Liver Transplantation

What is a liver transplant?

A liver transplant is surgery to replace an unhealthy liver with a healthy one. You may need a liver transplant if you have liver failure or liver cancer. Liver transplants are treatments for adults and children.

Liver transplants are the third most common type of organ donation. There were more than 10,000 liver transplants in the U.S. in 2023. Each week, between 200 and more than 300 people join the liver transplant waitlist. Almost all (94%) liver transplants involve whole livers from deceased donors. About 5% of people receive partial liver transplants from living donors.

Why would someone need a liver transplant?

Your liver is one of the most important internal organs. It manages essential tasks like removing toxins from your blood, metabolizing nutrients and making proteins, In short, you can’t live without a functioning liver. If your liver is failing, a liver transplant could save your life.

How hard is it to get a liver transplant?

It’s not easy. In general, more people are eligible for a liver transplant than there are donor livers. Unfortunately, in the wait for a donor liver, about 16% of people who meet the medical criteria for a liver transplant become too sick to go through surgery or die before they can be matched with a donor liver.

Who is not eligible for a liver transplant?

Not everyone who has liver failure or liver cancer will be a candidate. If you have certain medical conditions, you can’t have a liver transplant. Those include:

• Cancer that’s outside your liver. You may be able to have a liver transplant if cancer treatment cures the condition and follow-up tests show cancer hasn’t come back.
• Congestive heart failure.
• Infections that medication can’t control and that a liver transplant can’t cure.
• Dementia.
• Severe lung diseases.
• Severe pulmonary hypertension.
• Severe, unmanaged mental health disorders with psychosis.

What are the criteria for getting placed on the liver transplant waiting list?

The criteria to be on the liver transplant waiting list are:

• Have acute or chronic liver failure. Acute liver failure is when you get very sick very fast from liver failure. Chronic liver failure develops over time and usually happens because you have cirrhosis.
• Have cholangiocarcinoma or hepatocellular carcinoma. You may be eligible for a liver transplant if you have other kinds of cancer. But there are specific eligibility criteria for each cancer type.
• Have cancer that spread to your liver like metastatic colorectal cancer or gastrointestinal neuroendocrine tumors.
• Be well enough to have surgery.
• Don’t have substance use disorders or be considered at risk of these disorders.

If your healthcare provider recommends an organ transplant for you, they’ll refer you to a transplant hospital. The transplant center’s multidisciplinary team will evaluate you to decide if you’re a suitable candidate.

Each transplant hospital has its own criteria for accepting candidates for organ transplantation. If they accept you as a candidate, they’ll put you on the national waiting list maintained by United Network for Organ Sharing (UNOS). They’ll let you know when you join the waiting list.

The list ranks prospective recipients by need. For example, if you have acute liver failure, meaning you got very sick very fast, you’ll be at the top of the list.

If you’re like most people, you have chronic liver failure and/or liver cancer. In that case, the UNOS will use a scoring system called MELD (Model for End-Stage Liver Disease) or PELD (Pediatric End-Stage Liver Disease). The scoring system uses information about your liver and blood test results to determine your place on the waiting list.

How are donors matched with transplant recipients?

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

• Have the same or compatible blood type as the potential donor.
• Be about the same height and weight as the potential donor so that the donor liver is large enough to meet your body’s needs.

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

If there’s a match, your transplant coordinator will call you with instructions about what you need to do right away. For example, they’ll tell you not to eat or drink anything so that you’ll be ready to receive anesthesia just before your surgery.

They’ll tell you to get to the transplant hospital right away. The transplant surgery team will start surgery as soon as possible after the donor liver arrives at the transplant hospital. When you arrive at the transplant hospital, you’ll:

• Have standard health screening tests to confirm you’re still able to go through surgery. For example, you may have an electrocardiogram (EKG) to check your heart rhythm and a complete blood count (CBC) to confirm you don’t have an infection.
• Meet with your surgeon and anesthesiologist to prepare for surgery.

What happens during a liver transplant?

