Liver transplant surgery is a procedure that replaces a liver that no longer functions properly (a failing liver) with a healthy organ from a deceased or live donor. A liver from a deceased donor is a whole one, whereas a liver from a live donor is just a portion of one. If you or a loved one receive a portion of a liver, know that it grows back to full size once in the donor’s body.
The liver is the largest internal organ in the body and is responsible for over 500 bodily functions, many of which are critical to your survival. Some of the most essential of those 500 functions are as follows:
In addition to being the largest and one of the most important organs in the body, the liver is highly resilient. In fact, it is the only organ that can regenerate damaged tissue with new cells rather than replace it with scar tissue.
That said, if the liver is subject to constant attack — such as from a virus or chronic drug or alcohol use — it may become overwhelmed and unable to keep up with cell regeneration. In such a case, the organ has no choice but to replace damaged tissue with scar tissue. Once scarring of the liver occurs, a person has what is called “cirrhosis,” an irreversible condition that, if not managed, can lead to liver failure.
Cirrhosis is actually stage three of liver disease. Stage four is liver failure, or end stage liver disease (ESLD). Liver transplantation is reserved for persons in ESLD, and even then, only for individuals who experience significant complications from the condition. In rare cases is transplantation an option for individuals who experience sudden, or acute, liver failure.
The liver is the second-most-commonly transplanted organ each year. The Americas had the highest number of liver transplant surgeries in 2020, accounting for over 12,000 of the over 32,000 procedures that took place worldwide. Europe had the second highest number of liver transplants. Africa had the lowest number of transplants, accounting for just two that year.
The number of people in need of liver transplants is steadily increasing each year, with the number of people on lists for life-saving procedures at an all-time high for the ninth consecutive year. Currently, the need significantly exceeds the number of deceased-donor livers available.
As of 2020, approximately 95% of liver transplants involved whole livers from deceased donors. However, partial organ donation from live donors is on the rise, with the number of living donor transplants 30% higher in 2019 than in 2018.
It is impossible to survive, at least for long, without a functioning liver. For this reason, individuals whose livers stop working properly may need a transplant.
Livers stop working properly when an individual has one of two conditions: end stage liver disease (chronic liver failure) or acute (sudden) liver failure. Both are serious, life-threatening conditions that can be caused by several conditions.
The most common cause of ESLD is cirrhosis. Cirrhosis is a chronic liver disease that occurs when scar tissue replaces healthy liver tissue. As the liver becomes more scarred, it struggles to work properly. One of the most common causes of cirrhosis is heavy alcohol use, though chronic hepatitis C can also cause scarring.
Other causes of ESLD are as follows:
Though rare, individuals may experience acute liver failure, which typically requires immediate transplantation. Acute liver failure can occur for a few different reasons, one of the most common of which is acetaminophen overdose. Other causes of acute liver failure include viral hepatitis, toxin exposure, bad reactions to illegal drugs, prescription medications and herbal supplements, blockage of the blood vessels to the liver, genetic disorders and autoimmune disorders.
Liver transplants come from one of two sources: deceased donors and live donors. Regardless of from where the liver (or part of the liver) comes from, the donor liver must be fully functional and free of damage.
The overwhelming majority of livers for transplants come from individuals who have just died. During the deceased donor transplant process, surgeons remove all of the injured or diseased liver and replace it with the deceased donor’s organ. If an adult is the only recipient in urgent need, he or she will receive the entirety of the liver. However, if a child donor is also in urgent need, surgeons may split the liver in two. The larger part would typically go to the adult while the smaller portion to the child.
For a donor liver to be viable, tissue death must have not yet occurred. Tissue death occurs when blood flow to an organ ceases. What this means is that, even when a liver comes from a deceased donor, the liver must have active blood flow to it. This is only possible when the donor’s heart is still beating at the time of removal but whose brain has died.
In rare cases, a living person will donate a portion of his or her liver to a person in need. Typically, the donor is a family member or close friend of the recipient.
The procedure for transplanting a liver from a live donor looks slightly different than that involving a deceased donor. In this procedure, the surgeon removes part of the donor’s healthy liver. He or she then removes the recipients diseased or injured liver and replaces it with the portion of the healthy liver. Assuming the recovery process is smooth, the portion of the liver will eventually grow to normal size post-surgery. Likewise, the donor’s liver will return to normal size with time.
Liver transplantation does not require an excessive amount of liver to be successful. Most adults require only one liver lobe (hemisphere) from a donor. Assuming the liver is healthy, the lobe will regenerate to its former size. Surgeons often prefer the right lobe because it is slightly bigger than the left. However, the left lobe often serves the purpose just fine. Child recipients usually require no more than 20% of a healthy adult liver.
The liver transplant process is a highly involved, often lengthy one that involves several steps. Many of those steps occur before the procedure can even take place.
