Your liver is the largest organ inside your body. It helps your body digest food, store energy, and remove poisons. You cannot live without a liver that works. If your liver fails, your doctor may put you on a waiting list for a liver transplant. Doctors do liver transplants when other treatment cannot keep a damaged liver working.

During a liver transplantation, the surgeon removes the diseased liver and replaces it with a healthy one. Most transplant livers come from a donor who has died. Sometimes there is a living donor. This is when a healthy person donates part of his or her liver for a specific patient.

The most common reason for a transplant in adults is cirrhosis. This is scarring of the liver, caused by injury or long-term disease. The most common reason in children is biliary atresia, a disease of the bile ducts.

If you have a transplant, you must take drugs the rest of your life to help keep your body from rejecting the new liver.

What is a liver transplant?

A liver transplant is surgery to remove your diseased or injured liver and replace it with a healthy liver from another person, called a donor. If your liver stops working properly, called liver failure, a liver transplant can save your life.

How common are liver transplants?

In 2015, about 7,100 liver transplants were performed in the United States. Of these, almost 600 were performed in patients 17 years of age and younger.

When do people need a liver transplant?

People need a liver transplant when their liver fails due to disease or injury.

For adults in the United States, the most common reasons for needing a liver transplant in 2016 were

• alcoholic liver disease
• cancers that start in the liver combined with cirrhosis
• fatty liver disease (nonalcoholic steatohepatitis)
• cirrhosis caused by chronic hepatitis C

Biliary atresia is the most common reason children need a liver transplant.

Doctors may consider a liver transplant to treat rare disorders such as urea cycle disorders and familial hypercholesterolemia.

People may also need a liver transplant due to acute liver failure. Acute liver failure is an uncommon condition most often caused by taking too much acetaminophen. Other causes of acute liver failure include

• bad reactions to prescription medicines, illegal drugs, and herbal medicines
• viral hepatitis
• toxins
• blockage of the blood vessels to the liver
• autoimmune diseases
• genetic disorders

What are the types of liver transplant?

Deceased donor transplants

Most livers for transplants come from people who have just died, called deceased donors. During a deceased donor transplant, surgeons remove your diseased or injured liver and replace it with the deceased donor’s liver. Adults typically receive the entire liver from a deceased donor. However, surgeons may split a deceased donor’s liver into two parts. The larger part may go to an adult, and the smaller part may go to a smaller adult or child.

Living donor transplants

Sometimes a healthy living person will donate part of his or her liver, most often to a family member who is recommended for a liver transplant. This type of donor is called a living donor. During a living donor transplant, surgeons remove a part of the living donor’s healthy liver. Surgeons remove your diseased or injured liver and replace it with the part from the living donor. The living donor’s liver grows back to normal size soon after the surgery. The part of the liver that you receive also grows to normal size. Living donor transplants are less common than deceased donor transplants.

What are the survival rates after a liver transplant?

For patients receiving liver transplants from deceased donors, the survival rates are

• 86 percent at 1 year
• 78 percent at 3 years
• 72 percent at 5 years

The 20-year survival rate is about 53 percent.

Your chances of a successful liver transplant and long-term survival depend on your personal situation.

A liver transplant is a medical procedure that may be recommended by your doctor if you have a significant chance of dying from liver disease in the next 1-3 years. We are born with a liver that has many functions needed to maintain our health. Sustained injury, over time, can lead to decreased function and ultimate failure of the liver. There are many causes for this, with hepatitis C and alcohol being the most common. Patients are typically considered for transplant when the liver is working at roughly 10-20 percent of what is considered normal functioning. A few patients each year are referred for liver transplant on an emergency basis for "acute liver failure" — a condition that causes the liver to suddenly stop working and can lead to death in 1-2 weeks.

As you will read, evaluation for a liver transplant, receiving a liver transplant, and recovering from the procedure takes time, commitment, and is unique to each patient. The key to a successful transplant is the Transplant Team, which consists of you (the recipient), your caregiver/support person, family and friends, and the group of committed health care professionals working with you.

Definitions

A liver transplant replaces a sick (referred to as cirrhotic) liver, or a liver with a tumor, with a healthy one from someone else. Most of the time, a liver is donated from someone who has died. This was once called a cadaveric donor but is now known as a deceased donor. When an organ donor dies, the liver is removed by a surgeon and sent to the transplant recipient as quickly as possible. Livers for transplant are matched for body size and blood type. In some cases, a living person donates a portion of their liver (called a living donor).

Statistics

According to the Organ Procurement and Transplantation Network (OPTN), nationwide in 2018:

• Over 8,000 liver transplants took place
• Largest recipient age group is 50-64 years old

The Organ Procurement and Transplantation Network (OPTN) also reports:

• Survival rate for primary liver transplant (2008-2015):
  • 1 year after transplant is 89.6%
  • 3 years after transplant is 80.8%
  • 5 years after transplant is 72.8%
• As of February 2019, there are over 13,000 people nationwide waiting for a liver transplant.

When is a liver transplant considered?