Liver transplant surgery is a major operation. You’ll receive general anesthesia so you’re asleep during the surgery. Your surgeons will place a variety of tubes in your body to carry out certain functions during and right after your surgery. You’ll have:

• An IV (intravenous catheter) in a vein of your arm or hand to deliver fluids and medicine.
• An IV in a vein of your neck or thigh so providers can take blood samples and continuously check your blood pressure.
• A tube through your mouth and into your windpipe that connects to a mechanical ventilator. The ventilator will expand your lungs mechanically to make sure you keep breathing during surgery.
• Tubes in your abdomen to drain blood and fluid from around your liver.
• A nasogastric tube that your providers will insert through your nose to your stomach. The tube will drain fluid from your stomach.
• A catheter in your bladder to drain urine.

To begin the operation, your surgeon will:

1. Make one long incision across your abdomen to reach 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 are connected to your liver.
4. Remove your liver and gallbladder.
5. Put the donor liver in place.
6. Attach it to your blood vessels and bile ducts.
7. Close your incision.

How long is liver transplant surgery?

Your surgery may take up to 12 hours. If you have friends or family waiting at the hospital, a member of your care team will check in with them throughout your surgery.

How much of a donated liver is needed for a liver transplant?

That depends on the type of donation. If you receive a liver from a deceased donor, you receive the entire liver.

In living donor transplantation, most adults only need one liver lobe (hemisphere) from a living donor. If the donated lobe is healthy, it’ll regenerate to its former size. Surgeons often select the right lobe for transplant because it’s a bit bigger, but in a pinch, the left lobe will do fine, too.

What happens after liver transplant surgery?

You may remain in intensive care for several days following your surgery. You’ll have a nasogastric tube, and you’ll get nutrition from an IV line until your body can process liquids and solid food.

Your healthcare team will monitor your condition and watch for signs of complications. They’ll take blood samples to check how your new liver is working. They may need to manage issues like:

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

When tests show your new liver is working and your vital signs are stable, your providers will remove the IV tubes from your neck and nasogastric tube.

You’ll move from intensive care to another area in the hospital where you’ll stay for one to three weeks as your body continues to recover.

Next, your bowels will start working again, meaning you can pass gas or poop. You’ll begin drinking liquids. Your care team will start providing small amounts of solid food. They’ll begin reducing the amount of pain medication you receive via IV.

Before you go home, your team will show you:

• How to care for your surgical wound.
• How to take your medications, like the immunosuppressants you’ll take to reduce the chance your body will attack the donor liver.
• How to check your own blood pressure and pulse.
• How to recognize signs of infection.
• When it’s important to contact them.

What kind of follow-up care will I have during recovery?

As you continue to recover at home, you’ll have frequent checkups with your healthcare team. They’ll do blood tests to check your liver’s health.

What are the benefits of a liver transplant?

A liver transplant may be a lifesaving option for people with liver disease or liver cancer. When your liver disease is advanced, there’s no alternative to liver transplantation to save your life.

How successful are liver transplants?

The success rate for the transplant surgery itself is more than 90%. That means the transplant was successful, the new liver works and the person receiving the transplant came through the recovery process without major issues. Factors that may affect the success of the operation include how sick you are, your preexisting health conditions and the quality of the donor liver.

What are the risks of a liver transplant?

Liver transplantation, like any major surgery, comes with a range of risks, including minor to life-threatening complications. Possible complications include:

• Bile leak: Bile may leak from a new connection between your bile duct and the donor’s bile duct into your abdominal cavity.
• Blood clots in the new liver: This complication is rare. If it happens, you’ll need immediate treatment.
• Certain kinds of cancer: The immunosuppressants that you take to protect the donor liver increase the chance you’ll have certain cancers, especially skin cancer and lymphoma.
• Hemorrhage: You’ll receive blood transfusions, but you may need more surgery to control the bleeding.
• High blood sugar and Type 2 diabetes: Immunosuppressants can affect blood sugar levels.
• Hypertension: You may develop high blood pressure from taking immunosuppressants and corticosteroids.
• Infection: Immunosuppressants increase your risk of infection, from the common cold and the flu to bacterial and fungal infections. If you develop an infection, you may need antibiotics or antiviral medication. An infection may cause an abscess. If that happens, you may need treatment to drain it. A severe infection from an abscess may cause bloodstream infection (septicemia).
• Kidney disease and kidney failure: Long-term immunosuppression treatment increases the risk of kidney failure.
• Liver failure after transplant: About 5% of donor livers don’t work normally (primary nonfunction). Primary nonfunction is life-threatening. If this happens, you’ll need a new donor liver to replace it as soon as possible.
• Organ rejection: In organ rejection, your body attacks the donor liver. About 5% of people may have chronic organ rejection. This is repeat episodes that continue despite medication. Chronic organ rejection may eventually cause your liver to fail.

