Liver Transplantation: Eligibility, Surgery, and Immunosuppression Explained

When your liver stops working, there’s no backup. No second chance. No pill that can fix it. For people with end-stage liver disease, a transplant isn’t just an option-it’s the only way to survive. And while the idea of getting a new liver sounds like science fiction, it’s now a routine, life-saving procedure for thousands every year. But it’s not simple. It’s not quick. And it doesn’t end when the surgery is over. Understanding liver transplantation means knowing who qualifies, what happens during surgery, and how the body learns to live with a foreign organ.

Who Gets a Liver Transplant?

Not everyone with liver disease gets on the waiting list. The process starts with a full medical and psychological review at a transplant center. Doctors look at more than just how sick you are-they want to know if you’ll stick with the treatment after the transplant. That’s because a new liver won’t save you if you go back to drinking, skip your meds, or don’t show up for checkups.

The main tool used to decide who gets priority is the MELD score. It’s calculated using three blood tests: bilirubin, creatinine, and INR. The score ranges from 6 to 40. Higher numbers mean you’re sicker and closer to death. Someone with a MELD of 35 is in critical condition. Someone with a 10 might wait months or even years. In 2023, the MELD-Na system was updated to include sodium levels, helping people with fluid buildup get priority faster.

There are strict rules about who’s disqualified. Active drug or alcohol use? You’re off the list. Metastatic cancer? No. Untreated heart or lung disease? Same. But there are exceptions. For liver cancer patients, the Milan criteria apply: one tumor under 5 cm, or up to three tumors under 3 cm, with no spread to blood vessels. If your tumor is bigger or has spread, you might still qualify if you get successful treatment first and your tumor shrinks.

Psychosocial factors matter just as much. You need a support system. Stable housing. Reliable transportation. A team of doctors, social workers, and counselors evaluates whether you can handle the lifelong commitment. One patient in California shared how her transplant team helped her find housing and ride-share vouchers-things that made the difference between approval and denial.

Living Donor vs. Deceased Donor: What’s the Difference?

Most livers come from deceased donors. But in some cases, a living person can donate part of their liver. It’s not common, but it’s growing. About 10% of transplants in the U.S. now use living donors. Why? Because the wait for a deceased donor liver can be long-up to 18 months in some states. A living donor can cut that to just a few months.

Donors must be between 18 and 55, have a BMI under 30, and be in perfect health. No smoking, no drinking, no history of liver, heart, or kidney disease. The surgery removes 55-70% of the right lobe of the donor’s liver. That part regrows in about six to eight weeks. The donor’s remaining liver also grows back to full size. But it’s not risk-free. There’s a 0.2% chance a donor dies. About 20-30% have complications like infection, bile leaks, or blood clots.

New guidelines are starting to change the rules. In 2023, the AASLD began allowing donors with controlled high blood pressure and BMIs up to 32. Some centers, like Columbia University, are even considering donors up to BMI 35 with careful screening. Their 5-year graft survival rate for these donors is 92%, higher than the national average.

Deceased donor livers come from two sources: donation after brain death (DBD) and donation after circulatory death (DCD). DCD donors are people whose hearts have stopped, but their organs are still viable. These livers have a higher risk of bile duct problems-25% compared to 15% for DBD livers. But new technology is helping. Machine perfusion, which keeps the liver alive and functioning outside the body, has cut those complications down to 18%. The FDA approved the first portable perfusion device in June 2023, extending liver preservation from 12 to 24 hours.

What Happens During Liver Transplant Surgery?

The surgery takes between six and twelve hours. It’s done in three phases. First, the surgeon removes your damaged liver-this is called a hepatectomy. Then comes the anhepatic phase: you have no liver at all. Your body survives on machines that take over liver functions temporarily. Finally, the new liver is stitched in. Blood vessels and bile ducts are reconnected. Most surgeons use the “piggyback” technique, which leaves your inferior vena cava intact. This reduces bleeding and speeds recovery.

After surgery, you go to the ICU. You’ll be on a ventilator for a day or two. Tubes will drain fluid from your belly. You’ll have a catheter and IV lines. The first five to seven days are the hardest. You’ll be tired, sore, and confused. Pain is managed, but you’ll still feel it. Most people stay in the hospital for 14 to 21 days if nothing goes wrong.

The first sign of trouble? Fever above 100.4°F, yellowing skin, dark urine, or swelling in the belly. These could mean rejection or infection. You’ll be taught to recognize them before you leave the hospital.

