Liver Transplantation

Overview

What is a liver transplant?

A liver transplant is a surgical procedure to replace a failing liver with a healthy one that comes from another person’s body. You can receive a whole liver from a donor who has recently been pronounced dead, or you can receive a part of a liver from a living donor. A divided liver can grow back to full size in both your body and the living donor’s body.

Why would someone need to have a liver transplant?

You can’t live without a functioning liver. If your liver is failing, or if you have primary liver cancer, a liver transplant could save your life. Many things can cause your liver to stop working, including immediate (acute) causes like toxic poisoning and chronic liver diseases. There are many more people who need liver transplants than there are donor livers available.

What conditions can a liver transplant treat?

Liver transplant surgery is usually reserved for:

It’s usually a last-resort treatment. The competition for donor livers is high, and even if you do get one, it won’t always cure the underlying disease. Some chronic liver diseases will simply resume their destructive work on the new liver. But since these diseases tend to progress slowly, starting over with a healthy liver can buy valuable time.

Acute liver failure

Acute liver failure occurs when a previously healthy liver has severe damage. The damage may come from toxic poisoning or infection. If you have acute liver failure, you will have symptoms of liver insufficiency — evidence that your liver has stopped working. This is an emergency. Some livers recover from acute liver failure, but others don't.

Chronic liver failure

Chronic liver failure is the end-stage of chronic, progressive liver disease. It usually means that too much of your liver tissue has been replaced with scar tissue, which has no blood flow. This is also called cirrhosis of the liver. When your liver functions begin to break down, you’ll show signs of “decompensated” liver disease.

Primary liver cancer

The type of cancer that begins in your liver is called primary liver cancer, or hepatocellular carcinoma. If cancer doesn’t spread beyond your liver, removing the liver can remove cancer and cure it. Sometimes your provider can remove just a piece of your liver with the tumor in it (partial liver resection). But if your liver is in poor condition, a transplant may be needed.

How long can you live without a liver transplant?

If you have acute liver failure, you may recover, but this can’t be predicted. Those who don’t recover may die within days. Chronic liver failure is a more gradual process. People can live with cirrhosis for months or years while waiting for a liver transplant, although the need becomes more urgent when complications, such as portal hypertension, begin to develop.

If you’re waiting for a liver transplant to treat primary liver cancer, cancer itself may still be in the first stage. Liver transplant surgery is only a treatment for liver cancer if it hasn’t yet spread beyond your liver. However, most people with primary liver cancer also have chronic liver disease. As a result, your outlook depends on many individual factors.

How common are liver transplants?

Around 8,500 people a year receive liver transplants. Around 12,500 people each year are added to the donor waitlist. Almost all (95%) liver transplants are whole livers from deceased donors. However, partial transplants from living donors are on the rise. The number of living donor liver transplants performed in 2019 was 30% higher than in 2018.

Procedure Details

What are the criteria to qualify for a liver transplant?

There is a high demand for liver transplants, and not everyone who wants one will get one. Those who do will have intensive surgery and recovery. Healthcare providers want to do everything they can to ensure that the transplants they perform are successful. That’s why they require that you meet certain criteria to qualify for a liver transplant.

The minimum requirements to qualify for a liver transplant are:

  • That you have clinical signs of liver failure or primary liver cancer.
  • That you are well enough to have the surgery and recovery.
  • That you are not considered at risk of future alcohol or drug abuse.

There’s a lot involved in determining these things. Healthcare providers will fully evaluate your physical and mental health and any history of chemical dependencies. If you have any compromising conditions, these will need to be treated first. Once you meet the minimum criteria for a liver transplant, you’ll be placed on the national waiting list.

How is the liver transplant waiting list ranked?

A small number of people who are in critical condition with acute liver failure go straight to the top of the list. These people fall ill very suddenly, and they are only on the list for a matter of days. Most people on the list have chronic liver failure and/or liver cancer. If you’re among them, your healthcare provider will use a scoring system to rank your condition.

