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Liver transplant

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What is a liver transplant?

A liver transplant is an operation to remove a diseased or damaged liver from the body and replace it with a healthy one.

It is recommended when the liver has been damaged to the point that it cannot perform its normal functions and is likely to fail.

Read more about why you might need a liver transplant.

Although fairly common, a liver transplant is a major operation. One of the biggest risks is that the body will reject the new organ. To prevent this from happening, you will have to take medication to suppress the immune system for the rest of your life.

Read more about recovering from a liver transplant.

Liver damage

The liver can become damaged as a result of illness, infection or alcohol. This damage causes the liver to become scarred, which is known as cirrhosis.

Some of the most common causes of liver damage and cirrhosis are:

  • hepatitis C – a blood-borne virus that can cause extensive liver damage in a minority of people
  • alcoholic cirrhosis – the liver becomes scarred because of years of persistent alcohol abuse
  • primary biliary cirrhosis (PBC) – a poorly understood condition that causes progressive liver damage

Once cirrhosis reaches a certain level, the liver gradually loses all of its functions. This is known as liver failure, or end-stage liver disease.

The only hope for the long-term survival of a person with liver failure is a liver transplant.

Liver transplant

There are three types of liver transplant:

  • deceased organ donation involves transplanting a liver that has been removed from a person who died recently
  • living donor liver transplant, where a section of liver is removed from a living donor – because the liver can regenerate itself, both the transplanted section and the remaining section of the donor's liver are able to regrow into a normal-sized liver
  • split donation, where a liver is removed from a person who died recently and is split into two pieces, one large and one smaller piece – each piece is transplanted into a different person, where they will grow to a normal size

Read more about how a liver transplant is performed.

Life after liver transplant

Survival rates can be influenced by a number of factors, including:

  • age
  • general state of health
  • the reason behind the liver transplantation
  • whether complications develop after the transplant, such as diabetes or kidney failure

The long-term use of immunosuppressants can also cause a wide range of side effects and make a person more vulnerable to infection.

Read more about the complications of a liver transplant.

How common are liver transplants?

The number of people who need a liver transplant is much higher than the number of livers donated.

For adults, the average waiting time for a liver transplant is around 142 days, and for children it is about 78 days.

It is estimated that in the past 20 years, the number of people who could benefit from a liver transplant has increased by 90%, but the number of available donations has remained the same.

Consequently, deaths from liver disease remain high.

How is a liver transplant performed?

You will be contacted by staff at the liver transplant centre as soon as a suitable liver becomes available. It will need to be the right size and match your blood group.

The call could be at any time during the day or night, so you may be given a bleeper to alert you. If necessary, you may be given transport to the transplant centre.

It is important not to eat or drink anything from the time the transplant centre contacts you.

Once you arrive at the transplant centre, you will be given a chest X-ray and an electrocardiogram (ECG) so that your heart and lung function can be reassessed. You will then be given a general anaesthetic in preparation for the transplant.

Orthotopic transplant

The most common type of liver transplant is an orthotopic transplant, where a whole liver is taken from a recently deceased donor.

The surgeon will make a cut in your abdomen and remove your liver. The donor liver will then be put in position and connected to your blood vessels and bile ducts (small tubes that move bile out of the liver).

After the donor liver is in place, the incision will be sealed using dissolvable stitches. Drainage tubes will be attached to drain away extra fluids, and they will usually remain attached for several days after surgery.

Once the transplant has been completed, you will be moved to an intensive care unit (ICU) to recover.

Living donor transplant

During a living donor transplant, the donor will have an operation to remove either the left or right side (lobe) of their liver.

Right lobe transplants are usually recommended for adults. For children, left lobe transplants are recommended. This is because the right lobe is bigger and better suited for adults, while the left lobe is smaller and better suited for children.

After the donor operation, your liver will be removed and replaced with the donor's liver lobe. Your blood vessels and bile ducts will then be connected to the liver lobe.

Following transplantation, the transplanted lobe will quickly regenerate itself. In most cases of living donor transplants, the new lobe will grow to 85% of the original liver size within a week.

Split donation

A split donation may be carried out if a donor liver becomes available from a recently deceased person, and you and a child are both suitable candidates for a donation.

The donated liver will be split into the left and right lobes. Normally, you will be given the larger right lobe and the child will receive the smaller left lobe.

