What to Expect From a Liver Transplant

Woman showing transplant scars.

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A liver transplant is a complex surgical procedure during which a diseased liver is removed by surgeons and replaced with a donated liver from a living or deceased donor. The procedure is the only cure for end-stage liver disease or liver failure, which can be fatal.

For individuals with severe liver disease, a liver transplant can mean the difference between dying of liver failure and a decade or more of good health.

Reasons for a Liver Transplant

Liver failure happens when a disease or injury makes it impossible for the liver to function well enough to keep the body alive. The liver has many important functions and when it is not able to perform these functions well, a person will become very ill, and in severe cases will die from liver failure.

Because liver transplants are expensive and carry significant risk, doctors recommend them only as a last resort. This typically occurs when the liver is no longer functioning and the complications from liver damage can no longer be controlled.

Among the most common reasons for a liver transplant are:

  • End-stage cirrhosis from any cause, including chronic hepatitis B or C, alcoholic cirrhosis, and non-alcoholic fatty liver disease. While cirrhosis itself isn't an indication for a transplant, signs of decompensation (such as encephalopathy, bleeding varices, or recurrent ascites) can often serve as motivation.
  • Certain liver cancers, inlcuding cholangiocarcinoma, hepatocellular carcinoma (HCC), primary hepatocellular malignancies and hepatic adenomas.
  • Fulminant hepatic failure due to one of fulminant viral hepatitis (A, B, D and rarely C), medication-associated liver failure, hepatic thrombosis, Wilson's disease or other causes.
  • Severe dysfunction of the bile ducts, resulting in biliary cirrhosis and sclerosing cholangitis.

Who Is Not a Good Candidate?

Contraindications for liver transplantation are those that can either increase the likelihood of death for the recipient or will likely result in the failure or rejection of a transplant. Among some of the absolute contraindications for transplantation:

  • Current alcohol or substance addiction
  • Severe heart or lung disease
  • Cancers (not including some liver cancers or non-melanoma skin cancer)
  • Severe and multiple birth defects that will likely lead to premature death
  • Certain uncontrolled infections or life-threatening diseases

There are also a number of relative contraindications, so-called because they may or may not contraindicate treatment based on an assessment of one or several factors, including:

  • Advanced age (older than 65 years)
  • Kidney failure
  • Morbid obesity
  • Severe malnutrition
  • HIV (although less of an issue for patients with sustained viral control)
  • Severe pulmonary hypertension
  • Severe, uncontrolled (or untreated) psychiatric disorders

Types of Liver Transplants

There are two types of liver transplant surgeries, including:

  • Orthotopic approach: With this, the recipient's liver is removed and replaced with the donor liver. The surgery begins by removing the diseased liver from the four main blood vessels and other structures that hold it in place in the abdomen. Then, the healthy donor liver is connected and blood flow is restored. The final connection is made to the bile duct, a small tube that carries bile made in the liver to the intestines. This is the most common form of liver transplant surgery.
  • Heterotopic approach: In heterotopic liver transplantation, the recipient’s liver is left in place and a donor’s liver is sewn into a site outside the liver. Your physician can explain why this approach may better suit your needs.

Donor Recipient Selection Process

More people need liver transplants than there are livers available to transplant. Because of this, health policy experts have developed the Model for End-Stage Liver Disease (MELD) score, an algorithm used to assess the severity of chronic liver disease and to help prioritize patients for transplantation.

Other methods for determination can be used, including the Milan Criteria, which qualifies a person based primarily on the size and/or a number of liver lesions (i.e., no bigger than 5 centimeters, or no more than three lesions equal to or less than 3 centimeters in size).

Although transplants can be considered applicable to any acute or chronic condition that causes irreversible and permanent liver dysfunction, there can often be a number of loopholes to the decision-making process.

The organization in the U.S. responsible for matching individuals with available livers is the United Network for Organ Sharing (UNOS). The nonprofit organization works under contract for the Federal government to match and allocate organs.

Once a diagnosis of liver disease is made, it may be years before a liver transplant becomes necessary. Once the diagnosis of significant liver disease is made, a gastroenterologist—a specialist in the digestive system—can make a referral to the transplant center. At the transplant center, a variety of types of tests will be performed to determine if the patient is a candidate for a transplant.

If the patient is a candidate, the MELD score is used to calculate how ill the patient is, using blood tests. The sicker the patient is, the higher the MELD score is, and the higher the patient rises on the waiting list. This allows the sickest patients to receive an organ first.

