Liver Transplantation: Eligibility, Surgery, and Immunosuppression Explained

When your liver fails, there’s no backup system. No second chance. No pill that can replace its job. For thousands of people each year, liver transplantation is the only path back to life. It’s not a simple fix-it’s a complex, high-stakes journey that begins long before the operating room and lasts a lifetime.

Who Gets a Liver Transplant?

Not everyone with liver disease qualifies. The system is strict, and for good reason. There aren’t enough donor livers to go around. In the U.S., about 8,000 transplants happen each year, but over 10,000 people are on the waiting list. So who makes the cut?

The answer comes down to two things: how sick you are, and whether you can survive the procedure and stick to the lifelong rules afterward.

Your medical urgency is measured by the MELD score-a number between 6 and 40. It’s calculated using blood tests for bilirubin, creatinine, and INR. The higher the score, the closer you are to death without a transplant. A MELD score of 25 or above puts you in the top tier for urgency. If you’re at 30, you’re in critical condition.

But your score isn’t the whole story. You also need to pass a psychosocial evaluation. That means proving you have stable housing, reliable transportation, and a support system. If you’ve struggled with alcohol or drugs, you’ll need at least six months of documented sobriety. Some centers are starting to question this rule-studies show patients with three months of abstinence have survival rates nearly identical to those with six. But most still require the longer wait.

Certain conditions automatically disqualify you. Active cancer that’s spread beyond the liver? No. Untreated HIV or hepatitis B with high viral load? Usually no. Severe heart or lung disease that makes surgery too risky? Also no. Even obesity can be a barrier-donors need to be healthy, and recipients with a BMI over 35 often face extra hurdles.

If you have liver cancer, the rules get even tighter. The Milan criteria apply: one tumor under 5 cm, or up to three tumors each under 3 cm, with no spread to blood vessels. If your tumor is bigger or has invaded vessels, you’re typically ineligible unless you respond to treatment and bring your alpha-fetoprotein (AFP) level below 500. Some centers now offer special exceptions, but they’re rare.

The Surgery: What Happens in the Operating Room

Liver transplant surgery is one of the most complex procedures in medicine. It usually takes between six and twelve hours. The goal is simple: remove the damaged liver and replace it with a healthy one. But the steps are anything but.

There are two types of donors: deceased and living. About 85% of transplants come from deceased donors. The rest come from living donors-usually a family member or close friend who donates a portion of their liver. The liver is the only organ that can regenerate. After surgery, both the donor’s remaining liver and the transplanted piece will grow back to full size within weeks.

For adult recipients, surgeons typically remove the right lobe (55-70%) from the donor. For children, they take the left lateral segment. The donor’s remnant liver must be at least 35% of their original liver volume to ensure safe recovery. Donors must be between 18 and 55, have a BMI under 30, and be free of liver, heart, or kidney disease. The risk of death for a living donor is about 0.2%. Complications like bile leaks or infections happen in 20-30% of cases.

The surgery itself has three phases. First, the diseased liver is removed (hepatectomy). Then comes the anhepatic phase-when the patient has no liver at all. This is the most dangerous part. Blood flow is rerouted, and the body relies on temporary support. Finally, the new liver is stitched in. Most surgeons use the “piggyback” technique, which leaves the patient’s inferior vena cava intact. This reduces bleeding and speeds recovery.

New tech is making a difference. Machine perfusion, which keeps donor livers alive with oxygenated fluid outside the body, is now used in 30% of centers. It’s especially helpful for livers from donation after circulatory death (DCD) donors. These livers used to have higher complication rates, but with perfusion, biliary problems dropped from 25% to 18%.

After surgery, patients spend 5-7 days in the ICU. Total hospital stay is usually 14-21 days if there are no complications. Donors typically go home after 7-10 days and return to normal activity in 6-8 weeks.

Immunosuppression: The Lifelong Trade-Off

Your body sees the new liver as an invader. Left unchecked, your immune system will attack it. That’s why you need immunosuppressants-for life.

The standard regimen is triple therapy: tacrolimus, mycophenolate mofetil, and prednisone. Tacrolimus is the backbone. Doctors aim for a blood level of 5-10 ng/mL in the first year, then lower it to 4-8 ng/mL. Too high, and you risk kidney damage. Too low, and rejection kicks in.

Mycophenolate stops immune cells from multiplying. It’s taken twice daily. Side effects? Nausea, diarrhea, and low white blood cell counts. About 30% of patients get stomach issues. Ten percent need dose adjustments because their bone marrow slows down.