A number of liver transplant units have performed successful split donation transplants in two adults, although the adult receiving the smaller left lobe usually has to be much smaller than average for the transplant to be successful.

Recovery

Once your liver transplant is complete, you will be moved to an intensive care unit (ICU).

A ventilator will assist you with your breathing. A tube will be inserted through your nose and into your stomach to provide you with nutrients and fluid. These tubes can normally be removed after a few days.

After the transplant, you are likely to be in some pain. You will therefore be given pain relief as required.

Most people are well enough to move out of the intensive care unit (ICU) and into a hospital ward within a few days of having a liver transplant. They can leave hospital within two to three weeks.

Recovering from a liver transplant can be a long, slow process. Aim to gradually build up your health and fitness. It may take three to six months before you are ready to return to work and resume normal activities.

Immunosuppressants

After a liver transplant, one of the biggest risks is that your immune system will not recognise the new liver and begin to attack it. This is known as rejection.

Read more about rejection and liver transplant complications.

To prevent rejection, you will be required to take medicines that suppress your immune system. These medicines are called immunosuppressants.

As the risk of rejection is highest in the first three months after a transplant, it is likely that you will initially be given a relatively high dose of immunosuppressants.

Your dose will then be reduced to a level thought high enough to prevent your immune system rejecting your new liver, but low enough to minimise unpleasant side effects.

To assess how well the immunosuppressants are working, it is likely that you will be given regular blood tests when you first start taking them.

Achieving the balance between preventing rejection and minimising side effects can be challenging. It may take several months before the optimal dose for you is achieved.

Types of immunosuppressants

Two main types of immunosuppressants are used to treat people after a liver transplant:

Each type of medication is discussed in more detail below.

Calcineurin inhibitors

Calcineurin inhibitors work by blocking the effects of a protein called calcineurin, which is responsible for activating a type of white blood cell known as T cells. The immune system uses T cells to fight infection.

Blocking the effects of calcineurin should mean that your immune system will not send T cells to attack the tissue of your new liver.

The two most widely used calcineurin inhibitors are ciclosporin and tacrolimus, which can be given either in tablet or capsule form, or as an injection.

Common side effects of ciclosporin and tacrolimus include:

For a complete list of side effects and interactions with other medicines, see the Medicines information section on [ciclosporin].

Although these side effects may be troublesome, you should never stop or reduce the recommended dose of immunosuppressants because it could lead to your liver being rejected.

Always check with your pharmacist or doctor before you begin taking any other medication.

Corticosteroids

Corticosteroids can penetrate the wall of immune system cells. Once inside the cells, corticosteroids can "switch off" the genes responsible for releasing many of the chemicals that the immune system would otherwise use to attack your new liver.

A widely used corticosteroid in liver transplant patients is prednisolone.

Common side effects of prednisolone include:

  • mood swings
  • muscle weakness
  • weight gain

For a complete list of side effects, see the Medicines information section on [prednisolone].

The long-term use of corticosteroids can also lead to more serious side effects. Read more information about the side effects of corticosteroids.

Around 1 in 20 people have serious mental health symptoms while taking prednisolone, such as:

  • thinking about suicide
  • having hallucinations (seeing or hearing things that are not real)
  • feeling very confused and having problems thinking clearly
  • having strange, unusual and frightening thoughts

If you experience any of these symptoms, contact your doctor or a member of your care team immediately. If this is not possible, telephone your local out-of-hours service.

Waiting for a liver transplant

Because of the lack of available livers, it is rarely possible to have a liver transplant as soon as it is needed, so it is likely that you will be placed on a transplant waiting list.

Depending on the clinical need for a liver transplant, you will be placed either on a high-priority or medium-priority waiting list. Many people are well enough to stay at home until a liver becomes available.

The transplant centre will need to be able to contact you at short notice, so you must inform staff of any changes to your personal contact details. You should also inform staff if there are changes to your health – for example, if you develop an infection.

Waiting for a transplant

While waiting for a donated liver to become available, it is important that you stay as healthy as possible by doing the following:

  • eating a healthy diet
  • taking regular exercise, if possible
  • not drinking alcohol – if you are unable to abstain from alcohol, it is likely you will be removed from the waiting list
  • not smoking – read information about quitting smoking

The average waiting time for a liver transplant is 142 days for adults and 78 days for children.

