What is a liver transplant?

Liver transplantation is a surgical procedure

performed to remove a diseased or injured
liver 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, a
transplanted segment of a liver can grow to
normal size within weeks.

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 cirrhosis, 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, the most common
reason for a liver transplant is cirrhosis caused by chronic hepatitis C, followed by
cirrhosis caused by long-term alcohol abuse.
Many other diseases cause cirrhosis,
including the following:
• Other forms of chronic hepatitis,
including hepatitis B and
autoimmune hepatitis.
• NASH, or nonalcoholic
steatohepatitis, 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. How are candidates for liver transplant 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; and •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-posttransplant care should accompany you to the appointment. What tests are required for
evaluation? Extensive testing is required before someone can be placed on the transplant list. This
usually includes: •physical exam •detailed medical history •psychological and social evaluation
•diagnostic tests to evaluate the status of your heart, lung and other organs •imaging studies, such
as CT scans and ultrasound, to assess your liver and blood flow through various vessels •multiple
blood tests to determine your blood type, kidney function and liver function, and check for other
infectious, immune, and inherited diseases •HIV, hepatitis, drug and alcohol screening If you have
a history of drug and/or alcohol
abuse, documented sobriety from a
treatment facility may be required. Your
transplant center’s policy on drug and
alcohol use should be discussed at the first
visit.
Where do donated livers come
from?
We will now discuss transplantation in two
categories: deceased donor transplantation
and living donor transplantation.
Livers for transplantation come from either
a deceased or living donor. 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 the
victim is declared brain dead.

Deceased Donor Transplantation

How does the transplant waiting

List work?

Once you complete all required testing, the

Transplant selection committee will review

Your case. If the committee determines

You are a suitable candidate, your name

Will be placed on the national transplant

Waiting list. This list is maintained 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.

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 your 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 or not you’re currently

On dialysis and the results of the following

Four blood tests:

•INR (internal normalized ration),

Which reflects whether your liver is

Making the proteins necessary for

Your blood to clot

•creatinine, an indicator of kidney

Function

•bilirubin, an indicator of liver health

•sodium, an indicator of your 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.

While you’re on the waiting list, your score

May go up if your 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 at unos.org.

How long does it take to get a new

Liver?

It’s impossible to predict how long you’ll

Have to wait for a new liver. Sometimes

People wait only a few days or weeks before

Receiving a donor organ. It may take months

Or years before a suitable donor organ

Becomes available. Blood type, body size,

Severity of illness, and availability of donor organs in your geographic region will all
affect waiting time.

What happens during transplant

Surgery?

Liver transplant surgery is complex and

Generally takes between six and 12 hours.

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 complications are associated

With liver transplantation?

The two main risks following liver transplant

Are infection and rejection of the new

Liver by your body’s immune system. Your

Immune system attacks unwanted foreign

Substances – like bacteria and viruses – that

Invade your body. But the immune system

Can’t distinguish between the transplanted

Liver and unwanted invaders, so it may try

To attack – or reject – your new liver.

To prevent rejection, all transplant patients

Must take anti-rejection medications,

Called immunosuppressants. These drugs

Are given to suppress your immune

System in an effort to ward off rejection

Of the new liver. However, by suppressing

Your immune system you become more

Susceptible to infections. Fortunately, this

Problem usually lessens as time passes and

Most infections can be treated successfully

With other drugs.

The other thing to be aware of is that liver

Disease can recur in the transplanted liver.

One of the primary problems with hepatitis

C patients was universal recurrence of

The virus after transplantation. However,

With the advent of newer, more effective

Treatments, hepatitis C can be cured before

Or after liver transplantation. Patients with

Advanced liver disease from hepatitis B

Require lifelong medication to suppress the

Virus both before and after transplantation.

Autoimmune diseases such as primary

Biliary cholangitis (PBC) and primary

Sclerosing cholangitis (PSC) may also recur.

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 nearnormal

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.