Everything to Know About Liver Transplant

A liver transplant removes a diseased or failing liver and replaces it with a healthy one from a donor. It is the only treatment that can fully restore liver function once the organ has stopped working.

The liver performs over 500 functions in your body. It filters toxins from your blood, produces bile to help digest food, makes proteins that help your blood clot and stores energy. When it fails, all of these stop at once. A transplant has to happen at the right time too early and it may not be needed; too late and the patient may not be strong enough to survive the surgery.

When Is a Liver Transplant Needed?

Doctors consider a transplant when the liver can no longer keep the body functioning and no other treatment will help. They use a scoring system called the MELD score (Model for End-Stage Liver Disease) to measure how serious the liver disease is and decide where a patient sits on the transplant waiting list. A higher score means a more urgent need.

The typical candidates are people with cirrhosis that has led to serious complications such as:

• Repeated bleeding from the veins in the oesophagus
• Fluid build-up in the abdomen that medicines cannot control
• Bacterial infections in the abdominal fluid
• Confusion caused by toxins that the liver can no longer filter

People whose liver fails suddenly with no prior liver disease also need an urgent liver transplant procedure.

Why Are Liver Transplants Done?

Once liver damage crosses a certain point, the organ cannot recover on its own. Unlike kidney failure, where dialysis can take over some functions, there is no machine that can do everything the liver does. A transplant is the only way to restore full function.

Outcomes have improved a great deal over the past two decades. More than 90% of patients at experienced centres survive the first year. Around 75-80% are alive at five years. Many live 20 years or more after a successful transplant.

What Conditions Lead to a Liver Transplant?

Liver transplants are done for two main situations: chronic liver disease that has reached end-stage failure, and sudden acute liver failure with no chance of recovery on its own.

Accepted indications include:

• Cirrhosis from any cause like alcohol-related liver disease, fatty liver disease, viral hepatitis B or C, autoimmune hepatitis
• Primary biliary cholangitis and primary sclerosing cholangitis
• Sudden liver failure from paracetamol overdose, viral hepatitis, drug reactions or Wilson's disease
• Liver cancer (hepatocellular carcinoma) within specific size criteria - one tumour under 5 cm or up to three tumours each under 3 cm
• Inherited liver conditions like Wilson's disease, haemochromatosis, and alpha-1 antitrypsin deficiency
• Biliary atresia in children (the most common reason children need a liver transplant).

Common Conditions That Lead to a Transplant

• Cirrhosis: Scarring of the liver from long-term damage. Once advanced, the liver cannot heal. Alcohol, hepatitis B, hepatitis C and fatty liver disease are the most common causes.
• Non-alcoholic fatty liver disease (NAFLD) and NASH: Now the leading cause of cirrhosis and transplant listing in India. Linked to obesity, diabetes and metabolic syndrome.
• Viral hepatitis: Chronic hepatitis B and C damage the liver slowly over many years. New medicines have transformed treatment for hepatitis C, but liver damage already present at diagnosis may be permanent.
• Alcohol-related liver disease: The liver can recover from alcohol damage if drinking stops early enough. At the cirrhotic stage it cannot. Transplant programmes require that patients have stopped drinking and show commitment to staying sober.
• Autoimmune liver disease: Autoimmune hepatitis, primary biliary cholangitis and primary sclerosing cholangitis all cause ongoing liver damage that can reach the point of needing a transplant.
• Liver cancer: When liver cancer develops inside a cirrhotic liver and meets accepted size criteria, a transplant removes both the cancer and the diseased liver it grew in.

Tests Before a Liver Transplant

Before a transplant, the team does a thorough evaluation. This confirms that a transplant is the right option and checks for anything that could make surgery too risky. Tests and assessments include:

• Liver function tests, full blood count, kidney function, and clotting profile
• MELD score to assess how severe the disease is
• Ultrasound, CT scan and MRI of the liver and abdomen
• Heart tests like ECG, echocardiogram, stress test where needed
• Lung function tests
• Screening for hepatitis B, hepatitis C, HIV, CMV and EBV
• Cancer screening including colonoscopy, mammogram, cervical smear
• Bone density scan
• Nutritional and psychological assessment
• Social support review, the team assesses whether the patient has the support needed to follow the post-transplant plan.

How is Liver Transplant Done?

The operation takes six to twelve hours. The diseased liver is removed and the donor liver is placed in the same position in the abdomen. Surgeons connect four structures - the inferior vena cava, the portal vein, the hepatic artery and the bile duct. The bile duct connection is the most technically demanding and the most common site of complications after surgery.

In living donor transplants, surgeons use the right lobe of the donor's liver. The liver then grows back; both the donor's remaining liver and the recipient's new partial liver reach close to normal size within six to eight weeks. This ability to regenerate is what makes living donor transplantation possible.

How Are Candidates Selected?