A liver transplant is considered when you might die from liver disease within the next 1-3 years. In some situations, very severe liver disease may exclude you from receiving a liver transplant if you are too sick to tolerate the surgery and recovery. You may also be excluded if other parts of your body are too sick or have cancer. If cancer starts in the liver and is found early enough, a transplant can still be done and offers the best chance at a cure.

Your medical provider may think you need a liver transplant if you have symptoms of severe liver disease, which may include:

• Yellowing of skin or whites of eyes (jaundice)
• Fluid in your belly (called ascites) or in your legs (called edema)
• Vomiting blood or passing blood in your stool from dilated veins (varices) in your esophagus or stomach
• Unclear thinking or confusion (called encephalopathy) related to the build-up of toxins which affect the brain
• Changes in your liver tests that suggest your liver is working poorly
• Life-threatening bleeding
• Thinning of your muscles, especially in your face, neck, and arms
• Easy bruising or bleeding (due to low platelet count or decrease in"clotting" protein levels)

To treat these symptoms, you may be prescribed a diuretic (or "water pill,"which decreases the ascites and edema by increasing urination), lactulose or rifaximin (which gives you diarrhea as it helps you get rid of toxins that make you encephalopathic) or a beta-blocker (which lowers your heart rate and blood pressure in order to prevent bleeding from varices). Occasionally, an antibiotic is given to prevent infection in the ascitic fluid. Your provider may do procedures like paracentesis (tap) to remove excess fluid from your belly or transjugular intrahepatic portosystemic shunt (TIPS) where a stent is inserted in the liver.

These medications may seem like unusual ways of controlling liver failure, but they are vital and may extend your pre-transplant life. Stopping these medications can lead to a rapid decline in health, hospital admission, or even death.

The liver transplant process has many steps, including talking with your doctor, visiting a transplant center, and getting evaluated.

Talk with your doctor about a liver transplant

The first step is to talk with your doctor to find out whether you are a candidate for a transplant. Doctors consider liver transplants only after they have ruled out all other treatment options. However, a liver transplant is not for everyone. Your doctor may tell you that you are not healthy enough for surgery. You may have a medical condition that would make a transplant unlikely to succeed. If you and your doctor think a liver transplant is right for you, your doctor will refer you to a transplant center.

Visit a transplant center

During your first visit to a transplant center, health professionals will provide information about

• the evaluation and approval process
• placement on the national waiting list
• reasons for being removed from the national waiting list
• the waiting period
• how people are selected for liver transplants
• surgery and recovery
• the long-term demands of living with a liver transplant, such as taking medicines for the rest of your life

Get evaluated for a liver transplant

You will go through a series of evaluations at the transplant center, where you will meet members of your transplant team. You may need to visit the transplant center several times over the course of a few weeks or even months.

Your team will ask you about your medical history and perform medical tests. These tests may include

• a physical exam
• blood and urine tests
• tests that provide pictures of organs inside your body, called imaging tests
• tests to see how well your heart, lungs, and kidneys are working

The team will use the results of these tests to tell them

• how likely you are to survive transplant surgery
• what other diseases and conditions you have
• the cause and severity of your liver disease

Your team will find out if you are healthy enough for surgery. Some medical conditions or illnesses can make a liver transplant less likely to succeed. You may not be able to have a transplant if you have

• a severe infection
• alcohol or drug abuse problems
• cancer outside the liver
• serious heart or lung disease

Also, the transplant team will

• find out whether you or your caregivers are able to understand and follow your doctor’s instructions for care after your transplant. They need to be sure you are mentally prepared for caring for a new liver.
• find out whether you have a good support system of family members or friends to help care for you before and after the transplant.
• review your medical insurance and other financial resources. Many financial assistance programs are available to people receiving a liver transplant and their families to help with the cost of the surgery, medicines, and care.

Get approved for a liver transplant

The transplant center’s selection committee will review the results of your evaluation. Each transplant center has its own guidelines about who can get a liver transplant. Transplant centers often post their guidelines on their websites. The centers also follow national guidelines.

Keep in mind that you may choose not to have a transplant even though you have been approved.

Get placed on the national waiting list

If you are approved for a transplant and do not have a living donor, the transplant center will submit your name to be placed on the national waiting list for a liver from a deceased donor. If you have a living donor, the transplant center will not place you on the national waiting list.

The Organ Procurement and Transplantation Network (OPTN) has a computer network linking all regional organ-gathering organizations—known as organ procurement organizations—and transplant centers. The United Network for Organ Sharing (UNOS), a nonprofit organization, runs the OPTN under a contract with the Federal Government. When UNOS officially adds you to the national waiting list, UNOS will notify you and your transplant center.

UNOS policies let you register with more than one transplant center to increase your chances of receiving a liver. Each transplant center may require a separate medical evaluation.

Wait for a match

The waiting period for a deceased donor transplant can range from less than 30 days to more than 5 years. How long you will wait depends on how badly you need a new liver. Other factors—such your age, where you live, your blood type and body size, your overall health, and the availability of a matching liver—may make your wait time longer or shorter. The UNOS computer matches a deceased donor’s liver based on your blood type and body size.

