Liver Transplantation: Eligibility, Surgery, and Immunosuppression Explained

When your liver fails, there’s no backup. No reset button. No pill that can rebuild it. For people with end-stage liver disease, a liver transplant isn’t just an option-it’s the only chance to survive. But getting one isn’t as simple as signing up. It’s a long, strict, and deeply personal journey that involves medical evaluations, surgical risk, and a lifetime of medication. Here’s what really happens-from who qualifies, to what the surgery looks like, to how your body learns to accept a new organ.

Who Gets a Liver Transplant?

Not everyone with liver disease qualifies. The system is designed to give organs to those who need them most and have the best chance to survive. The key tool used to decide this is the MELD score-Model for End-Stage Liver Disease. It’s calculated using three blood tests: bilirubin, creatinine, and INR. The score runs from 6 to 40. Higher numbers mean you’re sicker. Someone with a MELD of 35 is in critical condition and will jump ahead of someone with a MELD of 15.

But the score isn’t the whole story. If you have liver cancer, 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 alpha-fetoprotein (AFP) level is above 1000 and doesn’t drop below 500 after treatment, you’re usually not eligible unless your case gets special review.

Then there’s the lifestyle part. Active alcohol or drug use is an automatic disqualifier. Most centers require at least six months of sobriety before listing. But here’s the catch: some centers are starting to question this rule. A 2023 study from Yale found that 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 six-month rule because they need to be sure you won’t go back to drinking after the transplant.

Psychosocial factors matter too. You need stable housing, a support system-someone to drive you to appointments, help you take pills, notice if you’re getting sick-and the mental health to handle the stress. Social workers, psychiatrists, and addiction specialists all weigh in. If you’re homeless, struggling with depression, or have no one to help you, you might be delayed-even if your liver is failing.

Living donors add another layer. Donors must be between 18 and 55, have a BMI under 30, and be in perfect health. No smoking, no drinking, no history of liver, heart, or kidney disease. They need to have enough liver left after donation-at least 35%-and the donated piece must be big enough for the recipient-usually at least 0.8% of the recipient’s body weight. Some centers are now considering donors up to BMI 32 or even 35, especially if they have exceptional liver quality.

What Happens During the Surgery?

A liver transplant isn’t a quick operation. It takes between six and twelve hours. The surgeon removes your damaged liver, waits for the new one to arrive, and then connects the blood vessels and bile ducts. Most surgeries use the “piggyback” technique-keeping your inferior vena cava (a major vein) in place-because it reduces bleeding and makes the procedure safer. About 85% of transplants use this method.

The surgery has three phases. First, the hepatectomy: removing your liver. Then, the anhepatic phase: you have no liver. Your body survives on temporary support systems. Finally, implantation: the new liver is stitched in. Blood flow is restored. Bile starts flowing. If everything goes right, you’re alive with a new organ.

For living donor transplants, surgeons remove 55% to 70% of the donor’s right lobe. For children, they take the left lateral segment. The donor’s liver regrows to nearly full size in about six to eight weeks. The recipient’s new liver also regrows, but faster-often within weeks.

Donor liver sources matter too. Most come from deceased donors who died from brain death. But in 12% of cases, organs come from donors after circulatory death (DCD)-people whose hearts stopped and couldn’t be restarted. These livers have a higher risk of bile duct problems-about 25% versus 15% for brain-dead donors. But new tech is helping. At the University of Pittsburgh, they use machine perfusion to keep DCD livers alive outside the body. This has cut bile complications down to 18%.

Geography plays a big role. If you live in California (Region 9), you might wait 18 months for a liver with a MELD score of 25-30. In the Midwest (Region 2), you might wait only 8 months. The system tries to be fair, but organs don’t move easily across state lines. That’s why some people travel to transplant centers with shorter wait times.

Life After Transplant: Immunosuppression

Your body doesn’t know the new liver is supposed to be there. To it, it’s an invader. That’s why you need immunosuppressants-drugs that calm your immune system. You’ll take them for the rest of your life.

