Liver Transplantation: Eligibility, Surgery, and Immunosuppression Explained

When your liver fails, there’s no backup. No reset button. No pill that can replace what’s broken. For thousands of people each year, a liver transplant is the only chance to live. It’s not a simple fix-it’s a life-altering journey that begins long before the operating room and lasts a lifetime. This isn’t just about surgery. It’s about who gets chosen, how the procedure works, and what happens after the new liver is in place.

Who Gets a Liver Transplant?

Not everyone with liver disease qualifies. The system is strict because organs are scarce. In the U.S., about 8,000 liver transplants happen each year, but over 10,000 people are on the waiting list. So how do they decide who gets priority?

The answer is the MELD score-Model for End-Stage Liver Disease. It’s calculated using three blood tests: bilirubin, creatinine, and INR. The higher the score, the sicker you are. A score of 6 means you’re relatively stable. A score of 40 means you’re in critical condition. Patients with MELD scores above 25 are at the top of the list. But it’s not just about numbers.

Certain conditions automatically disqualify someone. Active drug or alcohol use? No. Metastatic cancer? No. Severe heart or lung disease that makes surgery too risky? Also no. Even if your liver is failing, your body has to be strong enough to survive the operation and recovery.

There’s also the psychosocial evaluation. You need stable housing, someone to help you after surgery, and the ability to take medications exactly as prescribed. One patient on Reddit shared how a single missed appointment delayed his transplant by six months because his insurance didn’t cover transportation. That’s not rare. About 32% of candidates report being denied coverage for pre-transplant tests, according to a 2023 National Transplant Survey.

For liver cancer patients, the rules are even tighter. The Milan criteria say you can only qualify if you have one tumor under 5 cm, or up to three tumors each under 3 cm, with no spread to blood vessels. If your alpha-fetoprotein (AFP) level is over 1,000 and doesn’t drop below 500 after treatment, you’re usually excluded unless your case gets special review.

Living Donor vs. Deceased Donor

You can get a liver from someone who’s passed away-or from a living donor. About 15% of transplants in the U.S. come from living donors. That’s a growing trend, especially for patients who won’t survive the wait.

Living donors are usually healthy adults between 18 and 55. They must have a BMI under 30, no history of liver or heart disease, and must not smoke or drink. Surgeons remove about 55-70% of the donor’s right lobe. The liver regrows in both donor and recipient. Donors typically need 6-8 weeks to recover fully. The risk of death for the donor is low-about 0.2%-but complications like bile leaks or infections happen in 20-30% of cases.

The big advantage? Time. For high-MELD patients, waiting for a deceased donor can take a year or more. With a living donor, the transplant can happen in as little as three months. Some centers are pushing boundaries. Columbia University now considers donors with BMI up to 35 if they have excellent liver quality and no other risks. Their 5-year graft survival rate? 92%, compared to the national average of 89%.

Deceased donor livers come from two sources: donation after brain death (DBD) and donation after circulatory death (DCD). DCD livers used to have higher complication rates-especially with bile ducts-but new technology is changing that. Machine perfusion, which keeps the liver alive and beating outside the body, has cut biliary complications from 25% to 18% in some centers. The FDA approved the first portable perfusion device in June 2023, extending preservation time from 12 to 24 hours.

What Happens During Surgery?

Liver transplant surgery is complex and long-usually 6 to 12 hours. It’s done in three phases.

First, the hepatectomy: the surgeon removes your diseased liver. Then comes the anhepatic phase: you have no liver at all. Blood flow is rerouted, and your body survives on temporary support. This part is the most dangerous. The liver normally filters toxins, makes proteins, and regulates blood sugar. Without it, you’re vulnerable to infection, bleeding, and metabolic collapse.

Finally, the implantation: the donor liver is placed in. Surgeons connect the major blood vessels and bile ducts. About 85% of transplants use the “piggyback” technique, which leaves the recipient’s inferior vena cava intact. This reduces blood loss and speeds recovery.

