Liver Transplant

A liver transplant is a life-saving surgery that replaces a diseased or failing liver with a healthy one from a donor. This complex procedure offers patients with end-stage liver disease or acute liver failure the chance for restored health and an extended lifespan.

Table of contents

• What is a Liver Transplant?
• The Liver and Its Functions
• When is a Liver Transplant Needed?
• Who is Eligible for a Liver Transplant?
• Types of Liver Transplant
• The Evaluation Process
• The Waiting List
• The Transplant Surgery
• Recovery After Transplant
• Living with a Liver Transplant
• Survival and Quality of Life

What is a Liver Transplant?

A liver transplant is surgery to remove a liver that no longer functions properly and replace it with a healthy liver from another person, called a donor^[1]. When your liver stops working properly, called liver failure, a liver transplant can save your life^[3]. This is a major operation that removes your diseased or injured liver and replaces it with a healthy one^[1].

Liver transplants are treatments available for both adults and children^[4]. They are the third most common type of organ donation, with more than 10,000 liver transplants performed in the United States in 2023^[4]. In 2018, about 8,200 liver transplants were performed in the U.S. among adults and children^[1].

The Liver and Its Functions

• Liver
• Abdomen
• Upper right abdomen

Your liver is your largest internal organ and is located mainly in the upper right portion of the abdomen, beneath the diaphragm and above the stomach^[1]. It is one of the most important internal organs in your body^[4].

The liver performs several critical functions that are essential for life^[1]:

• Processing nutrients, medications and hormones
• Producing bile, which helps the body absorb fats, cholesterol and fat-soluble vitamins
• Making proteins that help the blood clot
• Removing bacteria and toxins from the blood
• Preventing infection and regulating immune responses

The liver also plays a crucial role in glucose metabolism, filtering blood, detoxifying drugs and alcohol, and storing vitamins^[6]. In short, you cannot live without a functioning liver^[4].

When is a Liver Transplant Needed?

People need a liver transplant when their liver fails due to disease or injury^[3]. A liver transplant is usually reserved as a treatment option for people who have significant complications due to end-stage chronic liver disease^[1]. Liver transplant may also be a treatment option in rare cases of sudden failure of a previously healthy liver^[1].

For adults in the United States, the most common reasons for needing a liver transplant in 2016 were^[3]:

• Alcoholic liver disease
• Cancers that start in the liver combined with cirrhosis
• Fatty liver disease (nonalcoholic steatohepatitis)
• Cirrhosis caused by chronic hepatitis C

Liver transplantation may be recommended if you have acute or chronic conditions resulting in irreversible liver failure or end-stage liver disease. Conditions that can lead to end-stage liver disease include^[6]:

• Cirrhosis (most common cause)
• Acute hepatic necrosis
• Autoimmune hepatitis
• Biliary atresia
• Hepatitis B or hepatitis C
• Liver cancer
• Metabolic disease
• Nonalcoholic steatohepatitis (NASH)

Biliary atresia is the most common reason children need a liver transplant^[3]. Doctors may also consider a liver transplant to treat rare disorders such as urea cycle disorders and familial hypercholesterolemia^[3].

People may also need a liver transplant due to acute liver failure. Acute liver failure is an uncommon condition most often caused by taking too much acetaminophen^[3]. Other causes of acute liver failure include bad reactions to prescription medicines, illegal drugs, and herbal medicines, viral hepatitis, toxins, blockage of the blood vessels to the liver, autoimmune diseases, and genetic disorders^[3].

Who is Eligible for a Liver Transplant?

Not everyone who has liver failure or liver cancer will be a candidate for transplant^[4]. The criteria to be on the liver transplant waiting list are^[4]:

• 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 you have certain medical conditions, you cannot have a liver transplant. Those include^[4]:

• 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

It’s not easy to get a liver transplant. In general, more people are eligible for a liver transplant than there are donor livers available. 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^[4].

Types of Liver Transplant

There are two main types of liver transplant based on where the donor liver comes from^[3].

