Liver transplant

Introduction

A liver transplant is an operation to remove a diseased or damaged liver and replace it with a healthy one.

It’s usually recommended when the liver has been damaged to the point that it cannot perform its normal functions. This is known as liver failure or end-stage liver disease.

The liver can become gradually damaged as a result of illness, infection or alcohol. This damage causes the liver to become scarred, which is known as cirrhosis. Liver failure can also occur very rapidly as a result of inflammation and death of liver tissue (necrosis).

Some of the main causes of liver damage and cirrhosis in the UK are:

• alcohol-related liver disease (ARLD) – where the liver becomes scarred because of years of persistent alcohol misuse
• hepatitis – blood-borne viruses, including hepatitis B and hepatitis C, that can sometimes cause extensive liver damage
• primary biliary cholangitis (often referred to as primary biliary cirrhosis) – a poorly understood condition that causes progressive liver damage
• primary sclerosing cholangitis (PSC) – a condition that causes long-lasting inflammation of the liver

A liver transplant may also sometimes be recommended as a treatment for liver cancer.

The only hope for the long-term survival of a person with liver failure is a liver transplant because – unlike the kidney, heart or lungs – there is no device (such as a dialysis machine) that can permanently replicate the functions of the liver.

Who can have a liver transplant?

There is a strict assessment process that decides who can have a liver transplant, as donated livers are scarce.

Under UK regulations, you are usually only considered a suitable candidate if you meet 2 conditions:

• without a liver transplant, it is highly likely that your expected lifespan would be shorter than normal, or your quality of life is so poor as to be intolerable 
• it is expected that you have at least a 50% chance of surviving for at least 5 years after the transplant with an acceptable quality of life

Most people who meet these criteria will be eligible for a transplant, although there are a few situations where you may be considered unsuitable. For example, you may not be able to have a transplant if you are unable to stop misusing alcohol, or you have liver cancer that has spread beyond the liver.

A series of tests will need to be carried out to determine whether you are suitable for a liver transplant.

Read more about who can have a liver transplant.

Types of liver transplant

There are three main ways a liver transplant can be carried out:

• deceased organ donation – involves transplanting a liver that has been removed from a person who died recently 
• living donor liver transplant – a section of liver is removed from a living donor; because the liver can regenerate itself, both the transplanted section and the remaining section of the donor’s liver are able to regrow into a normal-sized liver
• split donation – a liver is removed from a person who died recently and is split into two pieces; each piece is transplanted into a different person, where they will grow to a normal size

Most liver transplants are carried out using livers from deceased donors.

Waiting for a liver

There are more people in need of a liver transplant than there are donated livers, which means there is a waiting list.

While you’re on the waiting list, you will need to keep yourself as healthy as possible and be prepared for the transplant centre to contact you at any moment, day or night.

You should also keep the transplant centre informed about any changes in your circumstances, such as changes in your health, address or contact details.

Life after a liver transplant

Your symptoms should improve soon after the transplant, but most people will need to stay in hospital for up to 2 weeks.

Recovering from a liver transplant can take a long time, but most people will gradually return to many of their normal activities within a few months.

You’ll need regular follow-up appointments to monitor your progress and you’ll be given immunosuppressant medication that helps to stop your body rejecting your new liver. These usually need to be taken for life.

Risks of a liver transplant

The long-term outlook for a liver transplant is generally good. More than 9 out of every 10 people are still alive after 1 year, around 8 in every 10 people live at least 5 years, and many people live for up to 20 years or more.

However, a liver transplant is a major operation that carries a risk of some potentially serious complications. These can occur during, soon after, or several years after the procedure.

Some of the main problems associated with liver transplants include:

• your body rejecting the new liver
• bleeding (haemorrhage)
• the new liver not working within the first few hours (primary non-function), requiring a new transplant to be carried out as soon as possible
• an increased risk of picking up infections
• loss of kidney function
• problems with blood flow to and from the liver
• an increased risk of certain types of cancer – particularly skin cancer

There is also a chance that the original condition affecting your old liver will eventually affect your new liver.

Who can have one

There is a strict assessment process that decides who can have a liver transplant, as donated livers are scarce, both in the UK and worldwide.

Under UK regulations you are usually only considered a suitable candidate for a liver transplant if you meet 2 conditions:

• without a liver transplant, it is highly likely that your expected lifespan would be shorter than normal, or your quality of life is so poor as to be intolerable 
• it’s expected that you have at least a 50% chance of living at least 5 years after the transplant with an acceptable quality of life

Transplant centres use a scoring system to calculate the risk of a person dying if a transplant isn’t performed.

