Liver Transplantation: Eligibility, Surgery, and Immunosuppression Explained

When your liver fails, there’s no backup system. No second chance. No workaround. 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. This isn’t just about swapping an organ. It’s about meeting strict medical criteria, surviving a major surgery, and managing a lifelong drug regimen to keep your new liver alive.

Who Gets a Liver Transplant?

Not everyone with liver disease qualifies. The system is designed to give the organ to those who need it most and have the best chance of surviving. The Model for End-Stage Liver Disease, or MELD score, is the key. It’s calculated using three blood tests: bilirubin, creatinine, and INR. Scores range from 6 to 40. The higher your score, the sicker you are-and the higher your priority on the waiting list. A MELD score of 25 or above means you’re in critical condition. People with scores below 15 rarely get offered a liver unless they have liver cancer.

For liver cancer patients, the rules are even tighter. You must meet the Milan criteria: one tumor no bigger than 5 cm, or up to three tumors, each under 3 cm, with no spread to blood vessels. If your alpha-fetoprotein (AFP) level is above 1,000 and doesn’t drop after treatment, you’re typically ineligible unless your case goes through a special review.

But medical fitness isn’t enough. You also need to pass a psychosocial evaluation. This means proving you have stable housing, reliable transportation, and a support system. If you’ve struggled with alcohol or drugs, you’ll need to show at least six months of sobriety. Some centers are starting to question this rule-studies show people with three months of abstinence have similar survival rates. But most still require six months. Insurance companies often deny coverage for the pre-transplant workup, which can cost thousands. That’s a major barrier for many.

Living donors add another layer. They must be between 18 and 55, have a BMI under 30, and be free of liver, heart, lung, or kidney disease. They can’t smoke or use drugs or alcohol. Their liver must be healthy enough to regrow after giving up 55-70% of it. The remnant liver must be at least 35% of the original volume. The graft-to-recipient weight ratio must be at least 0.8%. These numbers aren’t arbitrary-they’re based on decades of survival data.

The Surgery: What Happens in the Operating Room

A liver transplant takes between six and twelve hours. Most surgeons use the piggyback technique-leaving the recipient’s inferior vena cava intact. This reduces blood loss and lowers the risk of complications. The surgery has three phases. First, the diseased liver is removed (hepatectomy). Then comes the anhepatic phase-when the body has no liver at all. This is the most dangerous part. Blood pressure drops, fluids shift, and the body struggles to maintain balance. Finally, the donor liver is stitched in. Blood vessels and bile ducts are reconnected.

For living donor transplants, surgeons remove the right lobe (about 60% of the liver) for adult recipients. For children, they take the left lateral segment. The donor’s liver regrows to full size in about six to eight weeks. The recipient’s new liver starts working almost immediately. That’s one of the biggest advantages of living donation: no waiting. While deceased donor waits can stretch to over a year, especially in high-MELD patients in California, living donor transplants can happen within three months.

But it’s not risk-free. Donors face a 0.2% chance of dying during surgery. About 20-30% experience complications-bile leaks, infections, or pain that lasts months. Still, most donors say it was worth it. One 58-year-old donor in the U.S., slightly over the age limit, was approved after his liver anatomy was found to be unusually strong. His case was rare, but it showed that rigid rules can bend when the science supports it.

Post-op care starts in the ICU. You’ll stay there for five to seven days. Total hospital time is usually two to three weeks. You’ll be on a ventilator at first, then slowly weaned off. Pain is managed with IV meds. Nurses watch your urine output, blood pressure, and liver enzymes like a hawk. Rejection can happen within days. That’s why you’ll get blood tests every single day.

Immunosuppression: The Lifelong Drug Regimen

Your new liver is a foreign object. Your immune system will try to kill it. That’s why you need immunosuppressants-drugs that silence your body’s defense system. The standard starting point is triple therapy: tacrolimus, mycophenolate mofetil, and prednisone.

