Liver Transplantation: Eligibility, Surgery, and Immunosuppression Explained

When your liver fails, there’s no backup system. No reset button. No pill that can replace what it does-filtering toxins, making proteins, storing energy, regulating blood sugar. For people with end-stage liver disease, a transplant isn’t just an option-it’s the only chance to live. But getting one isn’t simple. It’s a long, strict, and deeply personal journey that starts long before the operating room.

Who Gets a Liver Transplant?

Not everyone with liver disease qualifies. The system is built to give the organ to those who need it most and have the best shot at surviving. The Model for End-Stage Liver Disease (MELD) score is the main tool used to rank patients on the waiting list. It’s calculated using three blood tests: bilirubin, creatinine, and INR. Higher scores mean sicker patients. A MELD score of 6 is mild; 40 is critical. People with scores above 25 are often prioritized because they’re likely to die within three months without a transplant.

But MELD isn’t the whole story. If you have liver cancer, especially hepatocellular carcinoma (HCC), you must meet the Milan criteria: one tumor under 5 cm, or up to three tumors all under 3 cm, with no spread to blood vessels. If your alpha-fetoprotein (AFP) blood marker is above 1,000 and doesn’t drop after treatment, you won’t qualify under standard rules. Some centers will review these cases individually, but it’s rare.

Then there’s the psychosocial side. You need stable housing, a support system, and proof you can follow complex medical instructions. If you’ve struggled with alcohol or drugs, most centers require at least six months of sobriety. But this rule isn’t uniform. Some centers, like those in British Columbia as of late 2025, now accept three months if paired with strong social support and counseling. Others still stick to six. This inconsistency frustrates many patients-some get approved, others don’t, even with identical medical conditions.

You also can’t have other life-threatening illnesses. Active cancer elsewhere in your body, untreated heart or lung disease, or uncontrolled infections will disqualify you. Even obesity can be a barrier. Most centers require a BMI under 30 for donors and recipients. But new data from Columbia University shows that carefully selected donors with BMI up to 35 can still have excellent outcomes. That’s starting to change guidelines.

The Surgery: What Happens on the Table

A liver transplant surgery lasts between six and twelve hours. The surgeon removes your damaged liver, then places the donor liver in its place. Most transplants use the “piggyback” technique-keeping your inferior vena cava (a major vein) intact. This reduces blood loss and speeds recovery. About 85% of adult transplants use this method.

There are two types of donors: deceased and living. Deceased donor transplants are more common, but the wait can be long-up to 18 months in some areas like California. Living donor transplants cut that time dramatically. A healthy person donates part of their liver-usually the right lobe (55-70%) for adults. The liver regrows in both donor and recipient within weeks.

For living donors, safety is critical. The remaining liver must be at least 35% of the original volume. The graft-to-recipient weight ratio must be at least 0.8%. If not, the recipient’s new liver might not work well enough. Donors typically stay in the hospital for 5-7 days and take 6-8 weeks to fully recover. The risk of death for donors is low-about 0.2%-but complications like bile leaks or infections happen in 20-30% of cases.

New technologies are improving outcomes. Machine perfusion, which keeps donor livers alive with oxygenated fluid outside the body, is now used for livers from donation after circulatory death (DCD). These livers used to have higher complication rates, but with perfusion, biliary issues dropped from 25% to 18%. The FDA approved the first portable perfusion device in June 2023, extending preservation time from 12 to 24 hours. That means more organs can be safely transported across states.

Life After Transplant: Immunosuppression

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

Most patients start with a three-drug combo: tacrolimus, mycophenolate, and prednisone. Tacrolimus is the backbone. Doctors aim for blood levels of 5-10 ng/mL in the first year, then lower to 4-8 ng/mL. Too low, and your body rejects the liver. Too high, and you risk kidney damage, tremors, or diabetes.

Mycophenolate stops immune cells from multiplying. It’s great for preventing rejection, but it can cause nausea, diarrhea, or low white blood cell counts. Prednisone, a steroid, helps calm the immune system early on. But it’s a double-edged sword. It causes weight gain, bone thinning, high blood sugar, and mood swings. That’s why 45% of U.S. transplant centers now use steroid-sparing protocols. They drop prednisone after 30 days. Studies show this cuts diabetes risk from 28% to 17%.

About 15% of patients have an acute rejection episode in the first year. It’s often caught early through routine blood tests. Treatment usually means raising tacrolimus levels or adding sirolimus. Long-term, 35% of patients develop kidney problems from tacrolimus. One in four get diabetes. One in five have nerve issues like shaking or trouble sleeping.

Medication adherence is everything. Miss a dose, and rejection can start within days. Studies show you need at least 95% compliance to keep your transplant working. That means taking pills every day, at the same time, without fail. Many patients use pill organizers, phone alarms, or apps. Some centers assign dedicated transplant coordinators who call weekly. Patients with this support have 87% one-year survival-5% higher than those without.

Costs, Recovery, and Long-Term Reality

The surgery itself might be covered by insurance, but the lifelong care isn’t cheap. Annual medication costs average $25,000-$30,000. That’s before lab tests, doctor visits, or complications. One in five patients need another hospital stay in the first year for infection, rejection, or bile duct problems.

Recovery takes time. You’ll be in the hospital for 14-21 days. After that, you’ll need weekly blood tests for three months, then biweekly, then monthly. You’ll see your hepatologist every few months. You’ll also need regular ultrasounds and sometimes liver biopsies to check for hidden damage.

You’ll learn to watch for signs of rejection: fever over 100.4°F, yellowing skin, dark urine, extreme fatigue, or abdominal pain. Infection risk stays high for the first six months. You’ll avoid crowds, raw foods, and gardening. You’ll get flu shots, pneumonia shots, and avoid live vaccines.

Despite all this, survival rates are strong. Eighty-five percent of patients live at least one year. Seventy percent make it five years. Many live 20 or more. The first long-term survivor, transplanted in 1967, lived for over 25 years.

What’s Changing Now?

The liver transplant landscape is shifting. Non-alcoholic steatohepatitis (NASH), linked to obesity and diabetes, now causes 18% of transplants-up from just 3% in 2010. That number will keep rising.

New research is testing if some patients can stop immunosuppression entirely. At the University of Chicago, 25% of pediatric recipients were successfully weaned off drugs by age five using regulatory T-cell therapy. If this works in adults, it could change everything.

Geographic disparities remain a problem. In the Midwest, patients wait an average of 8 months for a liver with a MELD score of 25-30. In California, it’s 18 months. Some patients travel across states to get on shorter lists. That’s legal-but expensive and logistically hard.

And the future? Artificial liver devices can buy time, but none have kept patients alive more than 30 days without a transplant. For now, the only cure is still a healthy liver from someone else.

What to Do Next

If you or someone you know is considering a liver transplant, start by talking to a hepatologist. They can refer you to a transplant center for evaluation. The process takes 3-6 months and involves dozens of tests: heart stress tests, lung function checks, psychiatric evaluations, and social work interviews.

Don’t wait until you’re too sick. The higher your MELD score, the more urgent-but also the riskier-the transplant becomes. Early referral gives you time to improve your health, quit smoking or drinking, lose weight, and build a support system.

And if you’re healthy and considering donation? Talk to a transplant center. Don’t assume you’re too old, too overweight, or not perfect. Many centers now use more flexible criteria. Your liver might be the one that saves a life.