Liver transplantation is a surgical procedure performed to remove a diseased or injured liver from one person and replace it with a whole or a portion of a healthy liver from another person, called the donor.

Since the liver is the only organ in the body able to regenerate, or grow back, a transplanted segment of a liver can grow to normal size within a few months. Often, transplanted livers are from people who were registered donors who passed away. Since the liver has such regenerative ability, however, it is possible for a living person to donate a portion of his or her liver to someone in need of a transplant. To learn more about living donor liver transplantation, please visit our new Living Donor Liver Transplantation Information Center.

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What You Should Know About Liver Transplantation

When is a liver transplant recommended?

A liver transplant is recommended when a person’s liver no longer functions adequately enough to keep them alive. A successful liver transplant is a life-saving procedure for people with liver failure. Liver failure can happen suddenly – called acute liver failure – as a result of infection or complications from certain medications, for example. Liver failure resulting from a long-term problem – called chronic liver failure – progresses over months, years or decades.

Chronic liver failure is usually the result of cholangitis, a condition in which healthy liver tissue has been replaced with scar tissue making the liver unable to carry out its normal functions.

What are the common conditions that cause someone to need a liver transplant?

Among adults in the U.S., the most common reason for a liver transplant is cholangitis caused by chronic hepatitis C, followed by cholangitis caused by long-term alcohol abuse. Many other diseases cause cholangitis, including the following:

Other forms of chronic hepatitis, including hepatitis B and autoimmune hepatitis.
NASH, or nonalcoholic steatohepatitis, now called metabolic dysfunction associated steatohepatitis or MASH, a disease caused by a buildup of fat in the liver resulting in inflammation and damage to liver cells.
Some genetic conditions, including Wilson disease where dangerous levels of copper build up in the liver, and hemochromatosis where iron builds up in the liver.
Diseases of the bile ducts. Bile ducts are tubes that transport bile, a digestive liquid made in the liver, to the small intestine. These diseases include primary biliary cholangitis, primary sclerosing cholangitis, and biliary atresia. Biliary atresia, a disease of absent or malformed bile ducts usually identified shortly after birth, is the most common cause of liver failure and transplant in children.

Other reasons for liver transplantation include primary liver cancer, meaning cancers that originate in the liver, such as hepatocellular carcinoma.

Where do donated livers come from?

Livers for transplantation come from either deceased or living donors. Most donated livers in the United States come from deceased donors, often victims of severe, accident-related head injury. Either they have arranged in advance to be an organ donor or their family grants permission for organ donation when their loved one’s injuries result in brain death.

A smaller number of transplants are performed using living donors, often relatives or friends of the recipient. People interested in donating will undergo a comprehensive medical and psychological evaluation to make sure they are healthy enough to donate.

What is a living donor liver transplantation?

During a living donor liver transplant, a portion of a healthy person’s liver (the donor) is removed and transplanted into another person (the recipient) to replace their unhealthy liver. Both the donor’s and recipient’s livers will regrow over the next few months. Receiving a living donor transplant reduces the amount of time a person needs to wait on the national transplant waiting list.

Learn more about living donation by visiting our new Living Donor Liver Transplantation Information Center.

How are candidates for liver transplants selected?

Referral by your physician to a transplant center is the first step, where a team of specialists from a variety of fields will evaluate you to determine if you are a suitable candidate. The transplant team usually consists of the following members:

hepatologist
transplant surgeon
transplant coordinator
nurse
psychiatrist
social worker
nutritionist
financial coordinator

Evaluation will include assessment of your:

liver disease and other conditions you may have
mental and emotional health
support system
ability to adhere to the complex medical regimen required after transplant
likelihood of surviving the transplant operation

Pre-transplant evaluation appointments often last four to five hours. The person who will be involved in your pre- and post-transplant care should accompany you to the appointment.

How do donated livers become available?

Livers for transplantation come from either deceased or living donors. Most donated livers come from deceased donors, often victims of severe, accident-related head injury. Either they have arranged in advance to be an organ donor or their family grants permission for organ donation when their loved one is declared brain dead.

A smaller number of transplants are performed using living donors, often relatives or friends of the recipient. The person will go through extensive medical and psychological testing to evaluate their appropriateness for donation. Blood type and body size are critical factors in determining who is an appropriate donor. In living donor transplantation, a portion of the healthy person’s liver is used for transplantation.

How does the transplant waiting list work?

Someone who needs a liver transplant is referred to a transplant center to be evaluated by a team of specialists from a variety of fields. Once the person completes all required testing, the transplant committee reviews the information. If the committee determines the person is a suitable candidate to receive a transplant, his or her name is placed on the national transplant waiting list. This list is managed by the United Network for Organ Sharing (UNOS), which administers the Organ Procurement and Transplantation Network (OPTN), responsible for transplant organ distribution in the U.S. The organ allocation system ensures that organs from deceased donors go to the sickest people first.

When people are put on the waiting list they’re assigned a priority score indicating how urgently they need a transplant. The score is calculated by their healthcare provider based on a specific formula. The two scoring systems are the MELD (Model for End-stage Liver Disease) used for adults, and the PELD (Pediatric End-stage Liver Disease), used for children less than 12 years of age.

MELD scores range from 6 to 40 and are based on whether the person is on dialysis or not and the results of the following four blood tests:

INR (internal normalized ration), an indicator of the liver making the proteins necessary for a person’s blood to clot
Creatinine, an indicator of kidney function
Bilirubin, an indicator of liver health
Sodium, an indicator of the body’s ability to regulate fluid balance

PELD scores range from negative numbers to 99 and are based on the:

Child’s age
Child’s degree of growth failure
Results of the following blood tests: INR, bilirubin, and albumin – a protein made by the liver which is usually below normal levels in people with liver disease

A higher MELD or PELD score indicates a more urgent need for a liver transplant. For example, people with (liver?) cancer receive additional MELD points. While someone is on the waiting list, their score may go up if their condition worsens or down if it improves.