Prednisone, a steroid, was once a staple. But now, 45% of U.S. transplant centers use steroid-sparing protocols. They drop prednisone after 30 days. Why? Because steroids cause weight gain, diabetes, and bone loss. Removing them cuts the risk of new-onset diabetes from 28% to 17%.

Rejection happens in 15% of patients within the first year. Most are caught early through blood tests and biopsies. Treatment usually means boosting tacrolimus or adding sirolimus, another immunosuppressant that’s gentler on the kidneys.

Long-term side effects are real. After five years, 35% of patients have kidney damage from tacrolimus. One in four develop diabetes. One in five get tremors or trouble sleeping. Mycophenolate can cause anemia. And all of these drugs raise your risk of infections and skin cancer.

The goal isn’t to eliminate rejection-it’s to balance it. You want just enough suppression to protect the liver, but not so much that your body can’t fight off colds or flu.

Living Donor vs. Deceased Donor: The Real Differences

Choosing between a living donor and a deceased donor isn’t just about timing-it’s about trade-offs.

With a deceased donor, you wait. And wait. The national average wait for a liver is 12 months. But it varies wildly by region. In the Midwest, you might wait 8 months. In California, it’s 18. That’s because organ distribution is based on geography, not just medical need.

Living donor transplants cut that wait to about 3 months. That’s life-changing for someone with a MELD score of 30. But it comes with risks-for the donor. Donors face a 0.2% chance of death. About 1 in 5 have complications like bile leaks, bleeding, or hernias. That’s why many centers only offer living donation when the patient is unlikely to survive the wait.

DCD livers (from donors whose hearts stopped) are becoming more common-now 12% of all transplants. They used to have higher failure rates, but with machine perfusion, their 5-year survival is now nearly equal to brain-dead donors.

Life After Transplant: The Real Challenge

Getting the liver is only half the battle. Staying alive with it is the harder part.

You’ll need weekly blood tests for the first three months. Then biweekly, then monthly. You’ll see your transplant team every few weeks for the first year. After that, every three months.

Medication costs? $25,000 to $30,000 a year-just for the immunosuppressants. Insurance often covers most of it, but 32% of patients report being denied coverage for pre-transplant evaluations. That’s a huge barrier.

You must take your pills exactly on time. Miss even one dose, and rejection can start. The threshold for success? 95% adherence. That means no skipping, no forgetting, no running out.

You also need to watch for signs of trouble: fever over 100.4°F, yellow skin, dark urine, extreme fatigue, or swelling in your belly. These aren’t normal. Call your team immediately.

Infection prevention is critical. Avoid raw seafood. Don’t clean bird cages or change cat litter. Wash hands constantly. Get all recommended vaccines-except live ones.

The best outcomes come from centers with dedicated transplant coordinators. These teams handle everything: scheduling, insurance, social support, mental health. Patients at these centers have 87% one-year survival. At centers without them? 82%.

What’s Next for Liver Transplants?

The field is changing fast. New guidelines are relaxing donor age limits-some centers now accept donors up to 65 if they’re healthy. BMI limits are rising too. One study showed donors with BMI up to 32 had the same outcomes as those under 30.

Researchers are testing ways to stop immunosuppression altogether. At the University of Chicago, 25% of pediatric transplant patients were able to stop all drugs by age five using a therapy that boosts regulatory T-cells. If this works in adults, it could end the lifelong drug burden.

Portable liver perfusion devices are now FDA-approved. They keep livers alive for 24 hours instead of 12, giving teams more time to match donors and recipients. This could reduce waste and help more people.

And there’s growing awareness of inequity. In British Columbia, Indigenous patients now get culturally tailored evaluations. Abstinence requirements are adjusted based on personal history. This isn’t just fairness-it’s better outcomes.

One thing won’t change: there will never be enough livers. That’s why living donation, better organ preservation, and new treatments matter. But for now, if you’re on the list, the key is patience, discipline, and trusting your team.

Frequently Asked Questions

Next Steps if You’re Considering a Transplant

If you think you might qualify, start by asking your hepatologist for a referral to a transplant center. The evaluation process takes 3-6 months and includes cardiac tests, lung function studies, mental health reviews, and financial counseling. Don’t wait until you’re in crisis. The earlier you start, the better your chances of getting on the list before your condition worsens.

If you’re healthy enough to be a donor, talk to your family. Living donation saves lives. But make sure you understand the risks. Visit a transplant center for a full evaluation-don’t assume you’re eligible based on age or weight alone. Some centers now accept donors over 55 or with controlled high blood pressure.

And if you’re supporting someone on the list-be their reminder, their ride, their voice. The journey is long. You don’t have to carry it alone.