Deceased donor transplants: Most livers for transplants come from people who have just died, called deceased donors^[3]. Almost all (94%) liver transplants involve whole livers from deceased donors^[4]. During a deceased donor transplant, surgeons remove your diseased or injured liver and replace it with the deceased donor’s liver. Adults typically receive the entire liver from a deceased donor. However, surgeons may split a deceased donor’s liver into two parts. The larger part may go to an adult, and the smaller part may go to a smaller adult or child^[3].

Living donor transplants: Sometimes a healthy living person will donate part of his or her liver, most often to a family member who is recommended for a liver transplant. This type of donor is called a living donor^[3]. About 5% of people receive partial liver transplants from living donors^[4]. Living-donor liver transplant is possible because the human liver regenerates and returns to its normal size shortly after surgical removal of part of the organ^[1]. In 2018, about 390 liver transplants involved livers from living donors^[1].

The Evaluation Process

If your healthcare provider recommends an organ transplant for you, they’ll refer you to a transplant hospital^[4]. Before doctors can decide if a liver transplant is the best treatment option, you will need to complete an evaluation^[6].

The transplant center’s multidisciplinary team will evaluate you to decide if you’re a suitable candidate^[4]. This team can include^[17]:

• Liver doctor (hepatologist)
• Transplant surgeon
• Nurse coordinator
• Social worker
• Psychologist
• Psychiatrist
• Pharmacist
• Dietician
• Financial coordinator

An evaluation is scheduled testing to see how advanced your liver disease is as well as to ensure that the rest of your body is healthy enough to manage a liver transplant^[21]. You may undergo a variety of lab tests and diagnostic imaging^[6]. These may include^[11]:

• Blood tests to confirm blood type, evaluate serum chemistries, screen for clotting factors and hepatitis, test for other viruses (including HIV), and more
• Cardiac evaluation to ensure the heart is strong enough for a transplantation operation, which may include an echocardiogram (EKG) and stress tests

Each transplant hospital has its own criteria for accepting candidates for organ transplantation^[4]. The treatment team reviews test results to decide if the patient is eligible for transplant^[17]. It’s important that you have a care partner who can provide support, transport you to your clinic visits, and receive the necessary information about your continued care^[6].

The Waiting List

If they accept you as a candidate, they’ll put you on the national waiting list maintained by United Network for Organ Sharing (UNOS)^[4]. They’ll let you know when you join the waiting list. The number of people waiting for a liver transplant greatly exceeds the number of available deceased-donor livers^[1]. In 2018, about 12,800 people were registered on the waiting list^[1]. Each week, between 200 and more than 300 people join the liver transplant waitlist^[4].

The list ranks prospective recipients by need^[4]. Your MELD score or Model for End-Stage Liver Disease will determine how long you will wait for a new liver^[21]. The UNOS oversees the allocation of donor organs using the MELD system, which assesses the severity of chronic liver disease by examining renal function, bilirubin and coagulation^[6]. Your MELD score takes into account factors such as how sick you are and your chances of mortality during a three-month period. The higher the MELD score, the faster you may receive a liver transplant. MELD scores range from 6 (less ill) to 40 (gravely ill)^[21].

For example, if you have acute liver failure, meaning you got very sick very fast, you’ll be at the top of the list^[4]. A donor is matched based on compatible blood type and similarly sized liver^[6].

While waiting for transplant, you will be seen in clinics regularly^[21]. It is critical to stay as healthy as possible before liver transplant surgery to ensure that transplantation is successful^[6]. A donor liver can become available at any time, day or night^[6].

The Transplant Surgery

When a suitable donor becomes available, a donor transplant coordinator will call you. You will be expected to be at the hospital as quickly and safely as you can get here for surgery^[21].

The average operating time for a liver transplantation procedure is four to eight hours^[6]. The transplant will take four to six hours, after which you will be admitted to the surgical intensive care unit (SICU) for several days^[21].