UNOS policies rank people with the most urgent need for a new liver to prevent death at the top of the national waiting list.

When a matching liver from a deceased donor is found, your transplant team coordinator will call you right away, tell you what you need to do before going to the hospital, and ask you to come to the hospital right away.

Confirm living donor match if you choose this type of liver transplant

If a family member, spouse, or friend wants to be a living donor, the transplant team will determine whether you and the person have blood types that work together and a similar body size. The transplant team will

• ask the potential donor about his or her medical history
• perform medical tests to make sure the person is in good general health, with no major medical or mental illnesses

The potential donor must be able to understand and follow instructions before and after surgery, be between the ages of 18 and 60, and have an emotional tie to the person receiving the liver transplant.

The OPTN and UNOS provide detailed information on the organ transplant process.

As part of the transplant process, you will have a team of specialists and support working with you. This team may include some or all of the following people:

• Transplant surgeon — this is the specialist who will perform your transplant operation. He or she is trained specifically in transplant surgery. The surgery team will follow you daily after your transplantation.
• Hepatologist — this is a specialist trained in the study of liver disease; he or she is also trained in the medical aspects of transplantation and often follows you after surgery along with the surgeons.
• House Staff/Residents and GI/Hepatology Fellows — these are physicians who are still in training and work under the supervision of the transplant surgeon and hepatologists; they are an integral part of the team. They are available to care for you on a 24-hour basis while in the hospital.
• Clinical Nurse Specialist/Practitioner — an advanced practice nurse who will assist in your care.
• Transplant Nurse Coordinator — is a nurse who coordinates all elements of your care; he or she will teach you how to take charge of your own care and will help communicate your questions and concerns to the team during the evaluation and posttransplant time.
• Registered Nurses (RNs) — the nursing staff that will be available to assist with your pre- and posttransplant care.
• Physician Assistants — mid-level providers who will assist in your care.
• Social Worker — will meet with you to discuss concerns about financial issues, housing, and also provide emotional support. The social worker will help you organize the nonmedical aspects of your care and can help with referrals to community services.
• Dietitian — will work with you to develop a nutritional program to meet your needs both before AND after transplant in order to maximize your health.
• Pharmacist — an integral part of the team who helps in managing dosage, side effects, and interactions of your new medications. The pharmacist will assist you and your nurse in educating you about your medications prior to discharge.
• Psychiatrist/Psychologist — these providers can help address any mental health issues that come up in the transplant work-up and can assist you and your caregiver in exploring your feelings about the process and help with stress management. A psychologist or psychiatrist also conducts a pre-transplant psychosocial assessment that is included as part of your application package for liver transplant.
• Research Coordinators — these staff members conduct research studies in order to learn new approaches to transplantation. You may be asked to participate in one or more of these studies. Your participation is completely voluntary; if you decide not to participate, it will not affect the care you receive.

One of the most important parts of your transplant team is your support person(s). You may have more than one support person. This may be a spouse, parent, close friend, other family member, or some combination of these individuals. This person's job is to help you during the evaluation process and during the critical period of time before and after your surgery when you will be unable to care for yourself.

Who you choose to be your support person is probably the most important decision you will make if you are going to have a liver transplant. They need to be able to provide you with mental and emotional support as well as physical help during the process.This help is crucial for your evaluation, transplantation, and recovery.

Your personal support person will need to be available at all times from the time you are evaluated until about 2 years post-transplant. These are some of the specific duties your support person will have to agree to:

• Go with you to the pretransplant evaluation and followup appointments (unless other arrangements are made)
• Assist you with transport to the hospital when called in for transplant (unless other arrangements have been made with the pre-transplant coordinator)
• Attend discharge teaching with the transplant coordinator and learn the information in the discharge teaching manual to help you with your selfcare after the operation
• Help you for 24 hours a day for approximately 3 months after your discharge from the hospital after transplant
• Learn your medications and assume responsibility for monitoring the correct administration of medications during the early post-discharge period
• Arrange for safe housing for you upon your discharge from the hospital
• Transport you (or arrange for safe transport) to all clinic, lab, or other appointments

As you can see, your support person will play a major role during this process. We cannot stress enough how vital it is to have this personal help. Without a support person, you will not qualify for a transplant.

After all these tests and visits - then what? Will I get listed? Who makes that decision?

Who makes the decision about transplantation?

Once the final evaluation at the transplant center is complete, your case is presented to the Selection Committee (made up of hepatologists, transplant nurse coordinators, transplant surgeons, psychiatrists, psychologists, social workers, dietitians, and chaplains — many of whom you will have met) to determine if you meet the criteria for transplant. They typically will discuss your case the week after you have been there. You and your referring provider will receive a letter in the mail discussing the results of that decision.