Immunosuppression: The Lifelong Battle

Your body sees the new liver as an invader. Without drugs to stop it, your immune system will attack and destroy it. That’s why immunosuppression is non-negotiable.

The standard starting regimen is triple therapy: tacrolimus, mycophenolate, and prednisone. Tacrolimus is the backbone. Blood levels are checked weekly at first, then monthly. Doctors aim for 5-10 ng/mL in the first year, then lower it to 4-8 ng/mL. Too high? You risk kidney damage. Too low? Rejection kicks in.

Mycophenolate stops white blood cells from multiplying. It causes stomach upset in 30% of patients and lowers blood counts in 10%. Prednisone, a steroid, reduces inflammation but causes weight gain, diabetes, and bone loss. That’s why many centers now use steroid-sparing protocols. In 2023, 45% of U.S. transplant centers stopped prednisone after the first month. The result? Diabetes rates dropped from 28% to 17%.

About 15% of patients have acute rejection in the first year. It’s usually caught early with blood tests and treated by boosting tacrolimus or adding sirolimus. Long-term, 35% of patients develop kidney damage from tacrolimus. 25% get diabetes. 20% get tremors or headaches from neurotoxicity.

You’ll need blood tests every week for three months, then every two weeks for six months, then monthly for a year. After that, quarterly. You’ll also need annual ultrasounds and liver biopsies if something looks off. Medications cost $25,000 to $30,000 a year-without complications. Insurance often denies coverage for pre-transplant tests. One survey found 32% of candidates were turned down for evaluations.

Real Challenges and Changing Rules

The biggest controversy? The six-month sobriety rule for alcohol-related liver disease. Many centers require you to be sober for six months before listing. But a 2023 Yale study showed patients with three months of sobriety had the same 5-year survival rates as those with six. Critics say the rule is arbitrary and keeps people from getting help.

Reddit threads like “6-month sobriety rule destroyed my chance at transplant” have hundreds of upvotes. People report wildly different rules across centers. Some will list you after three months if you’re in rehab. Others won’t budge. In British Columbia, a new 2025 policy now includes cultural support and community elders in the evaluation process for Indigenous patients, recognizing that recovery isn’t one-size-fits-all.

Geographic inequality is another problem. If you live in California, you might wait 18 months for a liver. If you live in the Midwest, you might wait eight. The same MELD score can mean different wait times depending on your zip code.

What Comes After the Transplant?

Life after transplant isn’t a return to normal. It’s a new normal. You’ll take pills every day, forever. You’ll avoid crowds during flu season. You’ll wash your hands constantly. You’ll need to get vaccines for pneumonia, flu, and hepatitis A and B.

You can eat normally again. Most people regain their energy. Many return to work. Some even run marathons. But you’ll never be “cured.” You’ll always be at risk for rejection, infection, or side effects from meds. Your liver can fail again, even after years.

But here’s the truth: 85% of people are alive one year after transplant. 70% are alive five years later. That’s not just survival-it’s a second life. And for many, it’s worth every pill, every test, every fear.

What’s Next for Liver Transplants?

Researchers are working on ways to eliminate immunosuppression entirely. Early trials at the University of Chicago show 25% of pediatric patients were able to stop all anti-rejection drugs by age five using regulatory T-cell therapy. If this works in adults, it could change everything.

Artificial liver devices are improving, but none can replace a transplant for long-term survival. They’re useful as bridges-keeping people alive until a liver becomes available.

The liver transplant market is growing fast, driven by rising cases of fatty liver disease. NASH, or non-alcoholic steatohepatitis, now causes 18% of transplants-up from 3% in 2010. As obesity rates climb, so will the need for transplants.

The future isn’t just about more livers. It’s about smarter ones. Better preservation. Personalized drugs. Less rejection. And more fairness in who gets access.

What You Should Do Next

If you or someone you know is considering a liver transplant, start by talking to a hepatologist. Ask for a referral to a transplant center. Don’t wait until you’re desperate. The evaluation takes 3 to 6 months. Get your records in order. Start making lifestyle changes now-quit drinking, lose weight, manage your blood sugar. The sooner you start, the better your chances.

If you’re thinking about being a living donor, talk to a center that does living donor transplants. Ask about their donor outcomes, recovery times, and support services. This isn’t a decision to make lightly-but for the right person, it’s one of the most powerful acts of generosity possible.