The first step in the liver transplant process is qualifying for a liver. The evaluation process is extensive and usually involves meetings with several members of the transplant team, social and psychological evaluations, and comprehensive testing. Transplant teams maintain such strict evaluative processes to ensure candidates can physically handle and mentally care for the new organ.
Your transplant team will be located at a transplant center, which you can either select yourself, select based off your insurance company’s list of preferred providers, or select based off your doctor’s recommendations. Your transplant team will likely include but is not limited to the following people:
There are several important steps of the evaluation process, four of which are as follows:
Using the information it gathers from the entirety of the evaluation process, your transplant team will determine your eligibility. Though the rules for eligibility differ from center to center, you typically will not qualify if one or more of the following applies to you:
If none of these exceptions apply to you, you may quality for a liver transplant.
Qualifying for a liver transplant is the first step of many on the path to transplantation. Once you qualify, you must join a waiting list. How long you are on the waiting list depends largely on how urgent your need is. Individuals with acute liver failure typically only have days to live before their liver fails completely. As a result, they are on the transplant list for no more than a few days. Individuals with chronic liver failure, on the other hand, can be on the list for days, weeks, months or even years. To determine who gets a liver first, transplant teams use a scoring system to rank candidates’ conditions and urgency of need.
To determine a chronic liver disease patient’s need, transplant teams use a scoring system called MELD, or Model for End-Stage Liver Disease. If the patient is a pediatric patient, they use the term “PELD,” for Pediatric End-Stage Liver Disease. MELD and PELD scores are calculated using blood test results that measure the following:
Transplant teams use each of these numbers to determine how well candidates’ livers are functioning. In addition to these numbers, teams also use “exception points,” which are points to account for complications and secondary conditions that may make a candidate’s need more urgent. In children, low growth rates are a common exception point.
A person’s total score determines his or her place on the transplant list. Patients with higher scores rank higher on the list, while patients with lower scores are further down. Positions can change as new developments arise or as new candidates join the list.
Need is just one factor that transplant teams consider when allocating livers. Other factors that often come into play include:
To reduce the risk of organ rejection, it is crucial that the donor liver has a blood type that is compatible with the recipient’s. Similarly, the higher success rates stem from matches in which the liver size matches that of the body into which it is transplanted.
Transplant teams also like recipients to be in close proximity to the donor liver. Though teams will allow livers to be donated to recipients who are up to 500 miles away, they typically only allow this when the need is urgent. This is because a liver only remains a viable donor for between eight to nine hours, after which point, the tissue begins to die.
The wait times for a new liver vary considerably, with some people being on the list for only a few days while others must wait for months. In worst-case scenarios, candidates never receive a donor liver.
Because the complications of ESLD are serious, doctors often focus on managing them as they arise and making patients as comfortable as possible while they wait for a donor. It is not uncommon for candidates to undergo frequent hospitalizations as they wait. Though the outlook may seem grim for these patients, healthcare teams do update patients’ MELD scores as their conditions deteriorate in the hopes of moving them up the priority list.
Whether your transplant surgery is already scheduled or you are waiting for a donated liver, it is important to do what you can to stay as healthy as possible in the days leading up to the procedure. The more physically fit you are, the more likely the success of your transplant will be. While you wait, focus on doing the following:
Though you may want to hide significant changes in your health (especially health declines) from your transplant team, do not. The sooner your transplant team learns of complications, the better it can help you either overcome them or move you up the transplant list.
If you receive a call that your transplant team has a liver match, you must go to the hospital right away. Remember, you only have between eight to nine before the donor organ begins to die, meaning you have just a few hours to get to the operating room. The operation itself will take between six to 12 hours, during which time you will be under general anesthesia.
Before conducting the procedure, your surgical team will assess you to make sure you are well enough for surgery. If you are, you will start the surgical process, which begins with you undressing and being hooked up to IVs and tubes. For the duration of the procedure and the days following, you will be hooked up to these tubes and IVs, each of which will carry out various bodily functions until you fully recover. Though the types of tubes and IVs differ from patient to patient, you will most likely have the following:
Only once these tubes and IVs are in place will your surgical team make the first incision. After the surgeon makes the first incision, he or she will carefully separate the diseased liver from the rest of the organs, clamp off blood flow to the diseased liver and remove it. He or she will then insert the new organ and attach it to the bile ducts and blood vessels he or she had previously clamped off. Once the transplantation is complete, your surgeon will stitch you up and send you to the intensive care unit for recovery.
Though post-surgery care looks different for everyone, it typically entails a hospital stay, at-home care and a commitment to lifestyle changes.
Once your surgery is complete and you are situated in the ICU, you will likely stay there for several days. The ICU nurses will monitory your blood pressure, heart rate, oxygen levels and other vitals to ensure the surgery went fine. When it feels comfortable doing so, your transplant team will transfer you to a private room, where you will stay for monitoring for one to two weeks longer.