However, your waiting time may be a lot shorter if you are on a high-priority waiting list. In some circumstances, you may be able to shorten your waiting time if a relative, or possibly a friend, has the same blood type as you and is willing to take part in a living donor liver transplant.

If your child needs a liver transplant, you may also wish to discuss the possibility of taking part in a living donor liver transplant with staff at the transplant centre.

Prepare an overnight bag and make arrangements with your friends, family and your employer so that you can go to the transplant centre as soon as a donor liver becomes available.

It is possible for a planned transplant to be cancelled, for example because your health deteriorates to such as an extent that a transplant would no longer be safe or effective. You should discuss this possibility with the staff at your transplant centre and, if necessary, with friends, family and loved ones.

Coping with being on the waiting list

The stress of living with a serious liver condition can be bad enough, so the added anxiety and pressure while waiting for a liver to become available does not make the situation any easier.

Because of this extra stress, it is common for potential candidates for a liver transplant to have depression.

One study found that around one in four people waiting for a liver transplant had symptoms of moderate to severe depression.

Signs that you may be depressed include:

  • during the past month you have often been bothered by feeling down, depressed or hopeless
  • during the past month you have often had little interest or pleasure in doing things

It is important not to neglect your mental health as this can have an adverse effect on your physical health.

If you think you may be depressed, contact your doctor for advice.

Who can use it

There is a strict assessment process that decides who can have a liver transplant, as donated livers are scarce around the world.

Transplant centres use a scoring system to calculate the risk of a person dying if a transplant is not performed.

Assessing quality of life

Assessing your quality of life can be a subjective process. However, the following signs and symptoms represent a decline in quality of life that many people would find intolerable:

  • swelling of the abdomen caused by a build-up of fluid (ascites) that fails to respond to treatment
  • persistent and debilitating shortness of breath
  • damage to the liver that affects the normal workings of the brain (hepatic encephalopathy), resulting in mental confusion, reduced levels of consciousness and, in the most serious of cases, coma
  • persistent itchiness of the skin that fails to respond to treatment (for reasons that are still unclear, itchy skin is a common symptom of liver disease)
  • persistent liver pain that cannot be controlled by treatment

Estimating survival rates

The assessment of your likely survival rate is based on your individual circumstances and associated factors, such as:

  • your age (although transplants have been successful in people aged over 70)
  • whether you have another serious health condition, such as heart disease
  • how likely a donated liver would remain healthy after the transplant
  • your ability to cope (physically and mentally) with the effects of surgery and the side effects associated with immunosuppressant medication

A number of tests will also be carried out to assess your health and your likelihood of survival.

These tests can include extensive investigations of your heart, lungs, kidneys and liver, as well as checking for any signs of liver cancer.

Ruling out a liver transplant

It is unlikely that you will be offered a liver transplant if you have two or more of the following conditions:

  • kidney failure – where the kidneys have lost most or all of their function
  • extensive weight loss because of poor health and malnutrition
  • an active hepatitis B infection that is not responding to medication
  • a blood clot in one of the main blood vessels near the liver

A liver transplant will not be offered if you have any of the following conditions:

  • AIDS (the final stage of HIV infection)
  • irreversible brain damage
  • an infection – it would be necessary to wait for the infection to pass
  • multiple organ failure that would not be helped by a liver transplant
  • cancer in another part of the body (with the exception of skin cancer)
  • a serious heart and/or lung condition, such as heart failure or chronic obstructive pulmonary disease (COPD)
  • a serious mental health or behavioural condition, such as psychosis or bipolar disorder, which means you would be unlikely to be able to comply with the medical recommendations regarding life after a liver transplant
  • advanced liver cancer – by the time the cancer has spread beyond the liver into surrounding tissue, it is too late to cure the cancer with a transplant

Additionally, a liver transplant will also not be offered if you are:

  • abusing alcohol – most transplant centres only consider a person for transplant if they have not had alcohol for at least three months
  • abusing drugs – most transplant centres would only consider a person for transplant if they attend a drug rehabilitation course and remain free from drugs for at least six months (some transplant centres will accept people who are currently taking the heroin substitute methadone)

Why it is necessary

A liver transplant becomes necessary when the liver has been damaged to such an extent that it cannot perform its normal functions. This is known as liver failure.

Although liver failure can usually be managed by medication for a short while, a liver transplant is currently the only cure.

Unlike the kidney, heart or lungs, there is no mechanical device, such as a dialysis machine, that can replicate the function of the liver.

