A liver transplant replaces a diseased or failing liver with a healthy one from either a deceased or living donor. The surgery itself takes between 6 and 12 hours, but the full process spans months of evaluation before the operation and months of recovery afterward. Here’s how each stage works.
Who Qualifies for a Transplant
Transplant teams evaluate candidates based on how urgently they need a new liver, measured primarily through a scoring system called MELD-Na (Model for End-Stage Liver Disease). This score uses five blood markers that reflect how well your liver and kidneys are functioning: bilirubin (a waste product your liver clears), blood sodium, a clotting factor called INR, albumin (a protein your liver makes), and creatinine (a kidney function marker). The higher your score, the sicker you are, and the higher your priority on the waiting list. The formula estimates your probability of death within three months without a transplant.
Certain conditions disqualify someone from transplant entirely. These include active untreated infections, cancer that has spread beyond the liver, severe heart or lung disease that can’t be corrected, and active alcohol or substance abuse (though exceptions are sometimes made case by case). Conditions like chronic kidney failure or significant muscle wasting don’t automatically rule someone out but raise concerns that the transplant team weighs carefully, especially when multiple risk factors overlap.
How Donor Matching Works
When a deceased donor liver becomes available, a computerized system run by the Organ Procurement and Transplantation Network screens out any candidates who aren’t compatible based on blood type, body size, and other medical factors. The system then ranks remaining candidates using several criteria: medical urgency (MELD score), distance between the donor hospital and the candidate’s transplant center, blood type compatibility, whether the donor and candidate are both adults or both pediatric, and how long the candidate has waited.
Geography plays a significant role. The sickest patients (Status 1A and 1B, meaning acute liver failure) get priority within 500 nautical miles of the donor hospital, then nationally. For candidates with MELD scores of 37 or higher, organs are offered in expanding rings: first within 150 nautical miles, then 250, then 500, and finally nationwide. Lower MELD scores get narrower geographic reach. Blood type identical matches are offered first, followed by compatible but non-identical types.
Deceased Donor vs. Living Donor
Most liver transplants use organs from deceased donors, but living donation is a growing option. In a living donor transplant, a healthy person donates a portion of their liver, typically the right lobe, which makes up roughly 55% to 80% of the total liver volume. Both the donor’s remaining liver and the transplanted portion regenerate, eventually growing back to near-normal size. This option significantly shortens wait times and allows the surgery to be scheduled in advance rather than performed as an emergency.
Outcomes are slightly better with living donors. According to the Scientific Registry of Transplant Recipients, five-year survival rates for living donor recipients exceed those of deceased donor recipients. For deceased donor transplants, about 93% of adult recipients survive the first year, roughly 80% reach five years, and about 64% are alive at ten years.
What Happens During Surgery
The recipient operation follows a sequence of removing the diseased liver and connecting the new one to the body’s blood supply and bile drainage system. Surgeons first carefully separate the existing liver from surrounding blood vessels. The large vein running behind the liver (the inferior vena cava) is clamped above and below the organ, and the portal vein and hepatic veins are divided. The diseased liver is then removed.
Connecting the new liver requires precision. The donor’s hepatic vein is joined to an opening on the recipient’s vena cava. The portal vein, which carries nutrient-rich blood from the intestines, is reconstructed with careful attention to alignment, since even slight kinking can block blood flow. Once these connections are made, blood is allowed to flow into the new liver in a controlled way. Surgeons regulate portal blood flow by hand to prevent a sudden drop in the recipient’s core body temperature from the cold preservation fluid in the donor organ.
The hepatic artery is reconnected next, using a technique that stitches the back walls of the vessels together first, with steady tension to keep the connection smooth. Finally, the bile duct is restored. In living donor transplants, the donor’s bile duct is typically connected to a loop of the recipient’s small intestine. In deceased donor transplants, the bile ducts are often joined directly.
Risks and Complications
Bile duct problems are the most common surgical complication, affecting roughly 15 to 20 out of every 100 transplant recipients. These can include leaks at the connection site or narrowing of the ducts over time. Bile duct complications are more likely when the liver comes from a donor who died after circulatory death or when blood supply to the ducts is compromised by a clot, a condition called ischemic cholangiopathy.
Blood vessel complications, particularly clotting in the hepatic artery, are less common but serious. If the artery supplying the new liver becomes blocked, the bile ducts lose their blood supply, which can damage the graft and sometimes require a second transplant. Infection is another major concern, both from the surgery itself and from the immune-suppressing medications that follow.
Recovery After Transplant
Most recipients spend a few days in intensive care after surgery, then move to a regular hospital room. The total hospital stay typically runs 5 to 10 days. For the first several weeks at home, you’ll have frequent blood draws and clinic visits so the transplant team can monitor liver function and adjust medications. Returning to normal daily activities or work generally takes a few months.
Life on Immunosuppression
Your immune system will recognize the new liver as foreign tissue and try to attack it. Preventing this rejection requires medications you’ll take for the rest of your life, though doses typically decrease over time. The regimen usually starts with high-dose steroids given around the time of surgery, which are then tapered off over three to six months.
The backbone of long-term immune suppression is a class of drugs that block a key enzyme your immune cells need to activate. These are effective at preventing rejection but carry a real cost: they can damage the kidneys over time, raise blood pressure, increase blood sugar, and cause neurological side effects like tremors. Most recipients also take a second medication that works differently, slowing the reproduction of immune cells, to allow lower doses of the primary drug. Side effects of this second class include digestive problems and reduced blood cell counts.
A third option, sometimes used to spare the kidneys, works by blocking immune cell growth through a different pathway. These drugs come with their own trade-offs: elevated cholesterol, slow wound healing, mouth sores, and fluid retention. Your transplant team adjusts the combination and dosing over months and years, balancing the risk of rejection against the cumulative side effects of suppressing your immune system. Infections become a lifelong concern because your body’s defenses are intentionally weakened, and regular screening for skin cancers and other malignancies becomes part of routine care.
Long-Term Survival
Liver transplant is one of the most successful solid organ transplants. For deceased donor recipients, one-year mortality sits at about 6.8%, meaning more than 93 out of 100 people are alive a year later. At five years, roughly 80% are still alive, and at ten years, about 64%. Living donor recipients do even better across all time points. The gap is partly because living donor organs spend less time without blood flow and partly because the surgery can be timed to the recipient’s optimal condition rather than performed urgently when a deceased donor organ happens to become available.