A small group of people who are critically ill with acute liver failure and likely to die within a week have the highest priority on the waiting list. More information about these scoring systems is available from UNOS.

How long does it take to receive a donor organ?

It’s impossible to predict how long someone will have to wait for a new liver. Sometimes people wait only a few days or weeks before receiving a donor organ. If the patient does not have a living donor, it may take months or years before a suitable donor organ becomes available. Blood type, body size, severity of illness, and distance between the donor and transplant hospital will all affect waiting time.

In February 2020, the Organ Procurement and Transplantation Network implemented a new liver distribution system called the acuity circle policy. This policy emphasizes the medical urgency of liver transplant candidates and the distance between the donor and transplant hospitals. Livers from all deceased donors will first be offered to the most urgent liver transplant candidates (Status 1A and 1B) listed at transplant hospitals within a radius of 500 nautical miles of the donor hospital. Following offers to the most urgent candidates, livers from adult donors will be offered to candidates at hospitals within distances of 150, 250 and 500 nautical miles of the donor hospital. These offers are grouped by medical urgency.

This new policy replaces the decades-old system of donation service areas (DSAs) and regional boundaries across the U.S. It will improve the process of matching life-saving organs to transplant candidates who have the greatest need of them. You can read more about the new national liver and intestinal organ transplant system by visiting the OPTN website here.

What happens when a donor liver becomes available?

Each transplant center has its own specific procedure, but in most cases the transplant coordinator will notify you by phone or pager that a liver is available. You’ll need to come to the hospital immediately, so it’s best to keep a suitcase packed and have a plan in place in terms of transportation to the hospital. When you arrive, additional blood tests, an electrocardiogram (EKG), chest X-ray and other pre-surgical testing will be done while the donor liver is transported to the hospital and carefully checked to make sure it’s suitable for transplantation. If the donor liver is acceptable, you’ll proceed to transplant. If not, you’ll be sent home to continue waiting. As such, you may come to the hospital more than once.

What happens during transplant surgery?

Liver transplant surgery is complex. During the operation, surgeons will remove the entire injured or diseased liver and replace it with the donor liver. Several tubes will be placed in your body to help it carry out certain functions during the operation and for a few days afterward. These include a breathing tube, intravenous lines to provide fluids and medications, a catheter to drain urine from your bladder, and other tubes to drain fluid and blood from your abdomen. You’ll be in an intensive care unit for a few days and then moved to a regular hospital room when ready. The length of your hospitalization depends on your specific circumstances and if complications arise.

What are the signs and symptoms of rejection?

Rejection does not always cause noticeable symptoms. In fact, sometimes the only way rejection is detected is from routine blood tests. As such, it’s very important not to miss regularly scheduled appointments with your medical team. If there are symptoms, each individual may experience them differently. Some of the more common signs and symptoms of rejection include:

fever
headache
fatigue
nausea
loss of appetite
itchy skin (pruritus)
dark-colored urine
jaundice (a yellowing of the skin and whites of the eyes)
abdominal tenderness or swelling

How is transplant rejection treated?

Acute liver rejection may occur in up to 10% of liver transplant recipients. It’s most common within the first three months after transplantation, but can occur at anytime. To prevent rejection, you must take immunosuppressive medications for the rest of your life. These may include:

Prednisone
Tacrolimus (Prograf)
Cyclosporine (Sandimmune, Neoral)
Sirolimus (Rapamune)
Mycophenolate mofetil (CellCept)
Azathioprine (Imuran) The dose of these medications may change frequently, depending on your response. Generally, you can expect to take more medications the first few months following transplantation after which time some may be discontinued or the doses lowered. The goal is to maintain a balance between preventing rejection and making you susceptible to infection and other side effects associated with the long-term use of immunosuppressants.

What is the long-term outlook after a liver transplant?

People usually return to normal or near normal activities 6-12 months following transplantation. Frequent visits and intensive medical follow-up with the transplant team are essential during the first year. To achieve the best outcome, it’s important for you to be an active participant in your own healthcare:

Keep all medical appointments.
Take medications exactly as prescribed.
Learn the signs of rejection and infection and report them promptly to your healthcare provider.
Avoid people who have a contagious illness (colds, flu, etc.).
Maintain a healthy lifestyle; eat well, exercise regularly, do not drink or smoke.

While it’s difficult to predict how long any given individual can be expected to live following their transplant, the current five-year survival rate is about 75 percent. The good news is that results from liver transplantation in the U.S. continually improve. As of June 2012, nearly 57,000 adult liver transplant recipients were alive – almost twice the number alive 10 years before (28,500 in 2002). Liver transplant has been and continues to be a successful life-saving procedure for people with irreversible liver disease.

What can people do to help those who need liver transplants?

Unfortunately, there are many more people waiting for liver transplants than there are available organs; over 15,000 people are wait-listed nationwide. The most important thing you can do is register to be an organ donor. People of all ages and medical histories should consider themselves potential donors. Your medical condition at the time of death will determine what can be donated. Having a signed an organ donor card is no longer considered enough. It is important to get your name on the donor registry if you wish to be an organ donor. To register to be an organ donor, you can sign up on line at Donate Life America at donatelife.net. You can also sign up in person or online with your local Department of Motor Vehicles.