Candidacy is determined mostly by the following:

• Presence of advanced liver disease which cannot be cured by other treatments
• At least 6 months abstinence from alcohol and illicit substances. The patient must demonstrate convincing evidence that substance use issues have been addressed and can be determined to be of low risk of relapse in the future
• Ceasing any use of any nicotine products
• Stable, clean, and sober support system
• Full understanding of the transplant process
• Ability to demonstrate commitment and compliance to your medical care
• No active infections
• No other medical conditions (heart, lung, or weight issues) that will interfere with the surgery, your recovery or long-term health
• No active cancer, with the exception of some liver cancers

The Selection Committee will then decide and inform you and your referring provider if you are:

Accepted — You have met all of the medical, psychological and social criteria and are ready to be placed on a waiting list when any pending tests are completed.

Deferred — You have some medical and/or psychosocial issues that need to be taken care of (dental work, substance abuse treatment, ceasing nicotine use, improving social support, or further heart testing). Being deferred means that you need to address the concerns brought up during the evaluation before you can be re-considered for acceptance for listing. There is usually a time limit for this to occur. After all concerns are addressed, your referring provider will contact the transplant center to request reconsideration of your case. Your case will be re-discussed at their Selection Committee Conference where members will review how you addressed their concerns and will hopefully recommend you be approved for listing.

Declined — You may have medical or psychosocial support issues that disqualify you from being on the waiting list. Sometimes, it is possible that you can be re-referred at a later date if some of their concerns can be addressed or certain medical conditions improve.

The Wait

If you are accepted for transplantation, your name is placed on the waiting list, according to blood type. It is hard to say how long you will have to wait for a transplant once you are on the list. It could be anywhere from 5 hours to 5 years. The US national wait times for liver transplantation have decreased in recent years.

During the waiting period, you will follow-up regularly with the provider who referred you to the transplant center. The provider will be responsible for your care, checking your blood tests, and reporting to the transplant center if your condition changes. It is always a good idea for you to contact the transplant center as well with any concerns or questions that may be better addressed by them. If you wait more than a year, the transplant center will likely bring you in for a clinic visit to touch base with you, answer any questions, and review the status of your overall health.

How do transplant centers decide who gets transplanted first?

In the United States, the federal government is responsible for regulating the listing of patients and the allocation of organs. The method for determining this is complicated. As part of this process, the Organ Procurement and Transplant Network (OPTN), administered by a non-profit organization, the United Network for Organ Sharing (UNOS), has developed a system for determining which patients waiting for liver transplant should have priority. This system, called the MELD-Na Score (Model for End Stage Liver Disease Sodium Score), is based on statistical formulas that predict which individuals are most likely to die over the next 3 months from their liver disease. The number is calculated by a formula using four lab tests (bilirubin, International Normalized Ratio (INR), creatinine, and sodium) that are routinely checked each time you see your provider for follow-up. These labs tell us how your diseased liver is doing. The MELD-Na usually varies with each lab draw. Lab work needs to be drawn every three months and sometimes more frequently depending upon how sick you are from liver disease. Generally those with the sickest livers (highest MELD-Na scores) will be prioritized. Patients with liver cancers who meet transplant criteria also receive higher priority.

Your Waiting Time

While you wait, continue to take your medications as prescribed. Maximize your health. Follow recommended nutrition, exercise and lose weight if needed. Exercise, walk, and try to keep up some social activities. Keep all doctors' appointments. Make sure your doctor and the transplant center know of any health changes. Though you may feel too sick to be active, you will have to push yourself to keep active; even short walks will help. It is very important not to lose too much muscle mass since the surgery is more risky if you are malnourished. Set up childcare or guardianship, if needed; make plans for your pets, if needed. If you have concerns about your physical limitations and exercise, discuss it with your medical provider. If you notice a change in your health, you need to let your medical provider and the transplant center know as soon as possible.

Notification

When your name has come to the top of the waiting list, a transplant coordinator will notify you by phone/pager to come to the transplant center. Once you are at or near the top of the list, you may need to reside near the transplant center for up to 2-3 months since you will need to be at the transplant center within 6 hours from the time you are called for transplant. The transplant center will let you know if this is the case.

Patients with liver disease have to make changes in their diet in order to adjust for decreased liver functioning and to maintain their overall health. Nutrition recommendations are customized for individual patients, both pre- and posttransplant, by the dietitian with the Liver Transplant Team after a thorough evaluation. The following are general recommendations, however, that often apply to transplant and liver disease patients.

Pre-Transplant

Protein Malnutrition — Many patients with end stage liver disease do not eat enough protein. As you prepare for a possible liver transplant, it is very important that you NOT restrict the amount of protein you eat. Patients who do not get enough protein start to look thin in the arms and chest and begin to show indentations in their temples.

An unfortunate side-effect of protein consumption is an increase in ammonia in the bloodstream, which can contribute to encephalopathy (confusion and memory difficulties). This makes it even more important for you to take lactulose as prescribed in order to flush the ammonia from your body, while at the same time eating a sufficient amount of protein in your diet. Good sources of protein include poultry, eggs, fish, tofu, and soy protein.

Low Sodium — Symptoms of advanced liver disease include excess fluid and swelling in the belly (ascites) and in the legs (edema). A high level of sodium, or salt, intake increases the amount of water retained in the body, and this can make ascites and edema worse. So it is very important to stick to a low sodium diet, especially when these symptoms start to develop. This means that you should avoid salty foods (for example canned soups, pizza, and pickles). Even if you are not currently experiencing ascites or edema, you may want to start getting used to a low sodium diet now since you may have to switch to a low sodium diet later. A diet low in sodium has been shown to have other health benefits for many patients with high blood pressure or hypertension.