How long does it take to recover from liver transplant surgery?

Most people can return to work within three months and return to all their other activities within six to 12 months. You’ll continue to see your healthcare team regularly during this time.

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:

• Staying in touch with your healthcare team: Keep all your medical appointments and contact your team if you have any questions or concerns.
• Taking your medications as prescribed: Don’t skip a dose. If you forget, let your healthcare team know. Make sure to consult your team about any additional medicine you want to take, including natural supplements. They might not mix with your new medications.
• Protecting yourself from infection: Try to avoid crowded places and wear a mask if you need to be someplace where there are lots of people. Stay away from people who have contagious illnesses like colds and flu. Ask your provider if there are vaccinations you should have. And wash your hands frequently.
• Eating well: You might want to consult a dietitian for ways to make the most of your meals.
• Considering some lifestyle changes: If you smoke, try to quit. Avoid beverages that contain alcohol. Alcohol is very harmful to your new liver. Add activity to your daily routine but be sure to check with your provider.

Will I always need to take immunosuppressants?

Yes, if you have any kind of organ transplant, you’ll need to take immunosuppressants for the rest of your life. You’ll take a higher dose at first, and then typically taper off to a lower dose. Your healthcare team monitors your response to the medication through frequent blood tests and adjusts your prescription accordingly. 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).

What kind of scar will I have after a liver transplant?

You may have a specific type of surgical cut, called Chevron or Mercedes-Benz® incision. The incision starts below your chest on both sides and curves gently down toward the middle of your abdomen. The incision may make a scar that looks like a wide arrow that’s pointing up. Depending on your skin tone, your scar may appear reddish or brown.

What’s the liver transplant survival rate?

The average survival rate after liver transplant is 78% after five years and nearly 65% after 10 years. But your survival rate will depend on many factors, including your age, overall health status and the original liver disease that made a liver transplant necessary. In some cases, that disease may return or continue. Your surgeon is your best source for answers to survival rate questions.

What’s the average life expectancy after a liver transplant?

Some people live for decades after their transplants. But as is true with survival rate estimates, many things can affect how long you’ll live after a liver transplant. Your surgeon is the best person to ask what you can expect. They know your medical history and your current overall health.

When should I call my healthcare provider?

Before you leave the hospital, your care team will explain what changes in your body are signs of complications from your liver transplant surgery. In general, you should contact your care team if you have:

• Abdominal pain.
• Chest pain.
• Chills.
• Diarrhea.
• Fatigue.
• Feeling short of breath (dyspnea).
• Fever, when your temperature is 100.0 degrees Fahrenheit (37.8 degrees Celsius) or 100.4 degrees F (38 degrees C).
• Infrequent urination (not peeing as much as usual).
• Severe headache.
• Vomiting.
• Yellow eyes or skin (jaundice).

How long can you live without a liver transplant?

That depends on your situation. For example, people who have chronic liver failure may live for months or years while waiting for a liver transplant. Your situation can change, however, if you develop conditions like:

• Fluid in your abdomen (ascites).
• Swollen and sometimes bleeding veins in your esophagus (esophageal varices) or the lining of your stomach (gastric varices).
• Liver-related brain dysfunction (hepatic encephalopathy).

The situation gets more complicated if you have liver cancer. It’s understandable that you’d want to know what to expect as you wait for a donor liver. But since so many things can affect you, your best option is to ask your healthcare provider what you can expect.