During your hospital stay, you will likely have a tube in your throat to assist with breathing. Depending on your situation, you may need assistance for just a few hours or several days. You will also likely have a tube that goes through your nose and into your stomach to help remove air that you swallow. Until the tube is removed — which cannot happen until your bowels start working properly — you cannot eat or drink.
Your medical team will also be by often to check to see how your new liver is functioning. They will also assess your kidney, lung and circulatory system functions with the new liver in place.
To prevent infection, you may receive antibiotics.
You will also likely receive IV drips to control bleeding problems and help regulate blood pressure and heart rate.
During your hospital stay, you will also begin anti-rejection medications. These medications are imperative to your transplant’s success and are something you will have to take for the remainder of your life. Your team will monitor you closely while on these medications to ensure you receive the right dose and mixture.
As your recovery progresses, your team may allow you to get out of bed and walk around. You will slowly be able to eat more solid foods and drink liquids as the need arises. Around this time, your team will begin to prepare you for going home, where you will have to take care of yourself.
After about five to 10 days in the hospital, your transplant team may determine you are well enough to go home. Though you have been released, you are not in the clear yet. Your transplant team will have designed a comprehensive follow-up schedule, which you should follow exactly. In the early days of your recovery, you may have to make two to three appointments per week. However, as you get stronger, the appointments will grow more infrequent.
Recovery times vary from person to person, but most people require six months or more to feel fully healed after liver transplant surgery. Many people can resume normal activities, including returning to work, within a few months of the procedure.
Caring for your new liver will require ongoing diligence and care, and a commitment to leading a healthy, wholesome life. Though members of your transplant team will likely meet with you several times to go over the dos and don’ts of your post-transplant life, some advice is more general than others:
Anti-rejection medications are a major component of your liver transplantation recovery. Though you will likely be on several medications for the rest of your life, some of the most effective are immunosuppressants, which prevent your immune system from attacking your new liver. Though immunosuppressants help safeguard the liver against rejection, they do come with a few side effects:
Anti-rejection medications also put persons at increased risks for infection.
Liver transplant surgery comes with a few risks, which medical teams go over with patients before they agree to the procedure. Some of the most significant risks of liver transplantation include the following:
Transplant teams warn candidates about two possible post-surgery complications: organ rejection and infection.
Regardless of anti-rejection medications, organ rejection is a real concern. It is not uncommon for transplant recipients to experience “rejection episodes” for the first year post-transplant, with acute organ rejection occurring in as many as 25% to 50% of all liver transplant recipients. For most of these patients, the highest risk period of rejection is in the first four to six weeks following surgery.
Acute organ rejection is typically treated by simply adjusting medications. Unfortunately, some people experience chronic organ rejection, which is when rejection continues despite medication. For these people, eventual liver failure is likely.
The first signs of organ rejection often come in the form of blood test results that show elevated liver enzymes. If your tests reveal elevated enzyme levels, your medical team will want to confirm the diagnosis with a liver biopsy. If, however, your labs do not pick up on the rejection, or if you fail to make your doctor’s appointments, there are signs you can look for at home:
Because these symptoms are similar to other common illnesses, consult with your provider if and when you do develop one or more.
Infection is another common post-surgery complication. Though the risk of infection is high following any surgery, organ transplantation is particularly risky, as you must take immunosuppressants for the rest of your life. One side effect of immunosuppressants is that it weakens your immune system and reduces your body’s ability to fight off infection. For this reason, you must be extra careful from the day you leave the hospital going forward to avoid not just common infections, but common viruses as well. If you do develop an infection, or if you notice signs of an infection, contact your doctor right away. He or she can prescribe you an antibiotic and prevent the infection from developing into anything worse.
The survival rates for liver transplant surgery are positive, and they only grow more so as technology and medicine advance. The one-year survival rate is between 85% and 90%, meaning that between 85 and 90 liver disease patients live through the one-year recovery process. The survival rates do dip at years three and five, which experts attribute to personal circumstances and lifestyle choices:
Just as there are steps patients can take to manage and live with liver disease, so too are there steps they can take to increase their survival rates post-surgery.
Your liver is one of your body’s most essential organs, responsible for hundreds of vital functions. Unfortunately, the liver often goes unappreciated, until it begins to fail. When it starts to fail, it can set off a series of uncomfortable, painful and sometimes life-threatening reactions.
Regardless of what lead you to the point of liver failure, know that you are not without hope. Advances in technology and medicine have made it possible to replace diseased livers with healthy ones and to restore hope to thousands of individuals across the globe. If you are one such individual who is lucky enough to take advantage of a donor organ, your understanding of the process and what it took to get you here could help you appreciate your new liver as you should.