Weight Control — If you are overweight, you should work with your providers on a plan to lose weight sensibly and slowly, without causing malnutrition (especially protein malnutrition). Losing excess weight decreases the strain on your liver and other organs, and will make your recovery from surgery easier. You may have had some discouraging experiences in the past trying to lose weight, but shedding even just a few pounds can have significant health benefits.

Blood Sugar Control — Eating smaller meals more frequently helps reduce the risk of low blood sugar. This also helps with weight control.

Exercise — Exercise is a very important strategy to build up your strength prior to surgery. However, your exercise program should be sensible and should be discussed with your provider. DO NOT lift heavy weights since this can strain varices. Walking is likely the most appropriate type of exercise for you. You may want to see if there are any "mall walking" hours at a location near your home; these are times when the mall is open to the public before most stores open. If you have difficulty walking or have chronic pain that keeps you from walking a significant distance, then some type of aquatic therapy can help with both building strength and controlling chronic pain. There may be an aquatic therapy program available through physical therapy, and you may be able to follow up on the skills you learn at a pool near your home. Arm strengthening exercises are also good to do.

Avoid Herbal Supplements and Vitamins — Some herbal supplements (such as Kava-Kava) can cause liver failure. Since herbal supplements are not regulated by the Food and Drug Administration or any other agency, it may be hard to know the exact dosage of a particular substance you are taking or the contaminants in the product. At this point in your liver disease, it is best for you to take only what is prescribed by your providers to help prevent any injury to your liver. Remember that even over-the-counter medications can be potentially harmful so check with your doctor before taking these.

Post-Transplant

Immunosuppressive Drugs — These are the medications taken after transplant to prevent rejection. The side-effects of immunosuppressive medication can be very hard on the body. Unfortunately, the combination of drugs needed to prevent organ rejection can increase the risk of "metabolic syndrome," which is a collection of health risks that increase your chance of developing heart disease, stroke, and diabetes. Taking these medications can lead to an increase in your blood pressure, cholesterol, blood sugar, and weight gain. Heart disease is the leading cause of death with post-transplant patients after the first three months, so proper nutrition after transplant is very important to control these changes in your body. The transplant pharmacist will work with you and your caregiver to make sure you understand all your medications. The liver transplant dietitian will conduct an assessment with you after transplant, and you will get a set of nutritional guidelines based on your individual case. Eating a healthy diet now will help ease the transition to your post-transplant diet. A healthy perspective on nutrition is to think of food as medicine, as important as the medications you will take after your transplant. Eat what your body needs, as recommended, without overdosing on any one thing or neglecting any particular food group.

How do I prepare for liver transplant surgery?

How you prepare for liver transplant surgery depends on the type of liver transplant you are having.

• Deceased donor transplant. If you are on the national waiting list for a deceased donor liver, your transplant team coordinator will call you as soon as a matching liver is found. You must go to the hospital right away. Your transplant team coordinator will tell you what you need to do before going to the hospital.
• Living donor transplant. If you are receiving a liver from a living donor, you will schedule your surgery 4 to 6 weeks in advance. Your transplant team coordinator will tell you and the donor what you need to do before going to the hospital for the operations.

How do doctors perform liver transplant surgery?

Doctors perform liver transplant surgery by removing your diseased or injured liver and replacing it with the donor’s liver. Liver transplant surgery can take up to 12 hours or longer. During the surgery, the surgical team will

• give you general anesthesia
• put intravenous (IV) and other types of lines into your body so you receive medicines and fluids
• monitor your heart and blood pressure

If you are getting a liver from a deceased donor, your surgery will start when the donor liver arrives at the transplant center. If you are getting a liver from a living donor, the surgical team will operate on you and your donor at the same time.

What are the possible problems of liver transplant surgery?

Possible problems of liver transplant surgery should be discussed with your surgeon. Some possible problems include

• bleeding
• blood clots in your liver’s blood vessels
• damage to the bile ducts
• failure of the donated liver
• infection
• rejection of the donated liver

What happens after liver transplant surgery?

After your surgery, you will stay in an intensive care unit (ICU). Specially trained doctors and nurses will watch you closely while you’re in the ICU. You’ll begin taking medicines called immunosuppressants to prevent problems with your new liver. The doctors and nurses will perform

• blood tests often to make sure your new liver is working properly
• medical tests to make sure your heart, lungs, and kidneys are also working properly

When your doctors feel you are ready, you will move from the ICU to a regular room in the hospital.

Your transplant team will teach you how to take care of yourself before you get home. Transplant team members will give you information on follow-up medical care, the things you need to do to care for your new liver, and possible problems you may have with your new liver.

After a living donor’s surgery, the donor will stay in a recovery room for a few hours and spend his or her first night in an ICU. Specially trained doctors and nurses will watch the donor closely in the ICU. The day after surgery, the donor will usually move to a hospital room. The doctors and nurses will encourage the donor to get out of bed and sit in a chair the day after surgery and to walk short distances as soon as he or she is able.