In the UK, the system is known as the United Kingdom Model for End-Stage Liver Disease (UKELD). This is based on the result of a series of four blood tests that create an average score. The higher your UKELD score and your risk of death, the higher up the waiting list you will be.

Assessing quality of life

Assessing your quality of life can be a subjective process. However, the following symptoms represent a decline in quality of life that many people would find intolerable:

• persistent tiredness, weakness and immobility
• swelling of the abdomen, caused by a build-up of fluid (ascites), that doesn’t respond to treatment
• persistent and debilitating shortness of breath
• damage to the liver that affects the brain (hepatic encephalopathy), leading to mental confusion, reduced levels of consciousness and, in the most serious of cases, coma
• persistent itchiness of the skin

Estimating survival rates

The assessment of your likely survival rate is based on:

• your age
• whether you have another serious health condition, such as heart disease
• how likely a donated liver would remain healthy after the transplant
• your ability to cope (physically and mentally) with the effects of surgery and the side effects of immunosuppressant medication

Tests will also be carried out to assess your health and your likelihood of survival. This can include examining your heart, lungs, kidneys and liver, as well as checking for any signs of liver cancer.

Who can’t have a liver transplant

Even if you meet the above criteria, you may not be considered for a transplant if you have a condition that could affect the chances of success. For example, it’s unlikely that you will be offered a liver transplant if you have:

• severe malnutrition and muscle wasting
• an infection – it would be necessary to wait for the infection to pass
• AIDS (the final stage of an HIV infection)
• a serious heart and/or lung condition, such as heart failure or chronic obstructive pulmonary disease (COPD)
• a serious mental health or behavioural condition that means you would be unlikely to be able to follow the medical recommendations for life after a liver transplant
• advanced liver cancer – by the time the cancer has spread beyond the liver into surrounding tissue, it’s too late to cure the cancer with a transplant

Additionally, a liver transplant will not be offered if you continue to misuse alcohol or drugs. Most transplant centres only consider a person for a transplant if they haven’t had alcohol or used recreational drugs for at least a few months.

Waiting for one

Because of the lack of available livers, it’s rarely possible to have a liver transplant as soon as it’s needed, so you’ll usually be placed on a waiting list.

Depending on the clinical need for a liver transplant, you will be placed either on a high-priority or medium-priority waiting list. Many people are well enough to stay at home until a liver becomes available.

Preparing for a transplant

While waiting for a donated liver to become available, it’s important to stay as healthy as possible by:

• eating a healthy diet – read more about healthy eating
• taking regular exercise, if possible – read more about health and fitness
• not drinking alcohol – if you drink alcohol, you’ll usually be removed from the waiting list
• not smoking – read more about stopping smoking

The transplant centre will need to be able to contact you at short notice, so you should inform staff if your contact details change. You should also let staff know if your health changes – for example, if you develop an infection.

Prepare an overnight bag and make arrangements with your friends, family and your employer, so that you can go to the transplant centre as soon as a donor liver becomes available.

How long will I have to wait?

Your waiting time may be a lot shorter than average if you are on a high-priority waiting list. In some circumstances, you may be able to shorten your waiting time if a relative, or possibly a friend, has the same blood type as you and is willing to take part in a living donor liver transplant.

If your child needs a liver transplant, you may also wish to discuss the possibility of becoming a living donor with staff at the transplant centre.

Coping with being on the waiting list

Living with a serious liver condition can be strenuous enough, and the added anxiety of waiting for a liver to become available can make the situation even more difficult. This can have an effect on both your physical and mental health.

Contact your GP or the transplant centre for advice if you’re struggling to cope emotionally with the demands of waiting for a liver transplant.

You may also find it useful to talk to people in the same situation. The British Liver Trust website has a directory of support groups. You can also become a member of the HealthUnlocked liver disease community.

How it’s performed

You’ll be contacted by staff at the liver transplant centre as soon as a suitable liver becomes available.

The call could be at any time during the day or night, so you may be given a bleeper to alert you. If necessary, you may be given transport to the transplant centre.

Unless advised otherwise, it’s important not to eat or drink anything from the time the transplant centre contacts you.

Once you arrive at the transplant centre, you will be given a chest X-ray and an electrocardiogram (ECG) so that your heart and lung function can be reassessed. You will then be given a general anaesthetic in preparation for the transplant.