The scoring system for chronic liver disease is called MELD (Model for End-Stage Liver Disease) or PELD (Pediatric End-Stage Liver Disease). It's calculated by blood test results. The tests measure:

  • Bilirubin. High bilirubin levels indicate that bile is leaking into your bloodstream.
  • Prothrombin Time. This is how long it takes for a sample of your blood to clot.
  • Creatinine. This is a measure of how well your kidneys are functioning. It’s used for adults.
  • Albumin. This measure of kidney function is used instead of creatinine for children.

These factors help determine how well your liver is still functioning. Additional factors can add points to your score, called exception points. These include secondary conditions and complications that make your need more urgent. In children, low growth rates add exception points. Your total score determines your place on the waiting list.

If you have hepatocellular carcinoma (primary liver cancer), your healthcare provider calculates your mortality risk based on the tumor size and wait time.

How are donor livers matched with transplant recipients?

The liver transplant waiting list isn’t only sorted by need. It’s also sorted by:

  • Blood type.
  • Body size.
  • Geography.

Having a compatible blood type helps to prevent your body from rejecting the donor liver. Sharing a similar body size helps to ensure that your new liver will be the right size for your body. And being in the same geographical region helps to ensure that your donor liver will have time to be delivered to you while it’s still viable (within eight to nine hours).

In order to be a match for a donor liver, you usually have to be a match in all three of these categories. For urgent need, you might receive a liver from up to 500 miles away if one becomes available. Most of the time, the whole liver is matched to one recipient, but occasionally, healthcare providers are able to identify two candidates who can share one liver.

How much liver is needed for a liver transplant?

Most adults need only one liver lobe (hemisphere) from a donor. If the donated lobe is healthy, it will 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. Most children only need about 20% of an adult liver, which is about the size of one of the left lateral segments.

Where do donated livers come from?

A liver that’s viable for transplantation must be fully functional. That means that none of the tissues have yet died. Tissue death occurs when blood flow is lost. So, donor livers come from bodies that still have active blood flow — whose hearts are still beating — but whose brains have died. Often, they’ve had a catastrophic injury to their brain.

Sometimes the person has agreed in advance to donate their liver under these circumstances. Other times, their family donates the liver on their behalf. These circumstances, and the identity of the donor, remain confidential. Healthcare providers will evaluate the health of the donated liver and test it for any infections before matching it to a waiting recipient.

How does living liver donation work?

You can skip the liver transplant waiting list if you are able to obtain a living donor liver transplant. This is usually a friend or family member who shares a similar body size and compatible blood type and has volunteered to donate a portion of their liver to you. Occasionally, an altruistic individual who may be entirely unconnected to you becomes an anonymous donor.

Living donors are thoroughly screened before they are approved for the procedure. Healthcare providers evaluate their overall health and fitness for surgery, as well as the condition of their liver. They’ll make sure the potential donor fully understands the risks of the procedure and that they are psychologically prepared for the commitment they’re making.

One advantage of having a living liver donor is that you and your donor can schedule the surgery together in advance. You’ll have surgery at the same time. You’ll also have the advantage of having your liver transplant sooner than most. This makes it more likely that you’ll receive a healthier liver, and also that your health will be better off for surgery and recovery.

How serious is liver transplant surgery?

Hepatectomy — removal of part or all of the liver — is considered a technically difficult surgery. One reason is that the liver bleeds a lot, so liver surgeons have to be trained in special techniques to manage the bleeding. People with liver failure tend to bleed even more because blood clotting to stop excessive bleeding is one of the liver’s jobs that it stops doing.

You may need multiple blood transfusions during your operation, which can take between six and 12 hours. The length of the operation also raises the risk of possible complications, both during and after the procedure. Afterward, you’ll be under close observation for at least 24 hours, and you’ll stay in the hospital for one to three weeks after that.

What happens when I'm matched with a donor liver?

If your liver transplant coordinator calls to tell you they’ve found a liver, you’ll need to go to the hospital right away. You’ll be asked not to eat or drink anything until after the surgery. When you arrive, you’ll take some standard health screening tests and meet with your surgeon and your anesthesiologist to prepare for surgery. It will begin as soon as the liver arrives.