When can I go home after liver transplant surgery?

You can likely go home about 2 weeks after your transplant surgery. A living donor can typically go home about 1 week after surgery.

When can I go back to my normal activities?

Your doctor will let you know when you can go back to your normal activities. You can likely return to your normal activities after a few months. Most people are able to return to work, be physically active, and have a normal sex life. You will continue to have regular medical checkups to make sure that your liver is working properly and you have no other health problems. Doctors often recommend that women wait at least a year after their transplant before getting pregnant.

Although recovery times vary, most living donors can often return to their normal activities 1 month after surgery and can return to work within 4 to 6 weeks.

When you arrive at the hospital — Many tests (blood tests, electrocardiogram and chest x-ray) will be done the day of the surgery. A physician will perform a history and physical. Please bring a complete list of all your medications. Although you are at the hospital, ready for surgery, the transplant is not guaranteed until after the hospital has seen the donated liver and the surgeon has determined that it is safe to proceed.

Surgery prep — This occurs the same day of surgery. It includes consenting to the surgery and intravenous (IV) line placement.

The surgery — Once in the operating room, an anesthesiologist needs to place a number of tubes, lines, and monitors so you can be safely managed for this big operation. The next thing you will remember is waking up in the Intensive Care Unit. The surgery lasts anywhere from 6 to 12 hours (average). When you have recovered sufficiently, you will be transferred out of intensive care.

The incision for liver transplantation is quite large — it goes across your abdomen and may extend up toward your chest. Once the incision is made, the surgeon will proceed with removing your old liver (leaving behind parts of the major blood vessels and bile ducts to attach to the new liver). While the new liver is being sewn in, you may be placed on veno-veno bypass to allow blood to flow around the site where the surgeons are working while returning a normal amount of blood back to the heart. During the surgery, you will receive transfusions of blood products and have blood sent for frequent monitoring of clotting factors, blood counts, and body chemistries. The gallbladder is also removed at the time of liver transplant so that it will not cause problems later, since performing another surgery in that location later would be difficult.

At the completion of transplant, you will be taken to the Intensive Care Unit (ICU). You will be kept on a breathing machine (ventilator) for a day or so and will be followed very closely by the staff there. The average length of stay in the ICU is two days, after which you will be transferred to the medical floor/ transplant unit.

The Hospital Stay and the Clinic Follow-Up

Recovery in the hospital

• Typically, you will be in the hospital for 7 to 10 days, but this could be longer and will depend upon your postoperative course.
• Expect some restrictions (walking, food, visitors), but it will be important for you to get out of bed and moving soon after your surgery.
  • You will be able to see visitors as soon as you are on the transplant floor (visitation policies while on the ICU floor vary by facility).
  • Nutrition recommendations will be different for each individual; you will meet with a dietitian so that you are well informed of the diet that best suits your unique needs.
• Routine tests and labs will be done daily to monitor your progress.
• You will be ready to leave the hospital when you are walking, eating, comfortable with/and understand your medications and aftercare plan, and have your support person(s) able to care for you.

Interim recovery

Once you are out of the hospital, the transplant team will assume all aspects of your medical care. They can be reached 24 hours a day.

• Your medical provider will probably see you once a week, but this can vary as your recovery progresses.
• For the first two to three months, you will get your blood tested twice a week, but if there is a need for more, your transplant coordinator will notify you. Your blood tests will indicate to your medical provider if medication adjustments are needed. They also show how your body is responding to your new liver (even before you notice how your body is responding).
• For patients transplanted with hepatitis C infection, when you are stable, the team will recommend treatment to cure the hepatitis C.
• Following a liver transplant, some people develop conditions such as diabetes or irregular chemical levels. They need to receive treatments to address these problems. All liver transplant recipients will be treated with medication that stops the body from rejecting its new liver.
• You will begin physical therapy, which is a major factor in your recovery. Prior to the transplant, your body was extremely sick, emaciated, and out of shape. Physical therapy will assist you in regaining your strength for quicker recovery.

Recovery at home

Instructions are given from the liver transplant team to you, your personal support person, and your primary medical care provider. They include which lab tests to complete and how often. You will receive recommendations about your visits with your referring or primary medical care provider. You and your support person will have a solid understanding of the medications you will need to take. In fact, you may feel like a medication expert because you will be just as responsible for your health care as your medical providers are. You are part of your own treatment team! Do not, however, adjust medications without the knowledge of the transplant team.

Complications

Because several of these possible complications occur more often in the immediate post-transplant period (defined as first 3 months after transplant), transplant centers require you to remain nearby to allow for frequent monitoring by them so they can look for these events and take care of them quickly.

Related to Surgery:

A liver transplant is a complex process that requires hundreds of steps. While there are a number of possible complications, fortunately most are quite rare. One of the reasons you undergo so many tests before the surgery is to decrease the potential risks of heart attack, stroke or death. Despite all these tests, it is important to be aware that these things can happen. Occasionally, the new liver fails to work; if that happens, the transplant center does everything they can to find a new liver right away. In addition, one of the new anastamoses (connections) of the new liver, with blood vessels or other structures in the abdomen, can develop a complication requiring return to the operating room for repair or other procedures to open up the new connections.