The standard incision used for the liver transplant is called a “chevron incision.” It starts at the right side of the midsection just under the ribs and extends to the left edge of the abdomen. There is also a short incision starting under the sternum (breastbone) which extends to meet the horizontal incision^[19].

Recovery After Transplant

After surgery, the transplant team will monitor you carefully for signs of rejection^[6]. You will then be transferred to a transplant unit once you are stable. Typically, you will be in the hospital for two to three weeks^[21].

A liver transplant is a major operation and it can take time to recover (up to a year)^[22]. It typically takes between 6 to 12 months to get back to normal or near-normal activities after a liver transplant. The healthier you were before your transplant, the sooner you’ll recover afterward^[16]. The first three months following transplantation are the most difficult. The body is adjusting to the “new” liver and all the medications needed to maintain its health^[19].

By the time of discharge from the hospital patients are able to care for themselves, with some minor restrictions^[19]. Most patients can return to work within 3 to 6 months after a transplant^[19].

After your liver transplant, you will have frequently scheduled lab testing and clinic visits with your transplant team. For the first 2 to 3 months, these will probably be about once a week^[22]. Twice a week, you will need to have labs drawn, and the transplant team will see you in the clinic at least once a week. As you advance from your transplant surgery, your lab draws and clinic visits will become less frequent^[21]. You’ll then go less often as you recover – usually every few months, and then once a year^[22].

Living with a Liver Transplant

Living with a liver transplant requires lifestyle changes and a commitment to your medical and healthcare needs^[21]. It’s important to understand the commitment that you need to make to your own health after the operation^[22].

Organ rejection occurs when your immune system sees your transplanted liver as “foreign” and tries to destroy it. You have the highest chance of organ rejection in the first 3 to 6 months after your transplant^[15]. Abnormal liver blood test results may be the first sign of organ rejection. Rejection does not always cause symptoms you may notice^[15].

When symptoms of rejection are present, they may include^[15]:

• Feeling tired
• Pain or tenderness in your abdomen
• Fever
• Yellowing of the skin and the whites of your eyes
• Dark-colored urine
• Light-colored stools

You should talk with your doctor right away if you have symptoms of organ rejection^[15].

To help keep your body from rejecting the new liver, you will need to take medicines called immunosuppressants. These medicines prevent and treat organ rejection by reducing your immune system’s response to your new liver^[15]. You may have to take two or more immunosuppressants. You will need to take these medicines for the rest of your life^[15]. Failure to comply with the immunosuppression medical regimen is the number one cause of organ failure^[19].

Immunosuppressants can have many serious side effects. You can get infections more easily because these medicines weaken your immune system^[15]. Other possible side effects include^[15]:

• Brittle bones
• Diabetes
• High blood pressure
• High levels of cholesterol and triglycerides in the blood
• Kidney damage
• Weight gain

Long-term use of these medicines can increase your chance of developing cancers of the skin and other areas of your body^[15].

Playing sports and getting healthy exercise, socializing, and traveling for business and pleasure are all possible^[19]. The expectation is that people who undergo liver transplantation can and do go on to lead “normal” lives^[19].

Survival and Quality of Life

Liver transplant can have excellent outcomes. Recipients have been known to live a normal life over 30 years after the operation^[19]. According to the most recent year computed UNOS/OPTN (2004) national average one-year graft survival at 83%, and patient survival at 87% for patients receiving a deceased donor liver and 92% for those transplanted with an organ from a living donor. Five-year graft and patient survivals are 67% (deceased) 62% (living) and 76% (deceased) 81% (living), respectively^[19].

It is important to remember that many factors come into play with these statistics. They represent all patients transplanted, including the very old and the very young, those who were critically ill and those with less severe liver problems at the time of transplant^[19].

Transplant recipients directly contribute to the success of their transplant. Close follow-up with your transplant team and primary-care physician can help ensure a good outcome. Careful attention to medication schedules, lifestyle changes, infection-avoidance techniques are all important ways to prolong one’s life after transplantation^[19].