What happens during liver transplant surgery?

Liver transplant surgery is a major operation that will take between six and 12 hours. You’ll be asleep under general anesthesia during the surgery. For this kind of procedure, surgeons install a variety of tubes in your body to carry out certain functions while you’re unconscious. The tubes will remain in place for a few days 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 to monitor your blood pressure and take blood samples.
  • A tube through your mouth and into your windpipe attached 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 inserted through your nose into your stomach to drain secretions from your stomach. It will remain in place for a few days until your bowel function returns to normal.
  • A catheter in your bladder to drain urine.

To begin the operation, your surgeon will make one long incision across your abdomen to access your liver. They’ll carefully separate your liver and clamp your blood vessels and bile ducts that were connected to it. Then they’ll install the new liver and attach it to your blood vessels and bile ducts. After closing your incision, they’ll send you to intensive care.

What happens after liver transplant surgery?

You may remain in intensive care for several days following your surgery. 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 actively manage your fluid/electrolyte balance, blood sugar levels and blood volume through your IVs.

When your condition has stabilized, your tubes will be removed and you’ll relocate to a recovery unit to continue your stay for another one to three weeks. Your bowels will take a few days to begin working again. You’ll begin drinking liquids and slowly reintroduce solid foods. You'll slowly begin to wean from your IV pain medication before going home.

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 continue to take regular blood tests to check on your new liver. You may have your incision stitches removed after a couple of weeks. You’ll be on several medications immediately after surgery, and some you’ll continue to take for the rest of your life.

Your healthcare team will teach you:

  • How to care for your incision wound.
  • How to take your medications.
  • How to check your own blood pressure and pulse.
  • How to recognize signs of infection.
  • How to recognize signs of organ rejection.
  • When it is important to contact them.

What are immunosuppressants?

If you have any kind of organ transplant, you’ll need to take immunosuppressants for the rest of your life. These are drugs that suppress your immune system. Your immune system helps prevent infection from foreign invaders, such as viruses and bacteria. Unfortunately, since your new liver comes from outside of your body, it looks like a foreign invader.

Healthcare providers prescribe immunosuppressants to prevent your body from attacking your new liver. 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. It may include:

Risks / Benefits

What are the possible risks or complications of liver transplant surgery?

The most significant risks from the procedure itself include:

  • Blood clots. Liver transplantation is a longer surgery, and the longer you are on the operating table, the greater your risk is of blood clots. The risk is still less than 5%.
  • Hemorrhage. The liver bleeds a lot, especially when you have a blood clotting disorder due to liver damage. Liver surgeons expect this and often use automatic blood transfusion technology.
  • Bile duct injury. Injury during surgery could cause bile to leak into the abdominal cavity, which would be toxic. After surgery, scar tissue can develop where your bile ducts were injured and create a stricture or blockage, causing bile to back up into your liver.
  • Liver failure. Sometimes the donor liver is damaged in transit and fails to function after transplantation. If this happens, you’ll need a new donor liver to replace it as soon as possible. This occurs in about 5% of cases.

What kinds of problems might arise after a liver transplant?

The most significant post-operative complications of liver transplant are organ rejection and infection.

Organ rejection

Your healthcare team will prescribe anti-rejection medications (immunosuppressants) to help prevent your immune system from attacking your new liver. Even so, mild “rejection episodes” are common in the first year after your transplant. Acute organ rejection occurs in 25% to 50% of all liver transplant recipients within the first year, with the highest risk period being in the first four to six weeks after transplantation.

The first evidence of acute organ rejection usually comes from elevated liver enzymes in your blood test. Your healthcare team will confirm the diagnosis with a liver biopsy, a simple bedside procedure using a needle. They'll treat it by adjusting your medications. About 5% of people may have chronic organ rejection — repeat episodes that continue despite medication. Chronic organ rejection may eventually cause your liver to fail.