Rejection:

Your immune system helps fight infections. It does this by recognizing self (your own cells and proteins) from non-self (those things that are foreign to your body). Anything it sees as nonself is attacked by your immune system and destroyed. Your new liver naturally is recognized as non-self and is attacked by your immune system. This process is called rejection. To control this natural immune response, your providers give you a combination of immunosuppressive medications (prednisone, tacrolimus, azathioprine, mycophenylate mofetil, cyclosporine, and sirolimus). You must take these medications for life. These medications all have side effects (discussed later) that often lead to the need to take additional medications to manage the side effects.

Occasionally, your immune system still rejects the liver, and additional medications may be added. While it is rare to lose your liver to rejection, untreated rejection can lead to permanent liver damage or even death. Rejection is monitored by routine lab work and letting your medical provider know if you are experiencing any symptoms.

Infection:

Because of the immunosuppression needed to prevent rejection, you will be at increased risk for infections. Occasionally, these infections can be fatal. There are things you can do to help prevent infection such as washing hands regularly, avoiding exposure to possible airborne fungal spores (e.g. avoiding smoking marijuana, certain occupational exposures), and avoiding contact with sick persons. You do not need to wear masks after you return home.

Since the immune system also plays a role in fighting cancer, you will be at increased risk for developing certain types of cancers such as skin cancer or post-transplant lymphoma (PTLD). The lifetime risk for lymphoma is only 1-2%, however, it emphasizes the need for good follow-up.

Related to Immunosuppressive Medications:

These potent drugs have a lot of side effects and potential long-term complications. These side effects will be monitored at your clinic visits, and your providers will make every attempt to control or decrease medication side effects. Most patients, however, will develop one or more complications, which then need to be managed.

Diabetes, kidney problems, high blood pressure, and high cholesterol are some of the more serious side effects. Some of the more annoying side effects include hair loss, insomnia, diarrhea, nausea, headaches, swelling, and neuropathy (nerve symptoms).

Do not take any new medications without talking with the transplant center or a physician trained in transplant. Many medications can interact with each other and cause elevated levels of immunosuppression, which may lead to serious toxicity. Even antibiotics, herbal remedies, ibuprofen, and grapefruit can do this!

Medications

When you have a transplant, you will need to learn how to plan for your medication needs after transplant. You will be taking medications every day for the rest of your life. You will want to know about them as much as possible — how to take them, how they work, and their side effects.

Your medications are essential to the success of the operation and to your recovery.

Below, you will find a list of the medications you may be taking. There will be about 10-15 medications taken anywhere from once to four times a day. Over time, the number of drugs is tapered off so that usually by one year, you are taking 2-6 medications every day.

• immunosuppressive medications — help prevent rejection of the new liver; first doses are high and then are tapered down; you will take these for life
• antibiotics/antivirals — taken for the first 3-6 months after surgery when the immunosuppression is highest to prevent viral/bacterial infections
• antacids — taken to prevent stomach upset
• antihypertensives — may be prescribed to lower blood pressure
• diuretics (water pills) — may be needed to remove fluid
• multivitamins, calcium, and vitamin D
• insulin — occasionally needed to treat diabetes caused by the prednisone or other immunosuppressive medications
• cholesterol-lowering drugs — may be started later if you develop high cholesterol
• iron — may be prescribed in some cases if you have low blood counts
• aspirin — may be prescribed if you had narrowing or blood clots in any of the blood vessels supplying the liver

Other Considerations

• You will need to plan travel carefully and consider how you will have quick access to medical care if needed. You may want to avoid traveling to places with high risk of diseases that could be spread through water, food, or insect bites.
• You will have many medical appointments.
• You will still have hepatitis C (if you had it before the transplant). This will need to be treated using medications.
• You will have a lowered immune system because of the medications you will take to stop your body from rejecting your liver. This means that your body will be less able to fight off other illnesses.
• You will be discouraged from participating in activities that pose a high risk to your health.
• You will need to take medications for the rest of your life and may experience unpleasant side effects from them.
• If you are considering having a child, definitely discuss this with the transplant team prior to getting pregnant.
• You will feel better
• Food will taste better — watch your weight!
• Do not drink, smoke, use drugs — this is a lifetime commitment
• Always keep the transplant center informed of your address and phone number as they follow you for life

After a liver transplant, you will need to see your doctor often to make sure your new liver is working properly. You will have regular blood tests to check for signs of organ rejection and other problems that may damage your new liver.

What is organ rejection?

Organ rejection occurs when your immune system sees your transplanted liver as “foreign” and tries to destroy it. You have the highest chance of organ rejection in the first 3 to 6 months after your transplant.

What are the signs and symptoms of organ rejection?