Why liver failure happens

There are two main ways that a liver can fail:

  • chronic liver failure, where the liver fails because of damage over many months or years
  • acute liver failure, where extensive damage to the liver happens over a short period of time The main causes of chronic liver failure are listed below.

Alcoholic liver disease

Every time you drink alcohol, your liver filters out the poisonous alcohol from your blood. Each time your liver filters alcohol, some of the liver cells will die.

The liver can grow new cells, but if you drink heavily for many years, your liver will lose this ability and the dead cells will build up and scar your liver (cirrhosis).

If too much of your liver becomes scarred, it will lose its ability to function and liver failure will occur.

In most cases of alcoholic liver disease, you will have no symptoms until liver failure occurs.

Hepatitis C

Hepatitis C is a bloodborne virus that you can catch if you come into contact with the blood or, less commonly, body fluids of someone who is infected. Drug users sharing needles are at particular risk.

The virus can cause swelling and scarring of the liver tissue. In some cases it causes significant liver damage.

An estimated one in seven people who contract hepatitis C will have liver failure, often 20 to 30 years after contracting the initial infection.

Primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is a type of long-term liver disease thought to be caused by a build-up of bile inside the liver. Bile is a liquid produced inside the liver that helps the body digest fats.

PBC is a relatively rare condition, but it is one of the most common reasons why a person requires a liver transplant.

Hepatitis B

Hepatitis B is a less common type of viral hepatitis that can be spread during unprotected sex or by sharing needles.

An estimated 2-10% of people will go on to develop a chronic (long-term) infection where the virus stays in their body, although they may not necessarily have any symptoms.

Without treatment, an estimated 15-25% of people with chronic hepatitis B experience liver failure.

Primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a type of liver disease that causes long-lasting inflammation of the liver. It usually leads to liver failure.

PSC is a rare condition that affects about 1 in 16,000 people. It usually occurs in people who are 30-50 years old.

Autoimmune hepatitis

Autoimmune hepatitis is a rare cause of long-term hepatitis. The white blood cells attack the liver, causing inflammation and damage. This can lead to more serious problems, such as liver failure. The reason for this reaction is not known.

Biliary atresia

Biliary atresia is a rare childhood condition where babies are born with blockages in their bile ducts. This leads to a build-up of bile, similar to PBC, which results in scarring and, eventually, liver failure.

Biliary atresia affects only 1 in every 18,000 births, but is the most common reason why a child would need a liver transplant.

Liver cancer

Liver cancer is a rare and aggressive type of cancer.

Complications of a liver transplant

Complications of a liver transplant can include rejection, an increased risk of infection, graft failure, biliary conditions and a higher risk of developing certain conditions, such as diabetes.

Liver rejection

It is common for the immune system to attack the new liver. This occurs in up to 40% of cases, typically in the first 7-14 days after the transplant.

Symptoms of liver rejection include:

  • a high temperature of 38ºC (100.4ºF) or above
  • vomiting
  • diarrhoea
  • yellow skin and yellowing of the whites of the eyes (jaundice)
  • pale stools
  • dark urine
  • itchy skin

Most cases can be successfully managed by altering your dose of immunosuppressants.

Infection

Immunosuppressants make you more vulnerable to infection. You will be particularly vulnerable to:

  • fungal infections
  • cytomegalovirus (CMV) infection – a common virus that is part of the herpes family of viruses

Fungal infections

Aspergillosis and thrush (candidiasis) are fungal infections that commonly affect people after a liver transplant.

As a precaution, you will usually be given a course of antifungal medication, such as fluconazole, to take for several months after your transplant.

Symptoms of these types of fungal infection will depend on what part of your body is affected, but may include:

  • scaling and redness of the skin
  • itchiness
  • in cases of vaginal infection, a discharge of a thick, white fluid from the vagina

More serious fungal infections can also develop inside your body, such as in the lungs (fungal pneumonia) or bloodstream.

Symptoms include:

  • a high temperature of 38ºC (100.4ºF) or above
  • shortness of breath
  • dizziness
  • chest pain
  • a change in mental behaviour, such as confusion or disorientation

The symptoms of even a minor infection can rapidly get worse and can lead to fatal complications if you are taking immunosuppressants. You should see your doctor or transplant team as soon as possible if you notice the symptoms of a fungal infection.