If the liver disease was caused by drug abuse, such as alcoholism, ongoing abuse will make the individual ineligible for transplantation. Individuals in recovery from addiction may be a candidate for transplantation depending on their unique situation.

Approximately 11,000 people were on the waiting list for a liver in 2018, according to the Scientific Registry of Transplant Recipients.

The waiting time for a deceased donor liver can range from months to years.

Types of Donors

Donated livers come in two general types: an organ from a living donor or an organ from a deceased donor. It is possible to donate a segment of your liver to a friend or loved one. Due to the liver’s amazing ability to regenerate, the liver can return to its full weight within a few weeks of donation, and within a few months is back to normal size in a healthy donor.

A cadaveric liver, also known as an allograft or donation from a deceased donor, comes from an individual who died and they or their family decided to donate their organs after their death. 

Another, less common, type of living-donor liver transplant is called a domino liver transplant. In a domino liver transplant, you receive a liver from a living donor who has a heredity disease called amyloidosis, a rare disorder in which abnormal protein deposits accumulate and eventually damage the body's internal organs.

The donor with familial amyloidosis receives a liver transplant while their own liver is still healthy. Then you receive that liver. While you may eventually develop symptoms of amyloidosis, it usually takes decades to develop. For this reason, domino transplants are usually reserved for patients over 60, who aren't expected to develop symptoms before the end of their natural life expectancy. After a domino transplant, your doctor will monitor you for signs of the condition.

In 2017, 8,082 liver transplants were performed in the United States, higher than in any previous year. Approximately 95% were donated by deceased donors.

Before Surgery

Once it's been determined that you are a candidate for a liver transplant, you will need to choose a surgeon and a transplant center.

Seeing a transplant surgeon requires a referral from your own physician to the transplant center that performs liver transplants near your home. In many cases, there may only be one nearby, but in large cities, you may have multiple options. The referral is typically made by your gastroenterologist. A referral can also be made by primary care and other specialists involved in your treatment.

After meeting with the staff at a transplant center, you will be evaluated. This will include a review of your medical records, blood tests, possible imaging studies, and other tests designed to determine if you are well enough to tolerate transplant surgery, but sick enough to need a new organ.

When you consider transplant centers, you may want to:

  • Learn about the number and type of transplants the center performs each year
  • Ask about the transplant center's organ donor and recipient survival rates
  • Compare transplant center statistics through the database maintained by the Scientific Registry of Transplant Recipients
  • Consider other services provided by the transplant center, such as support groups, travel arrangements, local housing for your recovery period, and referrals to other resources

Once a donor liver becomes available, it must be transplanted into a recipient within 12 to 18 hours. You should keep a packed hospital bag handy and make arrangements for transportation to the transplant center in advance. Make sure the transplant team knows how to reach you at all times.

Surgical Process

Once a liver is obtained for transplant, the recipient is taken to the operating room and given general anesthesia. Once the patient is under general anesthesia, the procedure begins with a large abdominal incision that exposes the liver.

A normal liver is large, approximately three pounds, but most diseased livers are much larger and can weigh twice as much as a normal liver. For this reason, the full-size incision is used, rather than minimally invasive techniques.

With an orthotopic transplant, a patient’s own liver is surgically removed from the body, taking care to preserve blood vessels where possible, so that the new liver can be sewn into place. Once the new liver is in the patient and reconnected to the blood supply and ducts, the incision can be closed and the patient taken to the recovery area. With a heterotopic transplant, your own liver will remain in place and the new liver will be attached to another site in your abdomen.

Complications

In addition to the general risks of surgery and general anesthesia, transplant patients face risks associated with the procedure itself as well as with the immunosuppressant drugs necessary to prevent rejection of the donor liver after the transplant.

Surgical risks include:

  • Bile duct complications, including bile duct leaks or shrinking of the bile ducts
  • Bleeding
  • Blood clots
  • Failure of donated liver
  • Infection
  • Rejection of donated liver
  • Mental confusion or seizures

Long-term complications may also include recurrence of liver disease in the transplanted liver.

Side effects from anti-rejection, or immunosuppressant medications, include:

  • Bone thinning
  • Diabetes
  • Diarrhea
  • Headaches
  • High blood pressure
  • High cholesterol

While rare, it is possible to contract an infectious disease through a transplanted organ. In some cases, a liver from a donor with an infectious disease may be transplanted into a recipient who does not have it. This is often a calculated risk if the recipient is very ill and in danger of dying before a liver becomes available and a donated organ from a hepatitis positive donor becomes available, that organ may be accepted based on the knowledge that they can live with hepatitis B or die without a new organ. This circumstance is not common but can happen in very ill recipients.

