Liver Transplantation: Eligibility, Surgery, and Immunosuppression Explained

When your liver fails, there’s no backup. No second chance. No pill that can replace what it does. Liver transplantation is the only real fix for end-stage liver disease. It’s not a simple operation-it’s a life-altering process that involves strict rules, complex surgery, and a lifetime of medication. But for thousands each year, it’s the difference between dying and living.

Who Gets a Liver Transplant?

Not everyone with liver disease qualifies. The system is built to give organs to those who need them most-and who are most likely to survive. The key tool used to decide this is the MELD score. It’s calculated from three blood tests: bilirubin, creatinine, and INR. The higher the score, the sicker you are. Scores range from 6 to 40. If you’re at 30 or above, you’re near the top of the list. At 40, you’re in critical condition.

But a high MELD score isn’t enough. You also need to be free of active drug or alcohol use. Most centers require at least six months of sobriety before listing. Some doctors argue this rule is too rigid. A 2023 study from Yale showed patients with just three months of abstinence had nearly the same five-year survival rates as those who waited six months. Still, most programs stick to the rule because relapse after transplant can destroy the new liver.

Cancer patients face different rules. If you have hepatocellular carcinoma (HCC), you must meet the Milan criteria: one tumor under 5 cm, or up to three tumors under 3 cm each-with no spread to blood vessels. If your tumor is bigger or has spread, you’re usually not eligible unless you get special approval. And if your alpha-fetoprotein (AFP) blood marker is above 1,000 and doesn’t drop below 500 after treatment, you’re typically excluded.

Psychosocial factors matter just as much as medical ones. Do you have someone to help you take your pills every day? Do you have stable housing? Can you afford transportation to weekly lab visits? If you’re homeless, struggling with mental health, or can’t follow complex instructions, you won’t be approved. Transplant centers don’t turn people away because they’re “unworthy”-they do it because without support, the transplant will fail.

The Surgery: What Happens During the Operation

The surgery itself is long and intense. It takes between six and twelve hours. Surgeons remove your damaged liver, then carefully stitch in the donor liver. The most common technique used today is called the “piggyback” method. It keeps your inferior vena cava-the big vein that carries blood back to your heart-intact. This reduces bleeding and speeds up recovery.

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. In living donor transplants, surgeons remove 55% to 70% of the donor’s right liver lobe. The liver regenerates in both donor and recipient. Donors typically go home in 10 to 14 days and return to normal activity in six to eight weeks.

Living donor transplants have one big advantage: shorter wait times. While someone on the deceased donor list might wait over a year, a living donor transplant can happen in three months. But it’s not risk-free. Donors face a 0.2% chance of dying during surgery and a 20% to 30% chance of complications like bile leaks or infections. Still, for many families, the trade-off is worth it.

Geography plays a huge role in who gets a liver. In the Midwest (OPTN Region 2), patients with a MELD score of 25 to 30 wait about eight months. In California (Region 9), they wait 18 months. That’s not because one region is more efficient-it’s because organ availability varies wildly. Some areas have more donors. Others have more patients. The system tries to be fair, but it’s not perfect.

Immunosuppression: The Lifelong Trade-Off

Your body doesn’t know the new liver belongs to you. It sees it as an invader. That’s why you need immunosuppressants-for the rest of your life.

Right after surgery, most patients get a short course of anti-rejection drugs like basiliximab or anti-thymocyte globulin. Then comes the daily routine: tacrolimus, mycophenolate, and often prednisone. Tacrolimus is the backbone. Doctors aim for blood levels between 5 and 10 ng/mL in the first year, then lower it to 4 to 8 ng/mL to reduce side effects. Mycophenolate prevents rejection too, but it can cause nausea, diarrhea, and low blood counts. Prednisone, a steroid, helps control inflammation but causes weight gain, bone loss, and diabetes.

Here’s the good news: 45% of U.S. transplant centers now use steroid-sparing protocols. They drop prednisone after just one month. This cuts the risk of new-onset diabetes from 28% to 17%. That’s a major win.

But even with the best drugs, rejection still happens. About 15% of patients have an acute rejection episode in the first year. It’s usually caught early through routine blood tests. The fix? Increase tacrolimus or add sirolimus. Most patients bounce back fine.

Long-term side effects are the real challenge. After five years, 35% of patients have kidney damage from tacrolimus. One in four develop diabetes. One in five get shaky hands or memory problems. Mycophenolate causes stomach issues in 30% and lowers blood cell counts in 10%. These aren’t rare side effects-they’re expected. That’s why regular checkups, blood tests, and communication with your transplant team are non-negotiable.

What Happens After You Go Home

You’re not done when you leave the hospital. In fact, the hardest part often starts now.

For the first three months, you’ll go to the clinic every week for blood work. After that, every two weeks. By year one, it’s monthly. After that, quarterly. Each visit checks your liver function, kidney health, drug levels, and signs of infection.

Medication costs are high. On average, you’ll spend $25,000 to $30,000 a year just on anti-rejection drugs-not counting doctor visits, labs, or complications. Insurance coverage varies wildly. A 2023 national survey found 32% of transplant candidates were denied coverage for pre-transplant evaluations. That’s not a mistake-it’s a barrier.

You also need to learn what rejection looks like: fever above 100.4°F, yellowing skin, dark urine, extreme fatigue, or abdominal pain. These aren’t vague symptoms-they’re red flags. If you ignore them, you risk losing the transplant.

Infection risk stays high for years. You can’t go to crowded places without a mask. You can’t handle cat litter or gardening without gloves. You can’t eat raw fish or unpasteurized cheese. These aren’t suggestions-they’re survival rules.

New Trends and Future Hope

The field is changing fast. In June 2023, the FDA approved a portable liver perfusion device called Liver Assist. It keeps donor livers alive outside the body for up to 24 hours-double the old limit. That means more organs can be used, especially those from older or “marginal” donors.

Some centers are now accepting donors with controlled high blood pressure or a BMI up to 32. In the past, these donors were turned away. Now, data shows their livers work just as well.

And there’s hope beyond drugs. Researchers at the University of Chicago have successfully weaned 25% of pediatric transplant patients off all immunosuppression by year five using regulatory T-cell therapy. It’s still experimental, but it’s a glimpse of a future where you don’t need lifelong pills.

Meanwhile, the rise of fatty liver disease (NASH) is changing who needs transplants. In 2010, only 3% of liver transplants were for NASH. By 2023, it was 18%. That’s the fastest-growing reason for transplant in the U.S. And with obesity rates still climbing, that number will only go up.

Some regions are making equity a priority. In British Columbia, new policies now include cultural support and modified abstinence requirements for Indigenous patients. It’s a small step-but it’s the kind of change that saves lives.

Is It Worth It?

The numbers don’t lie. Eighty-five percent of patients survive at least one year after transplant. Seventy percent make it five years. Many live 20, 30, even 40 years with a new liver. You can return to work. You can travel. You can watch your kids grow up.

But it’s not a cure. It’s a reset. You’ll never be “normal.” You’ll always need pills. You’ll always be watched. You’ll always wonder if your body will reject the organ tomorrow.

Still, for those who have nothing left to lose-this is everything.