Cytomegalovirus (CMV) infection

As a precaution against cytomegalovirus (CMV), you may be given a course of antiviral medication to take for several months after your transplant.

Symptoms of a CMV infection include:

  • a high temperature
  • shortness of breath
  • loss of appetite
  • the appearance of large, painful ulcers in your mouth
  • joint pain
  • visual problems, such as blind spots, blurring and floaters (dark shapes that appear to be floating in your field of vision)

Contact your doctor or transplant centre as soon as possible if you think you have a CMV infection.

Biliary conditions

After a liver transplant, there is a risk of conditions that affect the biliary tract, including:

  • a bile leak
  • scar tissue causing an obstruction

These can usually be treated with an endoscopy. A short, wire-mesh tube called a stent can be inserted to allow bile to flow more freely. In some cases, further surgery is needed.

Diabetes

Type 2 diabetes is a common and potentially serious complication of a liver transplant. It affects an estimated one in five people.

Symptoms of diabetes include:

  • feeling very thirsty
  • going to the toilet a lot, especially at night
  • extreme tiredness
  • weight loss and loss of muscle bulk

Exactly why liver transplant patients have an increased risk of developing diabetes is unclear. But more than half of all cases of diabetes that develop after a liver transplant are in people with a history of hepatitis C.

Kidney failure

Kidney failure is another common and serious complication that affects one in five people with a liver transplant, usually within five years.

Kidney failure happens when the kidneys lose their function and are no longer able to filter out waste products from the blood.

It is thought the main cause of kidney failure is a side effect of the calcineurin inhibitor type of immunosuppressant. These medicines are known to damage the kidneys in certain people.

Symptoms of kidney failure include:

  • tiredness
  • swollen ankles, feet or hands (due to water retention)
  • shortness of breath
  • nausea
  • blood in the urine

Kidney failure can be treated with dialysis (artificially replacing some functions of the kidney) or a kidney transplant.

Graft failure

Graft failure is a medical term meaning that the transplanted organ is not working properly. It is one of the most serious complications of a liver transplant and occurs in 1 in 14 cases.

The most common cause of graft failure is a disruption to the blood supply to the transplanted liver caused by blood clots (thrombosis). This includes:

  • hepatic artery thrombosis, which affects the blood vessel between the heart and liver (hepatic artery)
  • portal vein thrombosis, which affects the vein between organs in the abdomen and the liver

Other causes of graft failure include:

  • primary non-function, where the new liver does not work within the first few hours and a new transplant is required

In many cases, however, no obvious cause can be found.

A person with graft failure will deteriorate rapidly and can have a range of symptoms, ranging from muscle spasms to double vision, eventually leading to a coma.

While medication can stabilise the body in the short term, the only cure is to transplant a new liver into the body.

Post-transplant lymphoproliferative disorder (PTLD)

Post-transplant lymphoproliferative disorder (PTLD) is an uncommon and serious complication occuring in around 1 in 50 people who have had a liver transplant.

PTLD is a general term used to describe a range of symptoms caused by the Epstein-Barr virus infecting white blood cells, which in turn can lead to abnormal growths spreading throughout the body.

PTLD typically occurs in the first year after a transplant, although it can develop at any time.

Symptoms of PTLD include:

  • high temperature
  • swollen lymph nodes
  • abdominal pain
  • swollen tonsils, which can cause breathing difficulties
  • weight loss
  • abdominal pain

PTLD is a serious complication as it can cause multiple organ failure and death. An estimated 40% of people who develop PTLD after an organ transplant will die from the condition.

PTLD is treated by temporarily withdrawing the immunosuppressants and using antiviral medication to fight off the underlying viral infection.

Cancer

People with a transplanted liver have an increased risk of developing some types of cancers, such as:

  • non-melanoma skin cancer
  • melanoma skin cancer
  • Kaposi's sarcoma (cancer that usually develops beneath the skin)
  • lymphoma (a cancer that develops inside white blood cells)
  • cervical cancer

It is thought this increased risk is a side effect of taking immunosuppressants.

The risk of skin cancer is particularly high – a person with a transplanted liver is thought to be 20 times more likely to develop skin cancer than the population at large.

Because of this increased risk, if you have had a liver transplant you should avoid prolonged exposure to sunlight or artificial forms of ultraviolet light, such as sunbeds or sun lamps. Regular check-ups with a dermatologist (skin specialist) will probably be recommended.

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