Abnormal liver blood test results may be the first sign of organ rejection. Rejection does not always cause symptoms you may notice. When symptoms of rejection are present, they may include

• feeling tired
• pain or tenderness in your abdomen
• fever
• yellowing of the skin and the whites of your eyes
• dark-colored urine
• light-colored stools

You should talk with your doctor right away if you have symptoms of organ rejection. Your doctor will often perform a liver biopsy to see if your body is rejecting the new liver.

How can I prevent organ rejection?

To help keep your body from rejecting the new liver, you will need to take medicines called immunosuppressants. These medicines prevent and treat organ rejection by reducing your immune system’s response to your new liver. You may have to take two or more immunosuppressants. You will need to take these medicines for the rest of your life.

Rejection can occur any time the immunosuppressive medicines fail to control your immune system’s response to your new liver. If your transplanted liver fails as a result of rejection, your transplant team will decide whether another transplant is possible.

What are the side effects of immunosuppressants?

Immunosuppressants can have many serious side effects. You can get infections more easily because these medicines weaken your immune system. Other possible side effects include

• brittle bones
• diabetes
• high blood pressure
• high levels of cholesterol and triglycerides in the blood
• kidney damage
• weight gain

Long-term use of these medicines can increase your chance of developing cancers of the skin and other areas of your body.

Prescription medicines, over-the-counter medicines, vitamins, and dietary supplements can affect how well immunosuppressants work. Tell your doctor if you are prescribed any new medicines. Talk with your doctor before using over-the-counter medicines, vitamins, dietary supplements, or any complementary or alternative medicines or medical practices.

How do I help care for my new liver?

Do the following to help take care of your new liver.

• Take medicines exactly as your doctor tells you to take them.
• Talk with your doctor before taking any other medicines, including prescription and over-the-counter medicines, vitamins, and dietary supplements.
• Keep all medical appointments and scheduled blood draws.
• Stay away from people who are sick.
• Tell your doctor when you are sick.
• Learn to recognize the symptoms of rejection.
• Have cancer screenings as recommended by your doctor.
• Keep up to date with vaccinations; however, “live” vaccines should not be used.
• Talk to your doctor, both before and after your liver transplant, about the use of contraceptives and the risks and outcomes of pregnancy.

Learn how to recognize the symptoms of infection. Symptoms of infection may include:

• fever
• chills
• a stuffy nose
• sore throat
• cough
• diarrhea
• vomiting

Talk with your doctor right away if you have symptoms of infection.

Make healthy choices and protect yourself.

• Eat healthy foods, exercise, and don’t smoke cigarettes
• Don’t drink alcoholic beverages or use alcohol in cooking if you have a history of alcohol use disorder.
• Protect yourself from soil exposure by wearing shoes, socks, long-sleeve shirts, and long pants.
• Avoid pets such as rodents, reptiles, and birds.
• Protect yourself against organisms that can transmit diseases, such as ticks and mosquitoes, by
  • using insect repellent
  • wearing shoes, socks, long-sleeve shirts, and long pants
  • not going outdoors at times when organisms are most likely to be active, such as at dawn and dusk
• If you are planning on traveling, especially to developing countries, talk with your transplant team at least 2 months before leaving to determine the best ways to reduce travel-related risks.

What should I eat after my liver transplant?

You should eat a healthy, well-balanced diet after your liver transplant to help you recover and keep you healthy. A dietitian or nutritionist can help you create a healthy eating plan that meets your nutrition and diet needs.

What should I avoid eating after my liver transplant?

Grapefruit and grapefruit juice can affect how well some immunosuppressants work. To help prevent problems with some of these medicines, avoid eating grapefruit and drinking grapefruit juice.

If you have a history of alcohol use disorder, do not drink alcoholic beverages or use alcohol in cooking.

You should avoid consuming the following:

• water from lakes and rivers
• unpasteurized milk products
• raw or undercooked
  • eggs
  • meats, particularly pork and poultry
  • fish and other seafood

Your dietitian or nutritionist may recommend that you limit your intake of

• salt
• cholesterol
• fat
• sugar

How do I know if I need a liver transplant?

Most people with liver disease will never need a transplant--including patients living with alcoholic liver disease, hepatitis B, hepatitis C, or non-alcoholic fatty liver. Only a very small fraction of patients will eventually need a transplant. Your provider will decide whether you need one. If a transplant is being considered, patients will need to have an extensive evaluation and undergo many tests, and then typically will be placed on a transplant wait list. For more information, go toLiver Transplant Program.

Will hepatitis B or hepatitis C infection go away after a liver transplant?

No. A liver transplant does not cure the hepatitis B virus or the hepatitis C virus infection itself. The virus will still be present in the body after a transplant and will come back in the new liver. Hepatitis B treatment and hepatitis C treatment can be used in patients before a transplant or after a transplant. For hepatitis B patients, the treatment will usually be lifelong. For hepatitis C patients, treatment will be for a fixed amount of time. Prescribing treatment of the hepatitis B virus or the hepatitis C virus either before or after transplant should only be done by an expert.

What is the survival rate after a liver transplant?

According to UNOS (United Network for Organ Sharing), about 90% of people who have liver transplants will be alive one year later. Approximately 73% of people will survive at least five years after a transplant.