What to Expect From a Liver Transplant

A liver transplant is a complex surgical procedure during which a liver that has been severely damaged is surgically removed 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 people with severe liver disease, a liver transplant can mean the difference between dying of liver failure and a decade or more of improved 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 them well, a person will become very ill; in severe cases, they will die from liver failure.

Liver transplants are expensive and carry significant risks, and healthcare providers 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 be indications.
• Certain liver cancers, including cholangiocarcinoma, hepatocellular carcinoma (HCC), primary hepatocellular malignancies, and hepatic adenomas
• Fulminant hepatic failure due to 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 are:

• Current alcohol or substance use
• Severe heart or lung disease
• Cancers (excluding some liver cancers and 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 preclude someone from a liver transplant:

• 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 surgical approaches to liver transplant surgeries:

• Orthotopic approach: With this, the recipient's liver is removed and replaced with a donated liver. This is by far the most common type of transplant.
• Heterotopic approach: In a heterotopic transplant, the recipient’s liver is left in place and a donor’s liver is attached to a site outside the liver. Heterotopic transplants are not common and are reserved for specific patients in whom removing the native liver could be risky.

Donor Recipient Selection Process

If your doctor suggests that you might need a liver transplant, a gastroenterologist—a specialist in the digestive system—can make a referral to a transplant center.

There, your medical records will be reviewed and a variety of tests will be performed to determine if you are ill enough to need a new liver and well enough to tolerate the transplant procedure.

These include:

• A thorough exam and assessment by a hepatologist (liver specialist)
• Blood tests
• X-rays and other imaging tests, such as CT or MRI scans
• An electrocardiogram (EKG)
• An endoscopy to examine your digestive tract
• A colonoscopy to examine your large intestine
• A psychiatric evaluation to determine your ability to handle the demands of the transplant process and care for yourself post-transplant

In 2018, 11,844 adults were added to the waiting list for a liver—up from 11,513 in 2017. Unfortunately, more people need liver transplants than there are livers available.

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.

The MELD score will use information from blood tests to calculate how ill you are. This matters because, for some, it may be years before a liver transplant becomes necessary. 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.

Other methods of recipient evaluation can be used as well, including the Milan Criteria, which is used to assess hepatocellular carcinoma and the criteria for a liver transplant. This criterion qualifies a person based primarily on the size and/or 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).

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

Types of Donors

Donor livers can come from a deceased person—who donates their organ either because of a pre-established wish or their family's decision—or from a living donor.

When you are placed on the waiting list, that is to receive a deceased donor's liver only. Livers from deceased donors are usually harvested from people under age 70 who were relatively healthy before dying as a result of an accident or other sudden event.

Living donors are almost always people you know and/or are related to. A segment of the liver is removed. Due to the liver’s ability to regenerate, the liver can return to its full weight within a few weeks of donation. Within a few months, it is back to normal size in a healthy donor.

It isn't necessary to match the donor and recipient for age, sex, or race, but blood types between donor and recipient must be compatible. Body size is also taken into account.

Infection Screening

Donors are screened for hepatitis and HIV. 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, such as hepatitis C (HCV) may be transplanted into a recipient who does not have the same disease. This is often a calculated risk if the recipient is very ill and in danger of dying before a liver becomes available.

In this case, if a liver from a hepatitis-positive donor becomes available, that organ may be accepted based on the understanding that the recipient is willing to risk contracting HCV rather than die waiting for a completely healthy organ. Because of major advances in drugs used to treat HCV, more HCV-positive livers are being accepted for transplant than ever before.

In 2018, 8,250 liver transplants were performed: 7,849 were from deceased donors and 401 were from living donors.

Domino Liver Transplant

Another, less common type of living-donor transplant is called a domino liver transplant. This type of transplant is done when a recipient is unlikely to be high enough on the waitlist to receive a healthy liver in time to help them—for example, someone with advanced liver cancer might be a candidate.

With the domino transplant, the recipient gets a liver from a living donor who has an inherited disease called amyloidosis—a rare disorder in which abnormal protein deposits accumulate and eventually damage the body's internal organs.

Because the donor will be far along in the disease process for amyloidosis, they qualify for a healthy liver. Their liver, however, is adequate for the recipient because it usually takes decades for amyloidosis to cause symptoms in someone who did not inherit the disease.

If you are the recipient of a domino transplant, you will be monitored for signs of the condition.

Before Surgery

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.

Before your surgery takes place, you will undergo standard pre-operative testing that includes blood tests, an EKG, a chest X-ray, and a urinalysis. Your vital signs—heart rate, blood pressure, and oxygen saturation—will also be assessed.

You will be asked to sign a consent form to show that you authorize and accept the risks of the surgery.

Surgical Process

Once a liver is obtained and you arrive at the hospital, you'll be taken to the operating room, given general anesthesia, and put on a ventilator. You will receive intravenous fluids, as well as a catheter to drain urine from your bladder and a tube to drain any liquid that collects in the abdomen.

