Liver Transplantation

What is a liver transplant?

Liver transplantation is surgery to replace a diseased liver with a healthy one. The healthy liver comes from either a deceased or living donor. You may need a liver transplant if you have liver failure or liver cancer.

Your liver performs many critical functions that keep you alive. If it becomes severely damaged, you’ll need a replacement to survive. If you meet the medical criteria for a liver transplant, you’ll be added to a U.S. national waiting list.

The wait can be long. There are far more people on the list than there are donor livers available. Each year, some people die or become too sick to have surgery while waiting for a transplant.

But surgery success rates are high. About 90% of people who have a liver transplant survive the surgery and recovery process, which can take up to 12 months. The current five-year survival rate is about 73%.

What are the criteria to have a liver transplant?

Liver transplantation is typically a last resort when your liver can no longer support your body. This may be because your liver is failing (losing its function) or because it has cancer that needs to be removed.

Conditions that may qualify you for a liver transplant include:

• Acute liver failure (when your liver becomes very sick very fast)
• Chronic liver failure (when cirrhosis gradually stops your liver from working)
• Primary liver cancer (like cholangiocarcinoma or hepatocellular carcinoma)
• Metastatic cancer that’s spread to your liver (like colorectal cancer)

Your healthcare provider must also determine that you’re well enough to have organ transplant surgery and likely to recover. Certain medical conditions may make the procedure too risky.

Conditions that may disqualify you from having a liver transplant include:

• Cancer that’s outside your liver (unless it’s been successfully treated)
• Congestive heart failure
• Dementia
• Infections that medications can’t manage and that a liver transplant can’t cure
• Severe lung diseases
• Severe pulmonary hypertension
• Severe, unmanaged mental health disorders with psychosis
• Substance use disorders

If your healthcare provider recommends a liver transplant for you, they’ll refer you to a transplant hospital. A multidisciplinary team will evaluate you to determine if you’re a candidate.

Each transplant hospital has its own criteria for accepting transplant candidates. If they accept you, they’ll put you on the national waiting list maintained by United Network for Organ Sharing (UNOS).

How are liver transplant candidates matched with donors?

To be a match for a donor liver, you’ll need to:

• Have a compatible blood type. This helps prevent your body from rejecting the new liver.
• Be about the same height and weight as the donor. This is to make sure their liver fits your body. (Children are an exception to this rule. They only need a small portion of an adult liver.)
• Be in the same geographical region. This is to ensure the donor liver can get to you in time.
• Have the most immediate need for it. UNOS will rank your need according to your condition.

How does UNOS determine your need for a liver transplant?

If you have acute liver failure with immediate need for a liver transplant, you’ll go to the top of the waiting list. Most people on the list have chronic liver disease, which tends to progress more slowly.

In those cases, UNOS uses a scoring system called MELD (Model for End-Stage Liver Disease) or PELD (Pediatric End-Stage Liver Disease). These scores are based on your blood test results to determine your place on the waiting list.

What happens when you’re matched with a donor liver?

When a donor liver becomes available, your transplant coordinator will contact you and ask you to come to the hospital right away. Surgery will begin as soon as possible after both you and the liver have arrived.

While you wait, you’ll have standard screening tests to make sure you’re ready for the operation. You’ll also meet with your surgeon and anesthesiologist to go over the plan and prepare for surgery.

What happens during liver transplant surgery?

Liver transplantation is a major operation that can take up to 12 hours. You’ll receive general anesthesia, so you’ll be asleep through the procedure. You’ll also have several tubes in place to support your body throughout the surgery.

You’ll have:

• An IV in a vein of your arm or hand to deliver fluids and medicine
• An IV in a vein of your neck or thigh to draw blood and check your blood pressure
• A breathing tube connected to a mechanical ventilator
• Drainage tubes in your abdomen to remove fluid and blood
• A nasogastric tube to empty your stomach
• A catheter in your bladder to drain your pee

During the operation, your surgeon will:

1. Make one long incision across your abdomen to access your liver.
2. Carefully separate your liver from the ligament that connects to your abdominal wall.
3. Place a clamp on your bile ducts and the blood vessels that connect to your liver.
4. Remove your liver and gallbladder.
5. Put the new liver in its place and attach it to your blood vessels and bile ducts.
6. Close your incision and move you to a recovery room.

If you have friends or family waiting at the hospital, a member of your care team will check in with them throughout your surgery. They’ll let them know as soon as you wake up from the anesthesia.

What are the benefits and risks of liver transplantation?

If you have end-stage liver disease or liver cancer, a liver transplant is your best hope of survival. It can extend your life and significantly improve your quality of life.

Like any major surgery, liver transplantation comes with risks. These range from minor complications to serious ones that may affect your recovery or long-term health.