Bile duct issues are often a problem after a liver transplant. In a few cases, the bile duct is damaged during the surgical process of removing the liver from the donor, or when transplanting the liver into the recipient. More common is that over time the bile duct becomes narrowed and does not allow the movement of bile to the gallbladder.

After Surgery

Most patients will recover from liver transplant surgery in the surgical intensive care unit. There they will be allowed to wake slowly from anesthesia and may remain on the ventilator for hours or several days while they regain their strength.

Most patients are able to go home in 10 to 14 days and return to normal activities in three to six months. Follow up appointments will be frequent in the first few months after surgery and then will be less frequent as the patient heals and begins to return to their normal life.

Prognosis

The prognosis following liver transplant depends on overall health as well as the underlying cause of the diseased liver. Around 70% of people who undergo a liver transplant live for at least five years. Failure of the new liver occurs in 10% to 15% of all cases.

Survival rates among liver transplant recipients also vary among U.S. transplant centers and can be found at the Scientific Registry of Transplant Recipients.

Support and Coping

It's normal to feel anxious or overwhelmed while waiting for a transplant or to have fears about rejection, returning to work, or other issues after a transplant. Seeking the support of friends, family members, and your transplant team can help you cope during this stressful time.

Your transplant team also can assist you with other useful resources and coping strategies throughout the transplant process, such as:

  • Joining a support group for transplant recipients: Talking with others who have shared your experience can ease fears and anxiety.
  • Getting mental health treatment: If you're depressed, talk to your doctor. He or she may recommend medications or refer you to a mental health professional.
  • Finding rehabilitation services: If you're returning to work, your social worker may be able to connect you with rehabilitation services.
  • Setting realistic goals and expectations: Recognize that life after a kidney transplant may not be exactly the same as life before a transplant. Having realistic expectations about results and recovery time can help reduce stress.
  • Educating yourself: Read as much as you can about your procedure and ask questions about things you don't understand. Knowledge is empowering.

Diet and nutrition

Maintaining a healthy weight with diet and exercise can help prevent many common post-transplant complications, including infection, heart attacks, and bone thinning.

Your transplant team should include a nutrition specialist (dietitian) who can discuss your nutrition and diet needs and answer any questions you have after your transplant. Your dietitian's recommendations may include:

  • Eating at least five servings of fruits and vegetables each day
  • Eating lean meats, poultry and fish
  • Eating whole-grain breads, cereals and other products
  • Having enough fiber in your daily diet
  • Drinking low-fat milk or eating other low-fat dairy products to help maintain healthy calcium levels
  • Limiting salt and sodium intake by using fresh herbs and spices to season foods and avoiding processed foods
  • Limiting unhealthy fats, such as saturated fats in butter and red meats
  • Limiting your caffeine and avoiding excessive alcohol intake
  • Staying hydrated by drinking adequate water and other fluids each day
  • Avoiding grapefruit and grapefruit juice, pomegranates, and Seville oranges due to their effect on a group of immunosuppressive medications called calcineurin inhibitors
  • Following food safety practices to reduce the risk of infection

Exercise

Exercise and physical activity should be a regular part of your life after a liver transplant to continue improving your overall physical and mental health. Regular exercise helps boost energy levels and increase strength. It also helps you maintain a healthy weight, reduce stress, and prevent common post-transplant complications such as high blood pressure and cholesterol levels.

Your transplant team will recommend a physical activity program based on your individual needs and goals.

Walking, bicycling, swimming, low-impact strength training, and other physical activities you enjoy can all be a part of a healthy, active lifestyle after transplant. But be sure to check in with your transplant team before starting or changing your post-transplant exercise routine.In the case of organs being donated by a deceased donor, if both the recipient and the donor family wish to meet, that can be arranged by the local organ procurement organization.

A Word From Verywell

A liver transplant is a very serious surgery, and the journey to an organ transplant is often a difficult one emotionally and physically. Waiting for an organ to become available can be difficult, especially as most people become sicker with each passing day. It is a double-edged sword—one must be sick enough to be high enough on the waiting list to receive an organ, but not so sick that they cannot tolerate the physical stress of surgery.

This can make the process more challenging than a more typical surgery, but the rewards of receiving a healthy liver are enormous.

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