Then the surgeon will begin the procedure by making a large abdominal incision that exposes your liver. A normal liver is large, approximately three pounds, but most diseased livers are much larger and can weigh twice as much as normal. For this reason, a full-size incision is used, rather than minimally invasive techniques.

• With an orthotopic transplant, your own liver is surgically removed from your body, taking care to preserve blood vessels where possible, so that the new liver can be sewn into place. 
• With a heterotopic transplant, your own liver will remain in place and the new liver will be attached to another site in your abdomen, such as the spleen.

Once the new liver is reconnected to the blood supply and the bile duct (a small tube that carries bile made in the liver to the intestines), your incision will be closed and you will be taken to the recovery area. The surgery takes around 10 hours to complete.

Complications

In addition to the general risks of surgery and general anesthesia, transplant patients face specific surgical risks and risks of immunosuppressant drugs that are used to prevent rejection of the donor liver after the transplant.

Surgical risks include:

• Bile duct complications, including bile duct leak or stricture and narrowing of the bile duct
• Infection
• Bleeding
• Blood clots
• Failure of the donated liver
• Rejection of donated liver
• Mental confusion or seizures

Long-term complications may also include recurrence of liver disease in the transplanted liver, as well as contracting HCV in cases where the liver donor was positive for that disease.

Side effects from anti-rejection (immunosuppressant) medications include:

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

Bile duct issues are often a problem after a liver transplant. The most common issue is that over time the bile duct can become narrowed and may not allow the movement of bile into the intestines. Rarely, the bile duct can be damaged during the surgical process of removing the liver from the donor or when transplanting the liver into the recipient. 

After Surgery

You will recover from liver transplant surgery in the surgical intensive care unit, where you will wake slowly from anesthesia and may remain on the ventilator for hours or several days while you regain 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 become less frequent as you start to return to your normal life.

For the best outcome:

• Keep all medical appointments.
• Take your medications exactly as prescribed.
• Be aware of symptoms of graft rejection (such as nausea, vomiting, and fever) and report them immediately to your healthcare provider.
• Avoid people who have a contagious illness such as the cold or flu.
• Maintain a healthy lifestyle by eating well, exercising regularly, abstaining from alcohol, and not smoking.

Prognosis

The prognosis following a liver transplant depends on overall health as well as the underlying cause of the diseased liver. Approximately 80% of people who undergo a liver transplant live for at least five years. In 2017, failure of the new liver occurred in 7% to 9% of cases.

Survival rates among liver transplant recipients also vary among U.S. transplant centers. Details are provided by the Scientific Registry of Transplant Recipients.

Support and Coping

Anticipating a liver transplant and then going through the surgery and recovery itself may be overwhelming and stressful, causing a rollercoaster of emotions.

Your transplant team will include a social worker to help you navigate these feelings and connect you with helpful resources to complement the support you are already hopefully receiving from friends and family.

Numerous types of support groups exist for transplant patients, both online and in-person. People who are going through the same experience as you are likely to be a helpful source of information, support, and comfort. Ask your medical team if they have any recommendations, or search for a group on the American Liver Foundation's website.

You may also want to seek out an individual therapist to help you process the anxiety that accompanies the various phases of a liver transplant.

If and when you are ready to re-enter the work environment, circle back with your social worker, who may be able to connect you with services and information related to having taken extended medical leave.

Setting realistic goals and expectations for yourself is also important. Understandably, you'll want to resume a normal life after your liver transplant, but it's important to try to readjust gradually to avoid putting any undue stress on yourself.

Diet and Nutrition

Your body requires more calories and protein while you are healing from a liver transplant, as the surgery takes a toll on energy and muscle strength. Your transplant team will likely include a nutritionist, who can help you come up with a healthy eating plan.

In general, protein should come from lean meats, fish, eggs, beans, and nuts. Fruits, vegetables, and whole grains are necessary as well.

Some immunosuppressant medications can cause weight gain, so you should exercise regularly and be mindful of calories after you have healed.

You will need to cut out alcohol entirely, as alcohol is a major cause of liver damage.

Exercise

After you've healed sufficiently from your liver transplant, getting regular moderate exercise is key, both to strengthen your bones and muscles and keep your weight in check. Your transplant team will likely refer you to a physical therapist to help with this.

Walking is a good way to begin resuming physical activity, with the goal being to walk for 30 minutes, five days a week. Bicycling and swimming are other options for low-impact cardio activities.

In general, you shouldn't lift more than five to seven pounds until you've healed from surgery, which usually takes four to six weeks. After that, it's a good idea to strength train on a regular basis.

Never begin an exercise program without your practitioner's OK. If you experience pain or any discomfort while working out, call your healthcare provider immediately.

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. Because of the limited availability of donor livers, 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. The majority of people who undergo a liver transplant are able to resume their lives and live much longer than they likely would have without a transplant.