Tacrolimus is the backbone. You’ll need blood tests to keep its level between 5-10 ng/mL in the first year, then 4-8 ng/mL after that. Too low, and your body rejects the liver. Too high, and you risk kidney damage, nerve problems, or diabetes. About 35% of patients develop kidney issues by year five. One in four gets diabetes. One in five has tremors or headaches.

Mycophenolate helps block immune cells. But it causes nausea, diarrhea, and low blood counts. About 30% of patients stop taking it because of stomach problems. Ten percent get anemia or low white blood cells.

Prednisone, a steroid, was once a must. But now, 45% of U.S. transplant centers skip it after the first month. Why? Because it causes weight gain, bone loss, and diabetes. Removing it cuts diabetes risk from 28% to 17%.

Some patients get induction therapy before surgery. Low-risk patients get basiliximab. High-risk patients get anti-thymocyte globulin. These are strong drugs given in the hospital over several days. They help prevent early rejection.

About 15% of patients have acute rejection in the first year. It’s often caught early through blood tests. Treatment? Increase tacrolimus or add sirolimus. Most respond well. But chronic rejection is harder to treat. That’s why lifelong monitoring is non-negotiable.

What Comes After: The Daily Reality

The first three months are intense. You’ll go to the clinic weekly for blood tests. Months four to six: biweekly. After that, monthly. Year two and beyond: quarterly. You’ll need to track every pill. Miss one dose, and rejection risk jumps. Studies show you need at least 95% adherence to avoid failure.

You’ll also learn to spot warning signs: fever over 100.4°F, yellow skin, dark urine, fatigue, or abdominal swelling. Call your team immediately. Infections are a major threat. You can’t be around sick people. No crowded places. No raw sushi. No gardening without gloves. You’ll need vaccines-but not live ones. Flu shots? Yes. MMR? No.

Medication costs are high. $25,000 to $30,000 a year, on average, just for the drugs. That’s not counting doctor visits, labs, or hospital stays. Insurance coverage varies wildly. Some patients lose coverage after a year. Others fight for years to get it approved.

Geographic disparities are real. In the Midwest, a patient with a MELD score of 25-30 waits about eight months. In California, it’s 18 months. The system is unfair. Some centers have dedicated transplant coordinators. Those centers have 87% one-year survival. Centers without them? 82%. That difference saves lives.

New Frontiers: What’s Changing Now

The field is evolving fast. In June 2023, the FDA approved a portable liver perfusion device. It keeps donor livers alive outside the body for up to 24 hours instead of 12. That means more livers can be used-especially those from donors after circulatory death (DCD). These livers used to have higher complication rates. Now, with machine perfusion, biliary problems have dropped from 25% to 18%.

New guidelines are expanding donor eligibility. The AASLD now allows donors with controlled high blood pressure and BMI up to 32. Some centers are testing donors up to BMI 35 with great success. One center reports 92% five-year survival in this group-better than the national average.

Researchers are also working on tolerance. Can we teach the immune system to accept the liver without drugs? Early trials in children show 25% can stop immunosuppression by age five. That’s huge. If it works in adults, it could change everything.

Meanwhile, the rise of fatty liver disease (NASH) is reshaping transplant lists. In 2010, NASH caused 3% of transplants. Today, it’s 18%. That number will keep climbing.

Final Thoughts: It’s Not Just a Surgery

Liver transplantation isn’t a cure. It’s a new beginning-with heavy responsibilities. The surgery is just the middle of the journey. The real work starts after you wake up in the ICU. You have to take pills every day. You have to show up for every test. You have to say no to alcohol, to risky foods, to crowded places. You have to live differently.

But for many, it’s worth it. People who were bedridden, jaundiced, and dying now walk their kids to school. They travel. They retire. They live. The survival rates are strong: 85% after one year, 70% after five. And with new tech, better drugs, and smarter protocols, those numbers are getting better.

The system isn’t perfect. Waiting lists are long. Costs are high. Rules can feel arbitrary. But for those who make it through, the reward is simple: time. And that’s more than most ever thought they’d get.