Liver Transplant

Key points

• A liver transplant is a life saving operation
• It replaces a diseased liver with a healthy donated liver
• A child or adult can receive either an entire liver or a portion of a healthy liver
• People who get a liver transplant can go on to live a normal life
• You will be on medicine your whole life after a liver transplant to keep you well

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What is a liver transplant?

A liver transplant is surgery to remove your diseased liver and replace it with a healthy liver from a donor. It is a very successful treatment for advanced liver disease and early liver cancer.

In Australia, most liver transplants used livers from deceased donors (someone who has died). Adults will usually receive a whole liver transplant. But sometimes one donated liver can go to 2 patients – an adult will receive part of a liver, so that a sick child can receive the smaller left lobe of the liver from the same donor. This is called split-liver transplantation. A split liver will grow to the size of a whole liver within months.

To be considered for a liver transplant, you need to be referred by your doctor to a liver transplant specialist. You will then have a series of tests and consultations with different doctors to see if you need a transplant, and if there are any reasons why a liver transplant may not be the right thing for you. If liver transplant is thought to be the right treatment for you, you will then go on a waiting list.

The waiting time for a transplant varies for many reasons. People with the most urgent need for transplant will be given highest priority. Your transplant team can tell you how long you might wait for transplant.

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Who can get a liver transplant?

Liver transplantation is considered for people who have liver disease that is likely to shorten their life span or is causing a very poor quality of life. They are usually for people with:

• Severe chronic liver failure that is due to long-term liver disease
• Early stages of liver cancer (called hepatocellular carcinoma)
• Severe polycystic liver disease with massive enlargement of the liver
• Acute liver failure
• Some inherited diseases that affect the liver

There are usually not enough donor organs for everyone who might need a liver transplant. People are only assessed for transplant when they really need it.

Doctors consider you might benefit from a liver transplant if:

• your liver disease is so severe that you are at more than 50% risk of dying in the next 2 years without one
• there is more than 50% likelihood of surviving at least 5 years after liver transplantation

For people with chronic liver failure, this is worked out using the Model for End-Stage Liver Disease (MELD) score. This uses a mathematical formula based on blood tests to work out how long someone is likely to survive without a new liver. In children, a similar score is used called the Paediatric End-Stage Liver Disease (PELD) score.

Some reasons people will be considered for liver transplant include:

• A MELD score greater than 15 in adults or a PELD score of greater than 17 in a child
• Early stage hepatocellular carcinoma (HCC) that has not spread to other parts of the body and can’t be treated effectively in other ways
• Fluid build-up (ascites) that is not responding to other treatments
• Hepatic encephalopathy (altered brain function caused by liver disease) that keeps coming back despite medical treatments
• Belly infections (peritonitis) that keep coming back
• Severe itching
• Other complications of liver disease that can be treated with a liver transplant
• Massive liver enlargement

To be considered for a liver transplant, you should not smoke or take illegal drugs, and should have stopped drinking alcohol for at least 6 months. Talk to your doctor for help with stopping drinking and smoking or taking drugs.

Sometimes people need an urgent liver transplant, for example, if they develop acute liver failure from medicines or a virus. These patients are normally placed at high priority on the waiting list.

Some people may not be suitable for a liver transplant. Some reasons a person may not qualify include:

• They have other untreatable conditions affecting other organs, such as cancer or severe coronary artery disease
• They have severe poorly-controlled metabolic syndrome (high blood pressure, obesity, high blood fats, diabetes and/or obstructive sleep apnoea)
• They have an active infection like tuberculosis
• They are very old or frail
• They don’t have good social supports
• They are unlikely to stick to medical advice and rehabilitation (for example, if they continue to drink alcohol or are considered at high risk of returning to heavy drinking after a transplant)
• They have serious mental health problems

If you are told you don’t qualify for a liver transplant, you have a right to get a second opinion.

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Where are liver transplants done?

Liver transplants are only done in certain hospitals in Australia:

State	Hospitals
NSW	Royal Prince Alfred Hospital (adult) and The Children’s Hospital Westmead (paediatric)
Victoria	Austin Hospital (adult) and Royal Children’s Hospital (paediatric)
Queensland	Princess Alexandra Hospital (adult) and Lady Cilento Hospital (paediatric)
South Australia	Flinders Medical Centre (adult)
Western Australia	Sir Charles Gardiner Hospital (adult)

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Where do donated livers come from?

In Australia, almost all liver transplants are performed from deceased donors.  Deceased donors are under care in an intensive care unit and in most cases have suffered permanent loss of brain function and blood flow. In some cases, a donor who has suffered severe, irreversible brain injury is removed from life support and declared dead after the heart stops beating.

