Liver Transplantation: Eligibility, Surgery, and Immunosuppression Explained

When your liver fails, there’s no backup system. No reset button. No pill that can fully replace what it does. For people with end-stage liver disease, a transplant isn’t just an option-it’s the only real chance to live. But getting one isn’t simple. It’s a long, complex journey that starts long before the operating room and lasts a lifetime after. This isn’t about miracle cures. It’s about hard facts, strict rules, and the daily work of staying alive.

Who Gets a Liver Transplant?

Not everyone with liver damage qualifies. The system is built to give the organ to those who need it most and have the best shot at surviving. The MELD score is the main tool used to decide who moves up the waiting list. It’s calculated using three blood tests: bilirubin, creatinine, and INR. Higher scores mean sicker patients. A MELD of 40? You’re in critical condition. A MELD of 10? You might wait months or years. In 2023, patients with scores between 25 and 30 waited an average of 8 months in the Midwest, but nearly 18 months in California. Location matters more than most people realize.

There are hard limits. If you’re actively using alcohol or drugs, you’re not eligible. Most centers require at least six months of sobriety before listing. But here’s the catch: some centers are starting to question that rule. 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, many programs stick to the old standard, leaving some patients stuck in limbo.

Liver cancer changes the rules. If you have hepatocellular carcinoma (HCC), you must meet the Milan criteria: one tumor under 5 cm, or up to three tumors, each under 3 cm, with no spread to blood vessels. If your tumor is bigger or your AFP blood marker is over 1,000 and doesn’t drop after treatment, you’re typically excluded unless you get special approval. For cholangiocarcinoma, you now need six months of tumor stability after radiation or other local therapy before even being considered.

It’s not just about your liver. Your heart, lungs, kidneys, and mental health all get checked. You need stable housing. You need people who can help you after surgery. You need to prove you’ll take your meds every single day. If you can’t manage a daily pill schedule now, you won’t be trusted with a new liver. The psychosocial evaluation isn’t a formality-it’s a make-or-break step.

The Surgery: What Happens in the Operating Room

A liver transplant isn’t a quick procedure. It takes between six and twelve hours. The surgeon removes your damaged liver, waits while your body adjusts to having no liver at all (that’s the anhepatic phase), then puts in the new one. Most transplants today use the “piggyback” technique, where the large vein behind the liver-the inferior vena cava-is left in place. This reduces blood loss and speeds recovery.

There are two kinds of donors: deceased and living. About 85% of transplants come from people who have died. The rest come from living donors-usually family members or close friends. In adult cases, surgeons remove about 55 to 70% of the donor’s right liver lobe. The liver regrows in both donor and recipient. Donors typically go home after two weeks and feel normal in six to eight weeks. But there’s risk: 20 to 30% of donors have complications, and 0.2% die.

Living donor transplants cut waiting time dramatically. For high-MELD patients, the average wait for a deceased donor liver is 12 months. With a living donor, it’s about three. That’s why centers like Columbia University are pushing to expand donor eligibility. New data shows donors with a BMI up to 32 or controlled high blood pressure can still have safe, successful outcomes. These changes are slowly being adopted.

Another shift is happening with organs from donors after circulatory death (DCD). These are livers from people whose hearts stopped, not those who were brain-dead. In 2022, 12% of liver transplants used DCD organs. They used to have higher rates of bile duct problems-25% versus 15% in brain-dead donors. But now, centers like UPMC are using machine perfusion to keep the liver alive and functioning outside the body. That’s cut bile complications down to 18%. It’s not perfect, but it’s getting better.

Life After the Transplant: Immunosuppression Is Non-Negotiable

Your body will try to reject the new liver. That’s normal. The immune system doesn’t know it’s supposed to accept a foreign organ. So you take drugs-every day, for the rest of your life. The standard combo is tacrolimus, mycophenolate, and prednisone. Tacrolimus keeps your immune system in check. You’ll need blood tests to make sure your levels stay between 5 and 10 ng/mL in the first year, then 4 to 8 ng/mL after that. Too low? Rejection. Too high? Kidney damage, tremors, or diabetes.

