Clinical Practice Guidelines for Liver Transplantation in Saudi Arabia Faisal A. Abaalkhail, MD, Mohammed I. Al Sebayel, MD, Mohammed A. Shagrani, MD, Wael A. O’Hali, MD, Nasser M. Almasri, MD, Abduljaleel A. Alalwan, MD, Mohammed Y. Alghamdi, MD, Hamad Al-Bahili, MD, Mohammed S. AlQahtani, MD, Saleh I. Alabbad, MD, Waleed K. Al-Hamoudi, MD, Saleh A. Alqahtani, MD. ABSTRACT عبء أمراضودية بارتفاعكة العربية السعملكبد في الى زراعة الطلب عل ارتبط ال فيتلقيد بي الات زراعة الكباهات وبائيات مؤشر اتغيرتملكة. تكبد في ال ال غير الكبد الدهنيلتهاب. طغى ا ا ً عام20 مدىودية علىكة العربية السعمل ال يجياتراتب استسبملكة بئي سي في اللوبا الكبد التهاب على فيروس ا الكحولي لصابة بـسي. أصبحت عوامل خطر ا الكبد الفيرولتهابلة لفيروس الفعاعلج ا ال ، مصدرت الدملسمنة وفرط شحميا وا2 النوع داء السكري من، مثلNASH اً لسعودية. هناك أيضكة العربية املكبد في ال لزراعة ال ا ً ا رئيسي ً لق كبير ومؤشر ق ملكة في اللبالغياض الكبد الوراثية لدى ا وحدوث أمرنتشار ملحوظة في ا زيادة تطور الفظ، ووللمناعة وحلثبطة لديدة ال العواملة السعودية. أدت ال العربي ة معدل ناحجها إلى زيادمراض وعلى البكر علتعرف الراحية، والقدرات ال ال اعة يكنلمنثبط لج العللانبية لر اللثاوف بشأن الخائج زراعة الكبد، لكن ا نتا منى الرغملخطر. عل لطويلدى الى الياة على قيد البقاء علئج العرض نتا أن ت ستمرةديات مؤدي إلى تلزيادة، ما يات زراعة الكبد في ار مؤشرستم ذلك، ت إجراء عملية الرضى مع توقع معدل وفياتيلملي وتقلتبرعي التد الة عد لزياد بالعضاءلتبرعضاء مركز وطني معترف لزراعة العركز السعودي ل. يعد ال الزرع . يستعرض الستندلعضاء وتخصيصها لتوفير ا ا ً هم ا م ً دعم الزرع، ويقدم من أجل يئة زراعة الكبد.ج الرضى في بة في علة الصحيلرعايعدة مقدمي اوجيهات لسا ت Te demand for liver transplantation in the Kingdom of Saudi Arabia (KSA) is associated with the country’s high burden of liver disease. Trends in the epidemiology of liver transplantation indications among recipients in KSA have changed over 20 years. Non-alcoholic steatohepatitis has eclipsed the hepatitis C virus in the country due to the efective treatment strategies for HCV. Risk factors for NASH, like type 2 diabetes mellitus, obesity, and hyperlipidemia, are becoming a major concern and a leading indication for liver transplantation in the KSA. Tere is also a signifcantly increased prevalence and incidence of genetic adult familial liver diseases in KSA. New immunosuppressive agents and preservation solutions, improved surgical capabilities, and early disease recognition and management have increased the success rate of liver transplant outcome but concerns about the side efects of immunosuppressive therapy can jeopardise long-term survival outcomes. Despite this, indications for liver transplantation continue to increase, resulting in ongoing challenges to maximize the number of potential donors and reduce patient mortality rate while expecting to get transplanted. Te Saudi Center of Organ Transplant is the recognized National Organ Donation Agency for transplantation, which renders important support for procurement and allocation of organs. Tis guidance document aims to help healthcare providers in managing patients in the liver transplant setting. Keywords: liver transplantation, Saudi Arabia, guidelines, living donor, deceased donor Saudi Med J 2021; Vol. 42 (9): 927-968 doi: 10.15537/smj.2021.42.9.20210126 From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America. Received 23rd February 2021. Accepted 22nd July 2021. Address correspondence and reprint request to: Dr. Faisal A. Abaalkhail, Department of Medicine, Gastroenterology Section, King Faisal Specialist Hospital & Research Center, Riyadh, Kingdom of Saudi Arabia. E-mail: faisal.abaalkhail@gmail.com ORCID ID: http://orcid.org/0000-0003-1287-9887 OPEN ACCESS The need for Saudi Practice Guidelines. Te frst human liver transplantation (L T) in the Kingdom of Saudi Arabia (KSA) was performed in 1990, but the frst LT program was commenced in 1994. 1 Until 1997, all LTs in KSA were from deceased donors. 1,2 Te living donor L T (LDLT) program for children started in 1997, and the LDLT program for adults was initiated in 2001. 3 Tus, as of 2017, there were 2,233 LTs conducted: 1,133 livers from living- related donors, 95 from living-unrelated donors, and Clinical Practice Guidelines 927 https://smj.org.sa Saudi Med J 2021; Vol. 42 (9)