The standard combo is three drugs: tacrolimus, mycophenolate mofetil, and prednisone. Tacrolimus is the backbone. Doctors keep your blood level between 5 and 10 ng/mL in the first year, then lower it to 4-8 ng/mL. Too high, and you risk kidney damage or tremors. Too low, and your body attacks the liver.

Mycophenolate stops white blood cells from multiplying. It’s great for preventing rejection, but it can cause nausea, diarrhea, and lower your blood cell count. Prednisone is a steroid. It’s powerful but causes weight gain, diabetes, bone loss, and mood swings. That’s why 45% of U.S. transplant centers now use steroid-sparing protocols. They drop prednisone after 30 days. This cuts the risk of new-onset diabetes from 28% to 17%.

About 15% of patients have an acute rejection episode in the first year. It’s often caught early through blood tests. If your bilirubin spikes or your liver enzymes rise, you’ll get more tacrolimus or add sirolimus. Most cases respond well.

Long-term side effects are real. At five years, 35% of patients have kidney damage from tacrolimus. One in four develops diabetes. One in five gets nerve problems-tingling, shaking, trouble sleeping. Mycophenolate causes GI issues in 30% and low blood counts in 10%. You’ll need regular blood work, kidney checks, and bone density scans.

Medication costs? Around $25,000 to $30,000 a year-just for the pills. Insurance covers most of it, but some patients still get denied coverage for pre-transplant tests. A 2023 survey found 32% of candidates faced this problem.

Recovery and Daily Life

You’ll be in the hospital for 14 to 21 days if there are no complications. The first week is intense-monitored in the ICU, hooked to machines, watching your labs like a hawk. You’ll start walking the day after surgery. By day three, you’ll be eating solid food.

After discharge, life becomes a routine. Weekly blood tests for three months. Then every two weeks. Then monthly. After the first year, you’ll go in every three months. You’ll learn to recognize rejection signs: fever above 100.4°F, yellow skin, dark urine, extreme fatigue. You’ll also learn infection prevention-no raw sushi, no gardening without gloves, no crowds during flu season.

Medication adherence is everything. Miss one dose, and rejection risk jumps. Studies show you need 95%+ compliance to avoid failure. Many patients use pill organizers, phone alarms, and family reminders.

Donors recover faster. Most return to work in six to eight weeks. They may feel tired for months, but their liver regenerates. Their long-term survival is nearly identical to the general population.

What’s Changing Now?

The field is evolving. In June 2023, the FDA approved the first portable liver perfusion device. It keeps donor livers alive outside the body for up to 24 hours instead of 12. That means better organs can be shipped farther, helping reduce geographic disparities.

New research is looking at whether some people can stop immunosuppression entirely. At the University of Chicago, 25% of pediatric transplant recipients were able to stop all drugs by age five using a special T-cell therapy. It’s still experimental, but it’s a glimpse of a future where you don’t need lifelong pills.

The AASLD is updating guidelines to allow donors with controlled high blood pressure and BMI up to 32. This could open up more living donors, especially in communities with high rates of obesity.

And equity is finally being addressed. In November 2025, British Columbia changed its policy to better support Indigenous patients. They now include cultural support teams in psychosocial evaluations and adjust abstinence requirements based on individual circumstances-not just a blanket rule.

Final Thoughts

A liver transplant gives you a second life. But it’s not a cure. It’s a trade-off: you get a functioning liver, but you trade one set of problems for another. You’ll take pills forever. You’ll worry about infections. You’ll have checkups for the rest of your life.

But for those who made it through-the ones who waited, who quit drinking, who found a donor, who survived surgery-it’s worth it. The one-year survival rate is 85%. Five-year survival? Around 70%. That’s not just hope. That’s real, measurable, life-changing success.

The system isn’t perfect. Wait times are unfair. Costs are high. Rules can feel arbitrary. But the science is getting better. The outcomes are improving. And for those on the edge of liver failure, it’s still the best shot they’ve got.