Liver Transplant

What is a liver transplant?

A liver transplant is surgery to replace a diseased liver with a healthy liver from another person. A whole liver may be transplanted. Or part of a liver may be transplanted from another person.

In most cases, the healthy liver will come from an organ donor who has just died (a deceased donor).

Sometimes a healthy living person will donate part of their liver. A living donor may be a family member. Or it may be someone who isn't related to you but whose blood type is a good match.

People who donate part of their liver can lead healthy lives with the liver that is left.

The liver is the only organ in the body that can replace lost or injured tissue (regenerate). In fact, the donor’s liver will soon grow back to normal size after surgery. And the part that you receive as a new liver will also grow to normal size in a few months.

Why might I need a liver transplant?

You can’t live without a working liver. If your liver stops working correctly, you may need a transplant.

A liver transplant may be advised if you have end-stage liver disease (chronic liver failure). This is a serious, life-threatening liver disease. It can be caused by several liver conditions.

Cirrhosis is a serious, late-stage form of liver disease. It happens when healthy liver tissue is replaced with scar tissue. This stops the liver from working correctly.

Other diseases that may lead to end-stage liver disease or other reasons for liver transplant include:

• Acute hepatic necrosis. This is when tissue in the liver dies. Possible reasons include acute infections and reactions to medicine, illegal drugs, or toxins. For instance, an overdose of acetaminophen.

• Biliary atresia. A rare disease of the liver and bile ducts that occurs in newborns.

• Viral hepatitis. Hepatitis B or C are common causes.

• Alcoholic hepatitis. This results from long-term alcohol use.

• NAFLD (nonalcoholic fatty liver disease) or NASH (nonalcoholic steatohepatitis). With NAFLD, too much fat builds up in the liver and damages it. This isn't caused by alcohol use. NASH is a form of NAFLD that includes fat buildup, hepatitis, and liver cell damage.

• Bile duct cancer. Transplant may be an option for some people in very specific circumstances.

• Metabolic diseases. Disorders that change the chemical activity in cells affected by the liver.

• Cancer of the liver. This includes primary liver cancer, which is when tumors start in the liver. Having cirrhosis puts you at risk of liver cancer.

• Autoimmune hepatitis. A redness or swelling (inflammation) of the liver. It happens when your body’s disease-fighting system (immune system) attacks your liver.

The transplant evaluation process

If your healthcare provider thinks you may be a good candidate for a liver transplant, they'll refer you to a transplant center for evaluation. Transplant centers are located in certain hospitals all over the U.S.

You'll have many tests done by the transplant center team. They'll decide if your name should be placed on a national transplant waiting list. The transplant center team will include:

• A transplant surgeon

• A transplant provider specializing in treating the liver (a hepatologist)

• Transplant nurses

• A social worker

• A psychiatrist or psychologist

• Other members, such as a dietitian, a chaplain, or an anesthesiologist

The transplant evaluation process includes:

• Psychological and social evaluation. Many different issues are assessed. They include stress, financial concerns, and if you'll have support from family or friends after your surgery.

• Blood tests. These tests are done to help find a good donor match and assess your priority on the waiting list. They can also help improve the chances that your body won’t reject the donor liver.

• Diagnostic tests. Tests may be done to check your liver and general health. These may include X-rays, ultrasounds, a liver biopsy, heart and lung tests, colonoscopy, and dental exams. Women may also have a Pap test, gynecology exam, and a mammogram.

The transplant center team will review all of your information. Each transplant center has rules about who can have a liver transplant.

You may not be able to have a transplant if you:

• Have a current or chronic infection that can’t be treated

• Have metastatic cancer (cancer that has spread from its main location to one or more other parts of the body)

• Have severe heart problems or other health problems

• Have a serious condition besides liver disease that wouldn't get better after a transplant

• Aren't able to follow a treatment plan

• Drink too much alcohol

Getting on the waiting list

If you're accepted as a transplant candidate, your name will be placed on a national transplant waiting list. People who most urgently need a new liver are put at the top of the list. Many people have to wait a long time for a new liver.

You'll be notified when an organ is available because a donor has died. You'll have to go to the hospital right away to get ready for surgery.

If a living person is donating a part of their liver to you, the surgery will be planned in advance. You and your donor will have surgery at the same time. The donor must be in good health and have a blood type that is a good match with yours. The donor will also take a psychological test. This is to be sure they're comfortable with this decision.

What are the risks of a liver transplant?

All procedures have risks. Some complications from liver surgery may include:

• Bleeding

• Infection

• Blocked blood vessels to the new liver

• Leakage of bile or blocked bile ducts

• The new liver not working for a short time right after surgery

Your new liver may also be rejected by your body’s immune system. Rejection is the body’s normal reaction to a foreign object or tissue. When a new liver is transplanted into your body, your immune system thinks it is a threat and attacks it.

To help the new liver survive in your body, you must take antirejection medicines (immunosuppressive medicines). These medicines weaken your immune system’s response. You must take these medicines for the rest of your life. Some liver diseases can come back after a transplant. To help the transplant be more successful, you may be started on hepatitis B or C medicines ahead of time, if you have these diseases.

How do I get ready for a liver transplant?

• Your healthcare provider will explain the procedure to you. Ask them any questions you have about the surgery.

• You'll be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if anything isn't clear.

• For a planned living transplant, follow any directions you're given for not eating or drinking before the surgery. If your liver is from a donor who has just died, you shouldn't eat or drink once you're told a liver is available.

• You may be given medicine to help you relax (a sedative) before the surgery.

Your provider may have other instructions for you based on your health.

What happens during a liver transplant?

Liver transplant surgery requires a hospital stay. Procedures may vary depending on your condition and your healthcare provider’s practices.