The team looks at both medical and personal factors. The patient must be sick enough to need a transplant but well enough to get through the surgery and the recovery. The assessment covers:

• MELD score and how quickly the disease is progressing
• No active infection or untreated cancer outside transplant criteria
• Heart and lung function strong enough for major surgery
• No conditions that would prevent long-term use of anti-rejection medicines.

The team also looks at the patient's understanding of what a transplant involves, their history of following medical advice, any substance use and whether they have support at home during recovery. For alcohol-related liver disease, a period of proven sobriety is a standard requirement.

How Do Donated Livers Become Available?

Types of liver transplant are:

• Deceased donor livers come from patients declared brain dead who are kept on life support until organs are retrieved, or less often from donors whose heart has stopped. The liver is matched to the right recipient based on blood type, MELD score and time on the waiting list.
• Living donor transplants use a portion of the liver usually the right lobe from a healthy family member or, in some programmes, an unrelated donor. The donor goes through a full medical and psychological evaluation before being accepted. In India, living donor transplants make up the majority of liver transplants performed because deceased donation rates remain low.

How Long Is the Wait for a Donor Organ?

Waiting time for a deceased donor organ depends on blood type, MELD score and donor availability in the region. Patients with higher MELD scores are prioritised. In India, the wait can stretch to months or years for patients who do not have a living donor available. Many transplant centres evaluate patients for living donor transplant at the same time as deceased donor listing, so that option is ready if a donor comes forward.

What Are the Signs of Rejection?

The body's immune system recognises the new liver as foreign and may try to attack it. Anti-rejection medicines prevent this, but rejection can still happen especially if doses are missed.

• Acute Rejection
  • This usually happens within the first few months. Signs include:
  • Fever and feeling unwell
  • Jaundice - yellowing of the skin and eyes
  • Pain over the liver area
  • Dark urine and pale stools
  • Rising liver enzyme levels on blood tests
• Chronic Rejection
  • This develops slowly and may not cause obvious symptoms early on. Regular blood tests during follow-up are the most reliable way to catch it before it causes serious damage.

Complications After a Liver Transplant

• Primary graft non-function: The transplanted liver fails to work right after surgery. This is rare but life-threatening and requires an urgent re-transplant.
• Vascular complications: Clotting in the hepatic artery (the main blood supply to the liver) is the most serious early complication. It can cause graft failure if not caught and treated quickly.
• Bile duct problems: Bile duct leaks or narrowing occur in 10 to 15% of patients and may need endoscopic or surgical repair. The bile duct relies entirely on the hepatic artery for its blood supply, so any artery problem affects it first.
• Infection: Anti-rejection medicines lower immunity, which raises the risk of bacterial, viral and fungal infections. Preventive medicines and close monitoring are standard in the weeks after surgery.
• Side effects of anti-rejection medicines: Long-term use of anti-rejection medicines can affect kidney function, raise blood pressure, increase the risk of diabetes and make infections harder to clear.
• Recurrence of the original disease: Hepatitis C can return in the transplanted liver without antiviral treatment. Alcohol-related disease comes back if the patient drinks again. NASH can recur if weight and metabolic factors are not managed.

FAQs

1. How long can you live after a liver transplant?

More than 90% of patients survive the first year at experienced centres. Around 75 to 80% are alive at five years. Many people live 20 years or more after a successful transplant. Long-term outcomes depend on the underlying condition, sticking to medicines and regular follow-up.

2. Can a person live with half a liver?

Yes. The liver is the only organ in the body that grows back. A living donor who gives their right lobe (roughly 60% of their liver) sees their remaining liver grow back to near-normal size within six to eight weeks. The recipient's new partial liver does the same. Both can go on to live full, healthy lives.

3. Is a liver transplant major surgery?

Yes it is one of the most complex operations in abdominal surgery. It typically takes six to twelve hours. Hospital recovery takes two to three weeks. Full recovery takes three to six months. Patients need to take anti-rejection medicines and attend regular follow-up appointments for life.

4. Is there an age limit for liver transplant?

There is no fixed upper age limit. Patients in their 60s and 70s are assessed and transplanted successfully when their overall health supports it. Biological age and general fitness matter more than the number on a birth certificate. Each case is reviewed individually.

5. What cannot be eaten after a liver transplant?

Grapefruit and grapefruit juice must be avoided because they interfere with anti-rejection medicines and can cause dangerous changes in drug levels. Raw or undercooked meat, fish, eggs and unpasteurised dairy carry infection risks that are too high for someone on anti-rejection medicines. Alcohol is permanently off limits. A transplant dietitian will give specific guidance based on each patient's medicines and recovery stage.

6. Can liver transplant patients have children?

Yes, in many cases. Women who have had a liver transplant have carried successful pregnancies. It is generally advised to wait at least two years after transplant before becoming pregnant. Some anti-rejection medicines are harmful to a developing baby and need to be adjusted before conception. The transplant team will guide this planning.