Liver transplant

The donated liver may be from:

• A donor who has recently died and has not had liver injury. This type of donor is called a cadaver donor.
• Sometimes, a healthy person will donate part of his or her liver to a person with a diseased liver. For example, a parent may donate to a child. This kind of donor is called a living donor. The liver can regrow itself in a living donor. Both people most often end up with fully working livers after a successful transplant.

The donor liver is transported in a cooled salt-water (saline) solution that preserves the organ for up to 8 hours. The necessary tests can then be done to match the donor with the recipient.

The new liver is removed from the donor through a surgical cut in the upper abdomen. It is placed into the person who needs the liver (called the recipient) and attached to the blood vessels and bile ducts. The operation may take up to 12 hours. The recipient will often need a large amount of blood through a transfusion.

A healthy liver performs more than 400 jobs each day, including:

• Making bile, which is important in digestion
• Making proteins that help with blood clotting
• Removing or changing bacteria, medicines, and toxins in the blood
• Storing sugars, fats, iron, copper, and vitamins

The most common reason for a liver transplant in children is biliary atresia. In most of these cases, the transplant is from a living donor.

The most common reason for a liver transplant in adults is cirrhosis. Cirrhosis is scarring of the liver that prevents the liver from working well. It can worsen to liver failure. The most common causes of cirrhosis are:

• Long-term infection with hepatitis B or hepatitis C
• Long-term alcohol overuse
• Non-alcoholic fatty liver disease (also called non-alcoholic steatohepatitis or NASH)
• Acute toxicity from an overdose of acetaminophen or due to consuming poisonous mushrooms.
  

Other illnesses that may cause cirrhosis and liver failure include:

• Autoimmune hepatitis
• Hepatic vein blood clot (thrombosis)
• Liver damage from poisoning or medicines
• Problems with the drainage system of the liver (the biliary tract), such as primary biliary cholangitis (previously called primary biliary cirrhosis) or primary sclerosing cholangitis
• Metabolic disorders of copper or iron (Wilson disease and hemochromatosis, respectively)

Liver transplant surgery is often not recommended for people who have:

• Certain infections, such as tuberculosis or osteomyelitis
• Difficulty taking medicines several times each day for the rest of their lives
• Heart or lung disease (or other life-threatening diseases)
• History of cancer
• Infections, such as hepatitis, that are considered to be active
• Smoking or an alcohol or drug use disorder, or other risky lifestyle habits

Risks of any anesthesia are:

• Problems breathing
• Reactions to medicines

Risks of any surgery are:

• Bleeding
• Heart attack or stroke
• Infection

Liver transplant surgery and management after surgery carry major risks. There is an increased risk for infection because you must take medicines that suppress the immune system to prevent transplant rejection. Signs of infection include:

• Diarrhea
• Drainage
• Fever
• Jaundice
• Redness
• Swelling
• Tenderness

Your health care provider will refer you to a transplant center. The transplant team will want to make sure that you are a good candidate for a liver transplant. You will make a few visits over several weeks or months. You will need to have blood drawn and x-rays taken.

If you are the person getting the new liver, the following tests will be done before the procedure:

• Tissue and blood typing to make sure your body will not reject the donated liver
• Blood tests or skin tests to check for infection
• Heart tests such as an electrocardiogram (ECG), echocardiogram, or cardiac catheterization
• Tests to look for early cancer
• Tests to look at your liver, gallbladder, pancreas, small intestine, and the blood vessels around the liver
• Colonoscopy, depending on your age

You may choose to look at one or more transplant centers to determine which is best for you.

• Ask the center how many transplants they perform every year, and their survival rates. Compare these numbers to those of other transplant centers.
• Ask what support groups they have available, and what travel and housing arrangements they offer.
• Ask what is the average waiting time for a liver transplant.

If the transplant team thinks you are a good candidate for a liver transplant, you will be put on a national waiting list.

• Your place on the waiting list is based on a number of factors. Key factors include the type of liver problems you have, how severe your disease is, and the likelihood that a transplant will be successful.
• The amount of time you spend on a waiting list is most often not a factor in how soon you get a liver, with the possible exception of children.

While you are waiting for a liver, follow these steps:

• Follow any diet your transplant team recommends.
• Do not drink alcohol or use drugs.
• Do not smoke.
• Keep your weight in the appropriate range. Follow the exercise program your provider recommends.
• Take all medicines prescribed for you. Report changes in your medicines and any new or worsening medical problems to the transplant team.
• Follow-up with your regular provider and transplant team at any appointments that have been made.
• Make sure the transplant team has your correct phone numbers, so they can contact you immediately if a liver becomes available. Make sure that, no matter where you are going, you can be contacted quickly and easily.
• Have everything ready ahead of time to go to the hospital.

If you received a donated liver, you will likely need to stay in the hospital for a week or longer. After that, you will need to be closely followed up by a doctor for the rest of your life. You will have regular blood tests after the transplant.

The recovery period is about 6 to 12 months. Your transplant team may ask you to stay close to the hospital for the first 3 months. You will need to have regular check-ups, with blood tests and x-rays for many years.

People who receive a liver transplant may reject the new organ. This means that their immune system sees the new liver as a foreign substance and tries to destroy it.

To avoid rejection, almost all transplant recipients must take medicines that suppress their immune response for the rest of their lives. This is called immunosuppressive therapy. Although the treatment helps prevent organ rejection, it also puts people at a higher risk for infection and cancer.

If you take immunosuppressive medicine, you need to be regularly screened for cancer. The medicines may also cause high blood pressure and high cholesterol, and increase the risks for diabetes.

A successful transplant requires close follow-up with your provider. You must always take your medicine as directed.

Hepatic transplant; Transplant - liver; Orthotopic liver transplant; Liver failure - liver transplant; Cirrhosis - liver transplant

Carrion AF, Martin P. Liver transplantation. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 97.

Everson GT. Hepatic failure and liver transplantation In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 145.

Updated by: Michael M. Phillips, MD, Emeritus Professor of Medicine, The George Washington University School of Medicine, Washington, DC. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.