Purpose of Review <p>Optimal timing of liver transplantation in the course of cirrhosis is important to ensure that the expected morbidity and mortality of the patient’s liver disease is greater than that of liver transplantation. This review evaluates the evidence and guidelines for initiating liver transplant evaluation in adult patients with cirrhosis.</p> Recent Findings <p>Historical data indicated that post-liver transplant survival was greater than survival on the transplant waitlist at a MELD ≥ 15. However, more recent studies suggest that transplant waitlist mortality is greater than post-transplant mortality at MELD scores as low as 11–12.</p> Summary <p>Appropriate timing of referral for transplant evaluation is critical for the optimal care of patients with cirrhosis. Early referral may allow for the identification of risk factors for mortality that may not be fully reflected in the MELD score and should be considered in any patient with persistent decompensation, major systemic complication of cirrhosis, or MELD 12 or greater.</p>