What is a liver transplant?

A liver transplant is surgery to replace a diseased liver with a healthy liver from another person. A whole liver may be transplanted, or just part of one.

In most cases the healthy liver will come from an organ donor who has just died.

Sometimes a healthy living person will donate part of their liver. A living donor may be a family member. Or it may be someone who is not related to you but whose blood type is a good match.

People who donate part of their liver can have healthy lives with the liver that is left.

The liver is the only organ in the body that can replace lost or injured tissue (regenerate). The donor’s liver will soon grow back to normal size after surgery. The part that you receive as a new liver will also grow to normal size in a few weeks.

Why might I need a liver transplant?

You can’t live without a working liver. If your liver stops working properly, you may need a transplant.

A liver transplant may be recommended if you have end-stage liver disease (chronic liver failure). This is a serious, life-threatening liver disease. It can be caused by several liver conditions.

Cirrhosis is a common cause of end-stage liver disease. It is a chronic liver disease. It happens when healthy liver tissue is replaced with scar tissue. This stops the liver from working properly.

Other diseases that may lead to end-stage liver disease include:

• Acute hepatic necrosis. This is when tissue in the liver dies. Possible reasons include acute infections and reactions to medicine, drugs, or toxins.

• Biliary atresia . A rare disease of the liver and bile ducts that occurs in newborns.

• Viral hepatitis . Hepatitis B or C are common causes.

• Metabolic diseases. Disorders that change the chemical activity in cells affected by the liver.

• Primary liver cancers. These are cancerous tumors that start in the liver.

• Autoimmune hepatitis . A redness or swelling (inflammation) of the liver. It happens when your body’s disease-fighting system (immune system) attacks your liver.

The transplant evaluation process

If your provider thinks you may be a good candidate for a liver transplant, he or she will refer you to a transplant center for evaluation. Transplant centers are located in certain hospitals throughout the U.S.

You will have a variety of tests done by the transplant center team. They will decide whether to place your name on a national transplant waiting list. The transplant center team will include:

• A transplant surgeon

• A transplant provider specializing in treating the liver (a hepatologist)

• Transplant nurses

• A social worker

• A psychiatrist or psychologist

• Other team members such as a dietitian, a chaplain, or an anesthesiologist

The transplant evaluation process includes:

• Psychological and social evaluation . Many different issues are assessed. They include stress, financial concerns, and whether you will have support from family or friends after your surgery.

• Blood tests . These tests are done to help find a good donor match and assess your priority on the waiting list. They can also help improve the chances that your body won’t reject the donor liver.

• Diagnostic tests . Tests may be done to check your liver and your general health. These tests may include X-rays, ultrasounds, a liver biopsy, heart and lung tests, colonoscopy, and dental exams. Women may also have a Pap test, gynecology exam, and a mammogram.

The transplant center team will review all of your information. Each transplant center has rules about who can have a liver transplant.

You may not be able to have a transplant if you:

• Have a current or chronic infection that can’t be treated

• Have metastatic cancer. This is cancer that has spread from its main location to 1 or more other parts of the body.

• Have severe heart problems or other health problems

• Have a serious condition besides liver disease that would not get better after a transplant

• Are not able to follow a treatment plan

• Drink too much alcohol

Getting on the waiting list

If you are accepted as a transplant candidate, your name will be placed on a national transplant waiting list. People who most urgently need a new liver are put at the top of the list. Many people have to wait a long time for a new liver.

You will be notified when an organ is available because a donor has died. You will have to go to the hospital right away to get ready for surgery.

If a living person is donating a part of their liver to you, the surgery will be planned in advance. You and your donor will have surgery at the same time. The donor must be in good health and have a blood type that is a good match with yours. The donor will also take a psychological test. This is to be sure he or she is comfortable with this decision.

What are the risks of a liver transplant?

Some complications from liver surgery may include:

• Bleeding

• Infection

• Blocked blood vessels to the new liver

• Leakage of bile or blocked bile ducts

• The new liver not working for a short time right after surgery

Your new liver may also be rejected by your body’s disease-fighting system (immune system). Rejection is the body’s normal reaction to a foreign object or tissue. When a new liver is transplanted into your body, your immune system thinks it is a threat and attacks it.

To help the new liver survive in your body, you must take anti-rejection medicines (immunosuppressive medicines). These medicines weaken your immune system’s response. You must take these medicines for the rest of your life.

Some liver diseases can come back after transplant.

To help the transplant be more successful, you may be started on hepatitis B or C medicines ahead of time, if you have these diseases.

How do I get ready for a liver transplant?

• Your healthcare provider will explain the procedure to you. Ask him or her any questions you have about the surgery.

• You may be asked to sign a consent form that gives permission to do the surgery. Read the form carefully and ask questions if anything is not clear.

• For a planned living transplant, you should not eat for 8 hours before the surgery. This often means not having any food or drink after midnight. If your liver is from a donor who has just died, you should not eat or drink once you are told a liver is available.

• You may be given medicine to help you relax (a sedative) before the surgery.

Your healthcare provider may have other instructions for you based on your medical condition.

What happens during a liver transplant?

Liver transplant surgery requires a hospital stay. Procedures may vary depending on your condition and your provider’s practices.