Complications from the procedure itself can include:

• Bile leak: Bile may leak from the new connection between your bile duct and the donor’s bile duct into your abdominal cavity.
• Blood clots in the new liver: This rare complication requires immediate treatment.
• Hemorrhage: Livers tend to bleed heavily, and liver disease can make bleeding worse. You may need blood transfusions or additional surgery to control bleeding.
• Infection: Any surgery carries a risk of infection, but that risk increases after organ transplantation. Anti-rejection medications weaken your immune system, which makes infections more likely.

Complications after the procedure can include:

• Liver failure after transplantation: About 5% of donor livers don’t function properly after surgery. If this happens, you’ll need another transplant as soon as possible.
• Organ rejection: This happens when your immune system attacks the donor liver. About 5% of people have ongoing rejection episodes despite taking medication. Over time, this can lead to liver failure.

What happens after liver transplant surgery?

You’ll likely stay in the intensive care unit (ICU) for several days after your surgery. During this time, you’ll receive fluids and nutrition through an IV until your body is ready to handle liquids and solid food. You’ll also receive pain medication as needed.

Your healthcare team will monitor you closely and check for any signs of complications. They’ll take blood samples to see how well your new liver is working and may need to manage things like:

• Blood sugar levels
• Blood volume
• Electrolyte levels
• Fluid levels

When your vital signs are stable and your new liver is functioning well, you’ll move out of the ICU to a regular hospital room. You’ll continue recovering there for another one to three weeks.

Before you go home, your care team will teach you how to:

• Care for your surgical wound
• Take your medications correctly
• Check your blood pressure and pulse
• Watch for signs of infection
• Know when to contact them

When should I call my healthcare provider?

In general, contact your care team right away if you experience:

• Abdominal pain
• Chest pain
• Fatigue
• Fever
• Decreased output of pee
• Severe headache
• Shortness of breath
• Vomiting
• Yellowing of your eyes or skin

How long is the recovery from liver transplant surgery?

Most people can return to work within three months and return to all other activities within six to 12 months. As you continue to recover at home, you’ll have frequent follow-up visits with your healthcare team.

What kind of scar will I have?

The scar from open liver surgery is typically six to 12 inches long. It may run horizontally across your abdomen or be shaped like a “V.” The scar may appear red or brown and raised above the skin. In some cases, it fades over time; in others, it may remain visible.

What medications will I take after liver transplantation?

After an organ transplant, you’ll need to take immunosuppressant medications for the rest of your life. You’ll usually start with a higher dose and then taper to a lower maintenance dose over time.

Immunosuppressants can cause side effects, so your healthcare team will monitor you closely with regular blood tests and adjust your medications as needed.

Common immunosuppressants include:

• Corticosteroids (methylprednisolone, prednisone)
• Monoclonal antibodies (basiliximab, daclizumab)
• Calcineurin inhibitors (cyclosporine, tacrolimus)
• Inosine monophosphate dehydrogenase (IMDH) inhibitors (mycophenolate mofetil, azathioprine)
• Mechanistic target of rapamycin (mTOR) inhibitors (sirolimus, everolimus)

These medications work by suppressing your immune system to prevent it from attacking your new liver. But this also means your body will be more vulnerable to everyday infections and certain diseases.

Possible side effects of immunosuppressants include:

• High blood sugar and Type 2 diabetes, especially if you already have metabolic syndrome
• Hypertension (high blood pressure)
• Increased risk of infections and certain cancers
• Kidney disease or kidney failure, especially if you had prior kidney damage

What is the prognosis after a liver transplant?

About 90% of people survive at least one year after liver transplantation, and nearly 65% are still alive after 10 years. Some people live for decades. However, many factors can affect your personal life expectancy, including:

• Your age and overall health at the time of surgery
• Any preexisting medical conditions
• Complications or side effects after liver transplantation
• The condition that caused you to need a transplant in the first place

Your healthcare provider is the best person to ask about your life expectancy and expected quality of life after liver transplantation. They know your medical history and current medical status.

How can I help take care of my new liver after transplant surgery?

You can take care of your new liver and your overall health by:

• Considering some lifestyle changes: Avoid alcohol completely, as it can be very harmful to your new liver. If you smoke, work with your provider to quit. Consider meeting with a dietitian to develop a liver-friendly eating plan. Try to add light physical activity to your daily routine.
• Protecting yourself from infections: Stay away from people who are sick and avoid crowded places when possible. If you need to be in a crowd, wear a mask. Wash your hands often and ask your provider which vaccines are safe and recommended for you.
• Taking your medications as prescribed: Don’t skip doses. If you forget to take your medicine, tell your provider. Always check with your care team before taking any new medications or supplements — some can interfere with your transplant medications.