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Liver Transplantation
Overview
- What is liver transplantation?
A liver transplant is a surgery where doctors remove a patient's sick liver and replace it with a healthy new liver from an organ donor. For the past 30 years, these transplants have been very successful, helping many people with serious liver problems get well again and go back to their normal lives. Most adults who get a new liver have a condition called cirrhosis, which means their liver is badly scarred, or they have liver cancer. Children usually need a new liver because of a liver problem they were born. Getting a liver transplant is a big operation, and people often have to wait a long time for a new liver. After the surgery, most people get better, but they need to take medications every day to make sure their body does not reject the new liver.
The biggest challenge is that there aren't enough healthy livers for everyone who needs one. A new liver can come from someone who has passed away, or it can come from a living person. When a living person donates a part of their liver, it's called a living donor liver transplant. This can be very helpful for people who might otherwise have to wait a long time for a new liver because they have a low MELD score (see below). For grown-ups, a larger part of the donor's liver is usually needed, while for kids, a smaller part is often enough.
Symptoms
- What symptoms indicate a need for a liver transplant?
People who need a liver transplant can have different signs that they are sick. Their eyes might turn yellow, which is called jaundice. They might also have fluid build-up in their belly, called ascites. Sometimes, they can get confused or even go into a coma because of a problem called hepatic encephalopathy. They might also have gastrointestinal bleeding from large veins that form in their esophagus, stomach or intestines. Some people with cirrhosis might feel sick for many years, while some other patients with healthy livers can develop acute liver failure which is very serious and can lead to death quickly without a transplant. Other signs that someone has advanced liver disease include bruising easily, generalized intense itching or losing a lot of muscle and loss of sex drive. Patients with cirrhosis also have a high risk for liver cancer. Your doctor will recommend doing a scan such as an ultrasound, CT or MRI every 6 months in order to detect these cancers early. This type of cancer can be cured using a transplant if it is found early. A person needing a transplant for cancer might not feel very sick because the part of their liver that isn't cancerous might still be working fine. For children, a common reason for a liver transplant is something called biliary atresia. This means the small tubes in their liver that carry bile (like plumbing) didn't form correctly before they were born. Babies with this problem often have jaundice soon after birth. Even if doctors try to fix it with surgery, many of these children will eventually develop cirrhosis and need a transplant by the time they get to adulthood.
Causes
- What causes liver disease requiring a liver transplant?
Most patients who need a liver transplant have cirrhosis. The most common causes of cirrhosis are heavy alcohol use, or a condition called nonalcoholic fatty liver disease. Nonalcoholic fatty liver disease happens when too much fat builds up in the liver. It is often seen in people who have overweight, diabetes, high blood pressure, or high cholesterol.
Other, less common ways to get cirrhosis, include infection with certain viruses such as hepatitis B or hepatitis C, autoimmune conditions like Primary Biliary Cirrhosis and Autoimmune Hepatitis and genetic conditions such as Hemochromatosis or Alpha-1-Antitrypsin deficiency.
Patients with liver cancer can sometimes benefit from a liver transplant. The main liver cancers are hepatocellular carcinoma (HCC) which is a primary cancer of the liver that can develop in patients which have a lot of scarring in their liver. Patients with hepatitis B have the highest risk of HCC. Another important type of liver cancer is called cholangiocarcinoma. This cancer grows in the bile ducts, which drain bile from the liver to the intestines. Patients with a condition called Primary Sclerosing Cholangitis, are particularly susceptible to this kind of cancer. While liver transplants for cholangiocarcinoma have not been as successful as for HCC, some patients with cholangiocarcinoma can still do well with a transplant if they also get other treatments like radiation and chemotherapy.
Besides cirrhosis and liver cancer, a sudden and very serious liver problem called acute liver failure is another important, though rare, reason for a liver transplant. This happens when a person who was healthy before suddenly gets severe damage to their liver. Things that can cause this include taking too much acetaminophen, getting a sudden infection from hepatitis A or B viruses, or damage from other medications or viruses. Sometimes the cause for acute liver failure cannot be determined.
Screening/Diagnosis
- How is liver disease diagnosed?
When doctors think someone might have cirrhosis, they will often order some tests to find out what caused it. Sometimes, the reason is clear from talking to the person, for example patients with a long history of heavy alcohol use but for most people, figuring out the exact cause of liver disease means doing more tests such as:
Blood Tests to check for:
- Chronic viral infections such as Hepatitis B or C.