Mycophenolate helps block immune cells. It’s tough on the stomach. About 30% of patients get nausea, diarrhea, or vomiting. Around 10% have low blood counts. Prednisone, a steroid, was once a staple. But now, 45% of U.S. transplant centers are dropping it after the first month. Why? Because it causes diabetes in 28% of patients. Without it, that number drops to 17%. That’s a big win.

Rejection still happens. About 15% of patients have an acute rejection episode in the first year. It’s usually caught early through blood tests or a liver biopsy. The fix? Increase tacrolimus or add sirolimus. Most patients bounce back fine. But long-term, side effects pile up. At five years, 35% of patients have kidney damage from tacrolimus. One in four develop diabetes. One in five deal with nerve issues like shaking or memory problems.

Medication costs are brutal. Even with insurance, you’ll spend $25,000 to $30,000 a year just on anti-rejection drugs. That doesn’t include labs, doctor visits, or complications. And you can’t skip a dose. Studies show you need at least 95% adherence to avoid rejection. One missed pill can be enough to trigger a crisis.

What Recovery Really Looks Like

You’re not out of the woods when you leave the hospital. The first three months mean weekly blood tests. Months four to six: biweekly. After a year, you’re down to quarterly. You’ll need to learn to spot rejection signs: fever over 100.4°F, yellow skin, dark urine, extreme fatigue. Infection is another big risk. You can’t go to crowded places. You can’t clean cat litter. You can’t eat raw sushi. Even a cold can turn dangerous.

Support systems make a huge difference. Centers with dedicated transplant coordinators have 87% one-year survival rates. Those without? Only 82%. That gap isn’t about surgical skill-it’s about who’s reminding you to take your pills, helping you get to appointments, and connecting you with food banks or housing help. One patient in San Francisco credited her social worker with getting her housing and transportation sorted. That’s what got her on the list. Another patient on Reddit said the six-month sobriety rule cost him his chance. His center didn’t make exceptions. He wasn’t alone.

There are new tools helping. The FDA approved a portable liver perfusion device in June 2023. It keeps donor livers alive for up to 24 hours instead of 12. That means organs can be shipped farther, used more efficiently, and even repaired before transplant. It’s not magic, but it’s helping more people get access.

The Future: Tolerance, Equity, and New Frontiers

The biggest hope for the future is operational tolerance-getting patients off immunosuppression entirely. In a University of Chicago trial, 25% of pediatric transplant recipients were able to stop all anti-rejection drugs by age five. They didn’t reject the liver. Their bodies learned to accept it. If this works in adults, it could change everything.

Equity is another big issue. In 2023, patients in the Southwest were 40% less likely to get a transplant within 90 days than those in the Mid-Atlantic, even with the same MELD score. British Columbia made a change in November 2025: they now include cultural support in psychosocial evaluations for Indigenous patients. They’ve adjusted abstinence rules to reflect community values, not just clinical ones. That’s the kind of shift the system needs.

Non-alcoholic steatohepatitis (NASH) is now the second leading cause of liver transplants in the U.S., up from 3% in 2010 to 18% in 2023. That means more people are getting transplants because of obesity and metabolic disease-not alcohol. It’s a public health crisis wearing a medical label.

There’s no artificial liver that can replace a transplant yet. Devices can keep people alive for a few weeks, but none have kept anyone alive for more than 30 days without a transplant. That means, for now, the organ is still the only answer.

What You Need to Know

A liver transplant isn’t a cure. It’s a trade-off. You get life, but you trade it for lifelong medication, constant monitoring, and the fear of rejection or side effects. The success rates are good-85% survive one year, 70% make it five. But those numbers mean nothing if you don’t make it through the process.

Eligibility is strict. Surgery is intense. Recovery is relentless. But for the right person, it’s the difference between dying and living. The system isn’t perfect. It’s uneven. It’s expensive. But it works. And for those who get through it, it’s worth every second of the fight.