Delisting for Clinical Improvement Emerges as a Practical Marker of Cirrhosis Recompensation : Liver Transpl | April 2026

Introduction

The concept of recompensated cirrhosis has gained increasing importance with the advent of effective disease-modifying therapies for chronic liver disease, including antiviral treatment and sustained alcohol abstinence. As more patients experience meaningful clinical recovery, reassessing transplant candidacy and determining when liver transplantation may no longer be necessary have become major clinical challenges.

Problem Statement

Although recompensation is increasingly recognized as a relevant therapeutic endpoint, standardized real-world markers for durable clinical improvement remain poorly defined. Delisting for clinical improvement (DCI) from the liver transplant waitlist has been proposed as a potential surrogate for recompensation, but the durability of improvement and risk of subsequent clinical deterioration remain uncertain.

Summary

This large national cohort study demonstrates that delisting for clinical improvement occurs in a meaningful subset of liver transplant waitlist patients and may serve as a practical surrogate marker for recompensated cirrhosis. Rates of DCI varied substantially according to liver disease etiology, with the highest frequencies observed in hepatitis B, alcohol-associated liver disease and autoimmune hepatitis, reflecting the greater reversibility of these conditions under effective therapy or sustained disease control. Importantly, the study shows that true durable recompensation is not fully captured by MELD improvement alone. Patients achieving both MELD reduction and improvement in Child–Turcotte–Pugh class had the lowest risk of relisting, suggesting that combined biochemical and clinical recovery better defines stable recompensation. Notably, many patients delisted for improvement still retained significant underlying liver dysfunction, as fewer than half normalized to Child–Turcotte–Pugh class A. Relisting remained relatively uncommon overall but was frequently driven by hepatocellular carcinoma, emphasizing the continued oncologic vulnerability of cirrhotic patients despite hepatic improvement. Additional predictors of relapse included hypoalbuminemia, male sex and underlying disease etiology. Overall, the study supports a more nuanced and multidimensional approach to defining recompensated cirrhosis and provides important real-world evidence that integrated clinical improvement metrics may help guide safer liver transplant delisting decisions.