- Special antibodies that show if someone has autoimmune hepatitis or Primary Biliary Cirrhosis.
- Excessive iron or copper levels
- Alpha 1 antitrypsin deficiency
Other blood tests, like bilirubin, albumin, sodium, creatinine and INR, help doctors calculate the MELD score which helps determine the severity of the liver disease and whether or not a patient needs a liver transplant. Patients with MELD scores of 15 or more are often referred for liver transplant because they have a higher risk of dying without a transplant. Imaging studies such as:
- Ultrasound
- CT Scan
- MRI
While these tests usually don't tell doctors the exact cause of the liver disease, they can still provide helpful information. For example these tests can show whether or not a patient has a fatty liver. These tests can also help diagnose certain complications of cirrhosis such as liver cancer or blood clots in the portal vein (the main vein supplying blood to the liver).
Liver Biopsy: A liver biopsy (taking a small piece of the liver to look at under the microscope) isn't always needed to diagnose cirrhosis. Usually, blood tests and imaging studies are enough. But sometimes, a biopsy might be needed to confirm cirrhosis or to help find out what caused the liver disease.
Other Special Tests: Besides imaging studies and blood tests, other special tests might be done. One of these is an endoscopy, where a doctor uses a thin tube with a camera to look inside the esophagus (the swallowing tube) and stomach. They are looking for varices, which are large veins that can form in people with cirrhosis and cause serious bleeding. Luckily, doctors can often prevent this bleeding by prescribing medications called beta blockers or by placing tiny rubber bands on the veins during the endoscopy.
Treatment
- How is liver disease diagnosed?
When a doctor determines that a patient needs a liver transplant, he or she will refer them to a transplant center. There, the patient will have visits with transplant surgeons, liver specialists and other members of the transplant team including psychologists, nutritionists and social workers. Sometimes they might need to meet with other specialists such as a cardiologist. The patient will also have tests to make sure they are physically fit for surgery, for example, a stress test to make sure their heart is in good health. A special nurse, called a coordinator, will help the patient through all the steps.
After all the tests and visits are done, the transplant team will review the patient's case. If everyone agrees, the patient's name goes on a transplant wait list to wait for a new liver. Patients are usually put on this list based on a score called "MELD." This score is a number that shows how sick their liver is. MELD scores go from 6 to 40. A higher score means the liver is sicker, so that patient gets a higher spot on the waiting list for a new liver. New livers are usually given out based on how high the MELD score is and what blood type the person has. How long someone has been waiting usually doesn't change their spot on the list much. Doctors usually think about putting someone on the list if their MELD score is higher than 15. There are some special cases, like patients with liver cancer. They might get a new liver sooner, even if their MELD score isn't very high, so the cancer doesn't get worse. This is because liver cancer might not make their liver sick enough to get a high MELD score. If someone's kidneys are also failing because of their liver disease, doctors might think about giving them both a new liver and a new kidney at the same time. While waiting, the patient will have regular checkups, blood tests, and imaging at the transplant center. It's important for the person to stay in touch with their transplant nurse coordinator while they wait.
When a possible new liver is found, the patient is told there's an "offer." If the new liver seems like a good match, the patient is told to come to the hospital to get ready for surgery. The surgery usually takes many hours and is done by a team of doctors. After the surgery, the patient goes to the Intensive Care Unit (ICU) for a few days. If they are getting better as planned, they will move to a regular hospital room for a few more days before going home. The patient will get medicines to stop their body from rejecting the new liver. These medicines can also make it easier to get an infection, so doctors give them antibiotics to help prevent this. After the transplant, the patient will have regular checkups to see how the new liver is working and to adjust their medications. Over time, the amount of anti-rejection medicine can be lowered if the new liver is working well.
The anti-rejection medicines can cause side effects, like high blood pressure and diabetes. Also, people with a new liver have a higher chance of getting certain kinds of cancer, especially on their skin. So, it's very important to see a skin doctor regularly. Even with these worries, a successful new liver surgery helps people go back to normal lives. They feel much better and have a much brighter future.
Author(s) and Publication Date(s)
Paul Martin, MD, FACG, University of Miami, Miami, FL – Published May 2008. Updated July 2013.
Nader A. Dbouk, MD, Emory Transplant Center, Atlanta, GA - Updated July 2026.