Types of transplant

There are 3 main types of liver transplant:

Orthotopic transplant

The most common type of liver transplant is an orthotopic transplant, where a whole liver is taken from a recently deceased donor.

The surgeon will make a cut in your tummy and remove your liver. The donor liver will then be put in position and connected to your blood vessels and bile ducts.

After the donor liver is in place, the incision will be closed using surgical clips. Drainage tubes will be attached to drain away extra fluids, and they will usually remain attached for several days after surgery.

Living donor transplant

During a living donor transplant, the donor – who will usually be a close family member – will have an operation to remove either the left or right side (lobe) of their liver.

Right lobe transplants are usually recommended for adults. For children, left lobe transplants are recommended. This is because the right lobe is bigger and better suited for adults, while the left lobe is smaller and better suited for children.

After the donor operation, your liver will be removed and replaced with the donor’s liver lobe. Your blood vessels and bile ducts will then be connected.

Following transplantation, the transplanted lobe and the donor’s remaining lobe will quickly regenerate themselves. In most cases, they will regrow to their normal size within 2 or 3 months.

Split donation

A split donation may be carried out if a donor liver becomes available from a recently deceased person, and an adult and a child are both suitable candidates to receive half.

The donated liver will be split into the left and right lobes. The larger right lobe will be transplanted into the adult, and the smaller left lobe will usually be transplanted into the child.

After the operation

Once the transplant is complete, you will be moved to an intensive care unit (ICU).

A machine called a ventilator will assist you with your breathing, and a tube will be inserted through your nose and into your stomach to provide you with fluid and nutrients. These will normally be removed after a few days.

You’ll also be given pain relief as required.

Most people are well enough to move from the ICU and into a hospital ward within a few days. You’ll usually be able to leave hospital within 2 weeks, although you will need to have regular follow-up appointments and take medication to help stop your body rejecting your new liver.

Living with a liver transplant

Recovering from a liver transplant can be a long, slow process, but most people will eventually be able to return to most of their normal activities and have a good quality of life.

It can take up to a year to fully recover, although you’ll normally be able to start gradually building up your activities after a few weeks.

Follow-up appointments

You’ll have regular follow-up appointments to monitor your progress after a liver transplant. These will be frequent at first – usually once a week for the first 4 to 6 weeks – but may eventually only be necessary once every few months, or even once a year.

During these appointments, you will have tests to assess your liver and kidney function, and to check the level of immunosuppressant medication (see below) in your blood.

Immunosuppressants

You’ll need to take immunosuppressants for the rest of your life after having a liver transplant, because there is a risk that your body will recognise the new liver as foreign and the immune system will attack it.

This is known as rejection. See our page on liver transplant complications for more information on rejection.

2 main types of immunosuppressants are used to treat people after a liver transplant: They are:

• calcineurin inhibitors – such as ciclosporin and tacrolimus
• corticosteroids – such as prednisolone

The risk of rejection is highest in the first 3 months after a transplant, so it’s likely that you will be given a relatively high dose at first. Your dose will then be reduced to a level thought high enough to prevent rejection, but low enough to minimise unpleasant side effects.

It may take several months before the optimal dose for you is achieved.

Side effects

Common side effects of calcineurin inhibitors include:

• headaches
• high blood pressure
• tremor (uncontrollable shaking or trembling)
• increased risk of infections
• kidney failure

Common side effects of corticosteroids include:

• mood swings
• muscle weakness
• increased appetite and weight gain – care will need to be taken to avoid overeating after the transplant
• changes to your mental state, such as confusion, hallucinations and suicidal thoughts – contact your GP or a member of your care team as soon as possible if you experience these

Although the side effects may be troublesome, you shouldn’t stop taking your medication or reduce your dose without consulting a doctor, because it could lead to your liver being rejected.

Exercise

It’s a good idea to get plenty of rest when you first get home from hospital, although you should start moving around as soon as you feel able to.

Start off with gentle activities, such as walking, and gradually increase how much you do over time. You may see a physiotherapist, who can advise you on specific exercises to try.

Contact sports and swimming should be avoided for several months until you have fully recovered, as there is a risk of picking up an injury or infection.

Diet

Most people will need to have a normal, healthy diet after a liver transplant.

Try to maintain a healthy weight as much as possible, although this can be difficult if you are taking steroid medication. Ask to see a dietitian if you think you may need advice on your diet.

Alcohol

If the previous problem with your liver was caused by alcohol misuse, you will normally be advised to abstain from alcohol for life after a liver transplant.