Some deceased donor livers will be split to provide a transplant for 2 people – an adult and a child.

A living liver donation is quite rarely used in Australia. It is usually when a parent donates part of their liver to their child who cannot wait for a deceased donor.

People can indicate their wish to be a donor by putting their name on the Australian Organ Donor Register. This tells loved ones they would like to donate their organs if they die in the right circumstances.

By law, someone having a transplant does not find out details of the donor or their family.

The donated liver is generally matched by blood group and the size of the liver. The medical team select the most appropriate person on the waiting list to have the liver transplant based on urgency, blood type and their size.

Some people need to be transplanted with multiple organs from the same donor, such as simultaneous liver-kidney transplant, liver-lung transplant or liver-heart transplant.

Find out more about liver donation

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What happens before a liver transplant?

If you are being considered for a liver transplant, you will have a series of very thorough tests. These look at your whole body.

You will have regular appointments with a series of different health professionals. They will check your:

• Weight
• Bloods
• Skin
• Kidney function
• Lung function
• Heart function
• Bones
• Whether you have cancer

Your medical team will make sure any other conditions are well managed. They will also want to make sure you getting enough nutrition. A dietitian may help you with this.

You may also see a psychologist, psychiatrist or addiction specialist to check you are suitable for a transplant.

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What are the risks of a liver transplant?

Liver transplantation is usually life changing. There is a very good survival rate: more than 4 in 5 people go on to live normal lives after a liver transplant.

But it involves major surgery. You’ll need to take medicines for the rest of your life to stop your body from rejecting the new liver (called immunosuppressive drugs).

There are several risks you should know about.

• There may be bleeding during surgery
• You may develop rejection, an immune reaction to the new liver, requiring treatment
• You could get an infection
• You may get a blood clot in the artery to the liver
• You might need kidney dialysis for a while
• You may developing narrowing of the bile ducts
• There might be heart complications
• Although donors are intensively screened, you might catch a disease from the donor
• The medicines you’ll need to take might have side effects including diabetes, kidney damage, high blood pressure, skin cancers and osteoporosis

There is a 1 in 100 risk of dying during the operation. There is a 1 in 100 risk of the liver not working in the first few days after the operation which might require urgent repeat transplantation from another donor.

Your transplant team will discuss risks and benefits of liver transplantation.

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What happens during liver transplant surgery?

When a suitable liver becomes available, you will hear from the transplant coordinator. You will need to come to hospital straight away.

You will need some more tests before surgery to make sure you are fit to undergo surgery that day.

During the operation, surgeons do a long incision (cut) under your right rib cage. They remove your diseased liver, trying not to damage the blood vessels or the bile ducts. Then they replace your diseased liver with the donor liver and connect the blood vessels and bile duct. The new liver should start producing bile straight away.

When you wake up, you will be cared for in the intensive care unit (ICU). You will have lots of tubes in your body. These include a breathing tube in your windpipe connected to a ventilator, catheters in blood vessels in your neck and arms to monitor your condition and give you fluids, a catheter in the bladder to drain urine, multiple drains through the skin on your belly to drain blood and fluid, and a tube through your nose to provide nutrition.

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What happens after surgery?

Your new liver should start working straight away. Almost immediately, your yellow skin and eyes will fade. Most people will stay in the ICU for a few days after the operation. You may stay in hospital for several weeks. Some people need to spend a lot longer in the ICU or in hospital because of complications.

Everyone’s recovery is different. I normally takes 3 to 6 months to fully recover.

You will be monitored to check that your immune system isn’t damaging the new liver. This is called rejection.  It’s more likely in the first 3 months, but it can happen any time.

Your doctors will check for rejection with blood tests. There are some signs of rejection:

• Fever
• Headache
• Feeling very tired
• Nausea
• Loss of appetite
• Itchy skin
• Dark urine
• Yellow skin and eyes (jaundice)
• Belly pain or swelling.

At first you will need to take a lot of medicines to prevent rejection and infection. Over the first year, the dosage will be reduced. But you will be on medication for the rest of your life.

You will need to come to the hospital for frequent check-ups. If you’re feeling unwell, you need to be sure you can get to hospital quickly – you might even need to move nearer the hospital for the first few months.

If the liver transplant fails, you may be assessed for another transplant.

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Living with a liver transplant

After transplant surgery, you can get the best outcomes by living a healthy lifestyle:

• Eat a healthy diet
• Keep to a healthy weight
• Make sure you don’t get food poisoning
• Avoid anyone who is sick
• Make sure you take all your medicines as instructed by your doctors
• See your medical team for regular check-ups
• Don’t drink alcohol
• Don’t smoke
• Have all your vaccinations and routine cancer screening

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Reviewed November 2022