantation, those on the waiting list become sicker before they receive a graft, and there is the likelihood of more deaths on the waiting list.

In the UK the majority of patients are referred by gastroenterologists in district general hospitals to one of the seven designated liver transplant units. To make the most efficient use of these scarce livers, it is important that those clinicians referring patients for transplantation are aware of the problems consequent upon the donor shortage.

Selection of patients for liver transplantation occurs at three stages. The first stage is when the patient's doctor (usually a gastroenterologist working in a district general hospital) refers the patient for transplantation. We believe that the greatest selection occurs at this point. The second stage is when the patient is referred to the transplant unit, is assessed, and accepted on the transplant list. Indications for liver transplantation and contraindications are now relatively well established1 so it is not surprising that most referred patients are accepted onto …