Generally, a liver transplant follows this process:

1. You'll be asked to remove your clothing and given a gown to wear.

2. An IV (intravenous) line will be started in your arm or hand. Other tubes (catheters) will be put in your neck and wrist. Or they may be put under your collarbone or in the area between your belly (abdomen) and your thigh (the groin). These are used to check your heart and blood pressure and to get blood samples.

3. You'll be placed on your back on the operating table.

4. If there is too much hair at the surgical site, it may be shaved off.

5. A catheter will be put into your bladder to drain urine.

6. After you're sedated, the anesthesiologist will put a tube into your lungs. This is so that your breathing can be helped with a machine (ventilator). The anesthesiologist will closely monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.

7. The skin over the surgical site will be cleaned with a sterile (antiseptic) solution.

8. The surgeon will make a cut (incision) just under the ribs on both sides of your abdomen. The incision will extend straight up for a short distance over the breastbone.

9. The surgeon will carefully separate the diseased liver from the nearby organs and structures.

10. The attached arteries and veins will be clamped to stop blood flow into the diseased liver.

11. Different surgery methods may be used to remove the diseased liver and implant the donor liver. The method used will depend on your specific case.

12. The diseased liver will be removed after it has been cut off from the blood vessels.

13. Your surgeon will check the donor liver before implanting it in your body.

14. The donor liver will be attached to your blood vessels. Blood flow to your new liver will be started. The surgeon will check for any bleeding where you have stitches.

15. The new liver will be attached to your bile ducts.

16. The incision will be closed with stitches or surgical staples.

17. A drain may be placed in the incision site to reduce swelling and remove excess fluid that may build up.

18. A sterile bandage or dressing will be applied.

What happens after a liver transplant?

In the hospital

After the surgery, you will be taken to the postanesthesia care unit (PACU) to be closely watched as you wake up from the anesthesia. Once you are stable, you will be taken to the intensive care unit (ICU). You will be closely watched in the ICU for several days.

You will be attached to many different monitors. They'll show your heartbeat, blood pressure, other pressure readings, breathing rate, and oxygen level. You'll likely need to stay in the hospital for 1 to 2 weeks or longer.

You may have a tube in your throat if you are not breathing well enough on your own. This is so you can breathe with the help of a ventilator until you can breathe on your own. You may need the breathing tube for a few hours or a few days, depending on your health.

You may have a thin plastic tube inserted through your nose into your stomach to remove air that you swallow or excess stomach fluids. The tube will be taken out when your bowels start working normally again. You won’t be able to eat or drink until the tube is removed.

Blood samples will be taken often to check how well your new liver is working. They'll also check that your kidneys, lungs, and circulatory system are all working.

You may have IV drips to help your blood pressure and heart and to control any problems with bleeding. As your condition gets better, these drips will be slowly decreased and turned off. You may receive antibiotics.

Once the breathing and stomach tubes have been removed and you're stable, you may start to drink liquids. You may slowly begin to eat solid foods as directed.

Your antirejection medicines will be closely watched to be sure you're getting the right dose and the right mix of medicines.

When your healthcare provider feels you're ready, you'll be moved from the ICU to a private room. You will slowly be able to move about more as you get out of bed and walk around for longer periods of time. You will slowly be able to eat more solid foods.

Your transplant team will teach you how to take care of yourself when you go home.

At home

Once you're home, you must keep the surgical area clean and dry. Your healthcare provider will give you specific bathing instructions. Any stitches or surgical staples will be removed at a follow-up office visit, if they weren't removed before leaving the hospital.

You shouldn't drive until your healthcare provider tells you to. You may have other limits on your activity.  

Call your provider if you have any of the following:

• Fever. This may be a sign of rejection or infection.

• Redness, swelling, or bleeding or other drainage from the incision site

• More pain around the incision site. This may be a sign of infection or rejection.

• Vomiting or diarrhea

• Yellowing of the skin and eyes (jaundice)

Your provider may give you other instructions, depending on your situation.

What is done to prevent rejection?

You must take medicines for the rest of your life to help the transplanted liver survive in your body. These medicines are called antirejection medicines (immunosuppressive medicines). They weaken your immune system’s response.

Each person may react differently to medicines. And each transplant team has preferences for different medicines.

New antirejection medicines are always being made and approved. Your healthcare provider will create a medicine treatment plan that's right for you. In most cases, you'll take a few antirejection medicines at first. The doses may change often, depending on how you respond to them.

Your provider will watch your progress closely. You will have routine blood work to watch for signs of rejection. Sometimes abnormal blood work is the first sign of rejection before physical symptoms occur. If there's a concern about rejection, you'll likely have a liver biopsy.

Antirejection medicines weaken the immune system. So people who have a transplant are at a higher risk for infections. Some of the infections you'll be at greater risk for include:

• Oral yeast infection (thrush)

• Herpes virus

• Respiratory viruses

• Bacterial infections

For the first few months after your surgery, stay away from crowds or anyone who has an infection.

Each person may have different symptoms of rejection. Some common symptoms of rejection include:

• Fever

• Yellowing of the skin and eyes (jaundice)

• Dark-colored pee

• Itching

• Swollen or sore belly

• Severe tiredness (fatigue)

• Irritability

• Headache

• Nausea and loss of appetite

Next steps

Before you agree to the test or the procedure, make sure you know:

• The name of the test or procedure

• The reason you're having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you're to have the test or procedure

• Who will do the test or procedure and what that person’s qualifications are

• What would happen if you didn't have the test or procedure

• Any alternative tests or procedures to think about

• When and how you'll get the results

• Who to call after the test or procedure if you have questions or problems

• How much you'll have to pay for the test or procedure