After surgery, you’re moved to the ICU. Most patients stay there 5-7 days. Total hospital time averages 14-21 days if there are no complications. But recovery doesn’t end there. You’ll need weekly blood tests for the first three months, then biweekly, then monthly. Medication adjustments are constant.

Immunosuppression: The Lifelong Trade-Off

Your body will try to reject the new liver. It doesn’t know it’s supposed to accept it. That’s why you need immunosuppressants-for the rest of your life.

The standard starting regimen is triple therapy: tacrolimus, mycophenolate mofetil, and prednisone. Tacrolimus is the backbone. Doctors aim for blood levels between 5-10 ng/mL in the first year, then lower it to 4-8 ng/mL. Too low? Rejection risk goes up. Too high? Kidney damage, tremors, or diabetes kick in.

Mycophenolate stops immune cells from multiplying. It’s tough on the stomach-about 30% of patients get nausea, vomiting, or diarrhea. It can also lower white blood cell counts, making you more prone to infection.

Prednisone, a steroid, was once used long-term. Now, 45% of U.S. transplant centers use steroid-sparing protocols. They drop prednisone after one month. Why? Because it causes weight gain, bone loss, and diabetes. Without it, the risk of new-onset diabetes drops from 28% to 17%.

About 15% of patients have acute rejection in the first year. It’s usually caught early through blood tests. Treatment means increasing tacrolimus or adding sirolimus. Long-term, 35% of patients develop kidney problems from tacrolimus. 25% get diabetes. 20% experience nerve issues like shaking or trouble sleeping.

There’s hope on the horizon. Researchers at the University of Chicago have successfully weaned 25% of pediatric transplant recipients off all immunosuppressants by age 5 using regulatory T-cell therapy. It’s experimental, but it’s a sign that someday, lifelong drugs might not be necessary.

Life After Transplant

The first year is the hardest. You’ll need to avoid crowds, wash your hands constantly, and never skip a dose. One missed pill can trigger rejection. Studies show you need at least 95% adherence to survive.

Medication costs are high-$25,000 to $30,000 per year, even with insurance. That doesn’t include doctor visits, lab tests, or hospital stays for complications. Many patients struggle with insurance denials or gaps in coverage.

But the payoff is real. Eighty-five percent of patients are alive one year after transplant. Seventy percent make it five years. Many return to work, travel, and even have children. One patient in California, approved after a social worker helped her secure housing and transportation, gave a 4.8/5 review: “They didn’t just save my liver. They saved my life.”

Geographic inequality is still a problem. In OPTN Region 9 (California), patients with MELD scores of 25-30 wait an average of 18 months. In Region 2 (Midwest), it’s just 8 months. New policies are trying to fix this. In November 2025, British Columbia changed its rules for Indigenous patients, replacing rigid abstinence requirements with culturally tailored support systems.

What’s Changing Now?

The field is evolving fast. The MELD-Na score now includes sodium levels for patients with fluid buildup-helping about 12% more people get priority. Non-alcoholic steatohepatitis (NASH) is now the second leading cause of liver transplants, accounting for 18% of cases. In 2010, it was just 3%.

Some experts argue the 6-month sobriety rule for alcohol-related liver disease is outdated. Yale researchers found no difference in 5-year survival between patients who stopped drinking for 3 months versus 6 months. Yet most centers still require the longer wait.

The liver transplant market is growing. Valued at $2.8 billion in 2023, it’s expected to grow over 5% annually through 2030. But the real progress isn’t in dollars-it’s in survival, in dignity, in second chances.

What If You’re Not Eligible?

If you’re turned down, it doesn’t mean the door is closed forever. Some centers allow re-evaluation after addressing issues-like quitting smoking, losing weight, or completing counseling. Others offer bridge therapies: artificial liver devices that keep you alive while you wait for a transplant. But none have proven they can replace a transplant long-term.

The truth is, liver transplantation isn’t perfect. It’s expensive, complex, and unfair in who gets access. But for those who make it through, it’s the difference between dying and living. Between watching your grandkids grow up-and not.