Generally, a liver transplant follows this process:

1. You will be asked to remove your clothing and given a gown to wear.

2. An IV (intravenous) line will be started in your arm or hand. Other tubes (catheters) will be put in your neck and wrist. Or they may be put under your collarbone or in the area between your belly and your thigh (the groin).These are used to check your heart and blood pressure, and to get blood samples.

3. You will be placed on your back on the operating table.

4. If there is too much hair at the surgical site, it may be clipped off.

5. A catheter will be put into your bladder to drain urine.

6. After you are sedated, the anesthesiologist will insert a tube into your lungs. This is so that your breathing can be helped with a machine (a ventilator). The anesthesiologist will keep checking your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.

7. The skin over the surgical site will be cleaned with a sterile (antiseptic) solution.

8. The doctor will make a cut (incision) just under the ribs on both sides of your belly. The incision will extend straight up for a short distance over the breast bone.

9. The doctor will carefully separate the diseased liver from the nearby organs and structures.

10. The attached arteries and veins will be clamped to stop blood flow into the diseased liver.

11. Different surgery methods may be used to remove the diseased liver and implant the donor liver. The method used will depend on your specific case.

12. The diseased liver will be removed after it has been cut off from the blood vessels.

13. Your surgeon will check the donor liver before implanting it in your body.

14. The donor liver will be attached to your blood vessels. Blood flow to your new liver will be started. The surgeon will check for any bleeding where you have stitches.

15. The new liver will be attached to your bile ducts.

16. The incision will be closed with stitches or surgical staples.

17. A drain may be placed in the incision site to reduce swelling.

18. A sterile bandage or dressing will be applied.

What happens after a liver transplant?

In the hospital

After the surgery you may be taken to the recovery room for a few hours before being taken to the intensive care unit (ICU). You will be closely watched in the ICU for several days.

You will be hooked up to monitors. They will show your heartbeat, blood pressure, other pressure readings, breathing rate, and your oxygen level. You will need to stay in the hospital for 1 to 2 weeks or longer.

You will most likely have a tube in your throat. This is so you can breathe with the help of a machine (a ventilator) until you can breathe on your own. You may need the breathing tube for a few hours or a few days, depending on your situation.

You may have a thin plastic tube inserted through your nose into your stomach to remove air that you swallow. The tube will be taken out when your bowels start working normally again. You won’t be able to eat or drink until the tube is removed.

Blood samples will be taken often to check your new liver. They will also check that your kidneys, lungs, and circulatory system are all working.

You may have IV drips to help your blood pressure and your heart, and to control any problems with bleeding. As your condition gets better, these drips will be slowly decreased and turned off.

You may receive antibiotics.

Once the breathing and stomach tubes have been removed and you are stable, you may start to drink liquids. You may slowly begin to eat solid foods as directed.

Your anti-rejection medicines will be closely watched to be sure you are getting the right dose and the right mix of medicines.

When your provider feels you are ready, you will be moved from the ICU to a private room. You will slowly be able to move about more as you get out of bed and walk around for longer periods of time. You will slowly be able to eat more solid foods.

Your transplant team will teach you how to take care of yourself when you go home.

At home

Once you are home, you must keep the surgical area clean and dry. Your provider will give you specific bathing instructions. Any stitches or surgical staples will be removed at a follow-up office visit, if they were not removed before leaving the hospital.

You should not drive until your provider tells you to. You may have other limits on your activity.

Call your healthcare provider if you have any of the following:

• Fever. This may be a sign of rejection or infection.

• Redness, swelling, or bleeding or other drainage from the incision site

• More pain around the incision site. This may be a sign of infection or rejection.

• Vomiting or diarrhea

• Bleeding

• Jaundice (yellowing of the skin and eyes)

Your healthcare provider may give you other instructions, depending on your situation.

What is done to prevent rejection?

You must take medicines for the rest of your life to help the transplanted liver survive in your body. These medicines are called anti-rejection medicines (immunosuppressive medicines). They weaken your immune system’s response.

Each person may react differently to medicines, and each transplant team has preferences for different medicines.

New anti-rejection medicines are always being made and approved. Your provider will create a medicine treatment plan that is right for you. In most cases you will take a few anti-rejection medicines at first. The doses may change often, depending on how you respond to them.

Because anti-rejection medicines affect the immune system, people who have a transplant are at a higher risk for infections. Some of the infections you will be at greater risk for include:

• Oral yeast infection (thrush)

• Herpes

• Respiratory viruses

For the first few months after your surgery, you should avoid contact with crowds or anyone who has an infection.

Each person may have different symptoms of rejection. Some common symptoms of rejection include:

• Fever

• A yellowing of the skin and eyes (jaundice)

• Dark-colored urine

• Itching

• Swollen or sore belly

• Feeling very tired (fatigue)

• Being easily annoyed

• Headache

• Upset stomach

The symptoms of rejection may look like other health problems. Talk with your transplant team about any concerns you have. It is important to see them and speak with them often.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure

• The reason you are having the test or procedure

• The risks and benefits of the test or procedure

• When and where you are to have the test or procedure and who will do it

• When and how will you get the results

• How much will you have to pay for the test or procedure