It may also be a good idea not to drink alcohol even if you’re liver problem wasn’t alcohol-related, although in some cases it may be fine to do so in moderation.

Speak to your care team for advice.

Sex and pregnancy

You can start having sex again as soon as you feel physically and emotionally ready.

Make sure you use appropriate contraception, however, as women who have had a liver transplant are usually advised to avoid becoming pregnant for at least a year.

If you do become pregnant, inform your care team, as immunosuppressant medication could potentially affect your baby and you may need extra monitoring.

If you’re thinking about planning a pregnancy, you should discuss this with your care team first because your immunosuppressant medication may need to be changed to reduce the risk to your baby.

Driving and returning to work

You should avoid driving for up to 2 months, because the transplant procedure and immunosuppressant medication can affect your vision, reaction times and ability to perform emergency stops.

Speak to your doctor first if you feel ready to drive again. It’s also often a good idea to inform your insurance company of your situation.

How long you need to be off work will depend on your job and how quickly you recover. Some people will be able to return to work after 3 months, although others may need more time off. Your care team can advise you on this.

Remember that you will need to continue taking your immunosuppressant medications after returning to your normal activities, as there is a risk that your body will reject the new liver if you stop taking them.

Complications

Complications of a liver transplant can include rejection, an increased risk of infection, graft failure, biliary conditions and a higher risk of developing certain conditions – including some types of cancer.

Liver rejection

In up to 1 in every 3 people, the immune system attacks the new liver and stops it from working properly. This is known as rejection and it usually occurs in the weeks or months after a transplant.

Rejection can occur without causing any specific symptoms, although possible signs can include:

• a high temperature (fever)
• vomiting
• diarrhoea
• a lack of energy
• abdominal (tummy) pain
• yellow skin and yellowing of the whites of the eyes (jaundice)
• pale stools, dark urine and itchy skin

In most cases, rejection can be successfully managed by altering your dose of immunosuppressant medication.

Infections

As immunosuppressant medication weakens your immune system,  they can make you more vulnerable to infection.

Do what you can to reduce your risk of picking up infections. As a precaution, you may be given a course of antiviral medication, antibiotics and/or antifungal medication for a few months after your transplant, to reduce your risk of picking up infections.

If you think you may have an infection, contact your GP or transplant centre for advice. Prompt treatment may be required to prevent serious complications.

Common symptoms of infection include a fever, headaches, aching muscles and diarrhoea.

Biliary conditions

After a liver transplant, more than 1 in every 10 people experience a problem affecting their biliary tract, such as a bile leak or an obstruction caused by scar tissue in the bile ducts.

If you have a bile leak, the bile may need to be removed from the abdomen by inserting a drainage tube.

Obstructions in the bile ducts can often be treated with an endoscopy – where a short tube called a stent is inserted to allow bile to flow more freely – although further surgery may be needed.

Kidney failure

Kidney failure affects up to 1 in every 3 people with a liver transplant, usually as a side effect of taking immunosuppressant medication.

Kidney failure happens when the kidneys lose their function and are no longer able to filter out waste products from the blood.

Symptoms of kidney failure can include:

• tiredness
• swollen ankles, feet or hands
• shortness of breath
• feeling sick
• blood in your urine

Your doctors will closely monitor your kidney function and the level of immunosuppressant medication in your blood during your follow-up appointments to detect potential kidney problems.

If your kidneys do fail, you will need to have dialysis (where a machine is used to replicate kidney function) or a kidney transplant.

Graft failure

Graft failure is a medical term meaning that the transplanted organ is not working properly. It’s one of the most serious complications of a liver transplant and occurs in around 1 in every 10 people.

The most common cause is a disruption to the blood supply to the transplanted liver, caused by blood clots (thrombosis).

Graft failure can develop suddenly, or slowly over a longer period of time. Symptoms can include jaundice, fluid retention (oedema), mental changes and a swollen tummy.

Medication can stabilise the body in the short term, but the only cure is to transplant a new liver into the body as soon as possible.

Cancer

People with a transplanted liver have an increased risk of developing some types of cancers, such as:

• non-melanoma skin cancer 
• melanoma skin cancer 
• cervical cancer

There is also around a 1 in 50 chance of developing a type of cancer that affects the white blood cells in people who have had an organ transplant – known as post-transplant lymphoproliferative disorder (PTLD).

Due to the risk of these conditions, it’s important to attend all of your follow-up appointments and any cancer screening tests you’re invited to. You should also avoid prolonged exposure to sunlight or artificial forms of ultraviolet light, such as sunbeds or sun lamps.