Infection

There is some risk of infection with any surgery, but more with organ transplantation. This is one side effect of taking immunosuppressant drugs. These medications weaken your immune system, so it isn’t able to defend you against infection as well as it did before. That includes infections from the hospital, but also those you encounter after you leave. From now on, you’ll be more at risk of contracting common cold and flu viruses, bacterial and fungal infections.

Your risk will be highest immediately after transplantation when your dosage of immunosuppressants will also be highest. During the first month, bacterial and fungal infections are most common. Viral infections such as cytomegalovirus may occur within the first six months. You might want to take extra steps to protect yourself from these risks, especially in the first six months after surgery. If they do occur, your healthcare team can treat them with antibiotics.

Possible long-term complications include:

  • Hypertension. Liver transplant recipients may not be able to control their blood pressure as effectively as others.
  • High blood sugar and Type 2 diabetes are potential side effects of immunosuppressant drugs in some people, especially if you already had metabolic syndrome.
  • Kidney disease and kidney failure. Previous liver disease can deteriorate kidney function, and in some transplant recipients, this process continues in spite of the new liver.
  • Cancer risk. People who’ve had liver transplants are more at risk of acquiring certain cancers, especially skin cancer and viral lymphoma, due to their suppressed immune systems.

Recovery and Outlook

How long will it take to return to normal life after liver transplant surgery?

Most people are able to return to work within one to two months and return to all of their other activities within six to 12 months. You’ll continue to see your healthcare team regularly during this time.

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

The laparotomy scar from open abdominal surgery is six to 12 inches long. It may be a horizontal scar, or shaped like a “V." It may appear red and raised above the skin. Sometimes it fades, and sometimes it doesn’t.

What is the success rate of liver transplant surgery?

The success rate for the transplant surgery itself is between 85% and 90%. That means the transplant was successful, the new liver was functional and the patient survived the year-long recovery process. Factors that may affect the success of the operation include your preexisting health conditions and the quality of the donor liver.

How long can you live after a liver transplant?

This depends on many factors, including your age, overall health status, and the original liver disease that caused you to need a liver transplant. In some cases, that disease may return or continue. The average survival rate after liver transplant is 75% after five years and 53% after 20 years.

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

  • Stay in touch with your healthcare team. Keep all of your medical appointments, take all of your regular tests, and contact your team if you have any questions or concerns.
  • Take 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.
  • Take steps to protect yourself from common infections such as viruses and food poisoning. Watch for signs of infection, such as fever, vomiting or swelling, and seek treatment right away.
  • Maintain a healthy diet and lifestyle. You might want to consult a nutritionist to help outline a long-term diet plan. Avoid alcohol and tobacco. Try to get a little exercise most days.

A note from Cleveland Clinic

Your liver is one of your essential organs. It performs so many complex functions that no medical or mechanical substitute can replace it. You don’t notice your liver doing this work until it begins to fail. But when you begin to experience the symptoms of liver failure, you understand.

Liver disease has many causes. Some are beyond our control, and some we don’t even know about until the damage has been done. To the many thousands of people on the waiting list, liver transplant surgery offers hope. If you're lucky enough to receive a liver donation, a transplant could save your life.

Last reviewed by a Cleveland Clinic medical professional on 04/13/2022.

References

  • American College of Gastroenterology. Liver Transplantation. (https://gi.org/topics/liver-transplantation/) Accessed 3/28/2022.
  • American Liver Foundation. Liver Transplant. (https://liverfoundation.org/for-patients/about-the-liver/liver-transplant/) Accessed 3/28/2022.
  • Medscape. Liver Transplantation. (https://emedicine.medscape.com/article/431783-overview) Accessed 3/28.2022.
  • Merk Manual Professional Version. Liver Transplantation. (https://www.merckmanuals.com/professional/immunology-allergic-disorders/transplantation/liver-transplantation) Accessed 3/28/2022.
  • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Liver Transplant. (https://www.niddk.nih.gov/health-information/liver-disease/liver-transplant) Accessed 3/28/2022.

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