Dr AvinashTank, is a super-specialist (MCh) Laparoscopic Gastro-intestinal Surgeon,


Liver transplantation is a surgery to remove a diseased or injured liver and replace it with a healthy whole liver or a segment of a liver from another person, called a donor. A successful liver transplant is a life-saving treatment for people with liver failure, a condition in which the liver no longer works as it should.

Role of Liver in body

The body’s largest internal organ, the liver has many important functions including: removes harmful substances from blood, it makes bile and enzyme for digestion of food and also converts food into substances that are important for growth of body and life. So a healthy liver is necessary for survival. A healthy liver can regenerate most of its own cells when they become damaged.

Candidate for Transplantation

People with either acute or chronic liver failure may need a liver transplant to survive.

  • Acute liver failure (ALF) happens suddenly. Drug-induced liver injury (DILI) is the leading cause, of overdose of acetaminophen.
  • Chronic liver failure, also called end-stage liver disease or cirrhosis, progresses over months, years, or decades. Cirrhosis is a condition in which scar tissue replaces healthy liver tissue until the liver cannot function adequately.

Most common reason for needing a liver transplant is cirrhosis caused by chronic hepatitis, alcohol abuse, autoimmune hepatitis, biliary atresia, primary biliary cirrhosis, and primary sclerosing Cholangitis, hemochromatosis (a genetic condition in which iron builds up in the liver), Wilson disease (a genetic condition in which copper builds up in the liver & nonalcoholic steatohepatitis (a disease caused by fat and inflammation in the liver).

In children, biliary atresia is the most common cause of liver failure and the need for a liver transplant. Biliary atresia is a disease in newborns in which the bile ducts are absent, damaged, or blocked. As a result, toxic bile builds up in the liver, resulting in cirrhosis.

Other reasons for liver transplantation include cancers originating in the liver.

Not all patients need liver transplantation as soon as they are diagnosed to have cirrhosis. This condition is known as “compensated cirrhosis, that means your liver is damaged but still liver is able to do needful functions in body. These patients are advised to meet regularly to expert to watch the ongoing function of liver. Initially cirrhosis is treated with medicines.

Liver transplantation is indicated when person develops the complications due to cirrhosis, this is known as “Decompensated Cirrhosis. Cirrhosis induced complications are vomiting of blood (hematemesis), blood in stool (melana), accumulation of water in tummy (ascites), yellow colouration of eye, skin (jaundice) & abnormal behaviour (encephalopathy). These patients required sadmission for treatment of these complications and advised to consult liver transplant team for assessment & counselling for future transplantation.

Assessment for Liver Transplantation

Person with cirrhosis, undergoes evaluation in three steps and normally takes 5-7 days in hospital.

  • To confirm the definite diagnosis, to assess the severity of liver disease and the urgency of the transplant surgery.
  • To assess the fitness of the patient for a transplant. The other body systems such as heart, lungs, and kidneys are tested to assess the functions of these organs and any sort of infection in body.
  • The final phase is the psychological and mental preparation of the patient. The patient and the family are counselled about the procedure, hospital stay, the likely course after surgery, follow up and aftercare.


After evaluation, if there is a willing and blood group matched family donor available, he/she is evaluated for donation and a transplant is scheduled.

After evaluation, if the patient don’t have family member of donation, he/she is placed on the waiting list for cadaveric donation. While on the cadaver waiting list, the patient follows up with the Transplant Team until a suitable liver becomes available. If the patient's condition shows signs of deteriorating, we normally suggest the family to consider living liver donation.

Scoring Systems

When people are registered on the waiting list, they are assigned a score that indicates how urgently they need a transplant. The two scoring systems are the Model for Endstage Liver Disease (MELD) scoring system, used for people age 12 and older, and the Pediatric End-stage Liver Disease (PELD) scoring system, used for children younger than 12.

MELD and PELD scores are calculated by computer using the results of blood tests. MELD scores range from 6 to 40. PELD scores can range from negative numbers to 99. These scores are used to estimate the likelihood of dying within the next 90 days without a transplant. A higher score indicates a more urgent need for a liver transplant.

Unsuitable candidate for liver

If the person has infection throughout the body, advanced heart or lung disease, an alcohol or drug abuse problem, AIDS, the inability to follow a treatment regimen a lack of psychosocial support, is not suitable for transplantation.

Source of New Liver (Donor)

Deceased donor (brain dead donor)

Its the most common source of liver. Brain death is usually due to a large stroke or massive trauma to the head from blunt injury (impact to the head from accident) or penetrating injury (a gun shot wound). The trauma has stopped all brain function although other organs including the liver may continue to function normally. We can get liver only if the family of patient wishes to donate the person's organs before discontinuing life support.

Deceased donor (heart dead donor)

Sometimes a patient suffers a serious brain injury and carries a poor neurological outcome but fails to meet the strict criteria defining brain death in that there is still detectible brain function. In these circumstances, the patient's family may decide to withdraw life-sustaining medical support with the intention of allowing the patient to die. In this scenario, death is not defined by brain death but rather cardiac death.

An urgent operation is then performed to preserve and remove organs for transplantation. This mode of cardiac death, in contrast to brain death, results in increased injury to the organs during two time periods. The first period is that between withdrawal of life support and death. As the donor's breathing and circulation deteriorates, the organs may no longer be receiving sufficient oxygen. The second time period constitutes the minutes immediately after death and until the organs are flushed with preservation solution and cooled. As a result, livers procured from cardiac death donors are associated with an increased risk of primary non function or poor early organ function, hepatic artery thrombosis, and biliary complications

We can get liver only if the family of patient wishes to donate the person's organs before discontinuing life support.

After removal from the donor (a process called liver retrieval) the liver can safely be kept preserved outside the body in special preservation solutions for 12-15 hours.

Adults usually receive the entire liver from a deceased donor. Child recipient more often receive a portion of a liver from an adult donor. Occasionally, an adult liver is split into two portions and given to two different recipients. For example, the smaller left lobe may be given to a child and the larger right lobe given to an adult.

Living Donor

In india, most of the liver transplants are performed using living donors. Most living donors are relatives of the recipient. In living donor transplantation, a segment of the donor’s healthy liver is surgically removed and transplanted into the recipient. Because a healthy liver can regenerate, the donor’s liver soon grows back to normal size after the surgery, while the segment of the liver that was transplanted into the recipient also grows to normal size.

For children, the entire left lobe or a portion of the left lobe of the liver from a living adult donor is usually sufficient. For adult recipients, the larger right lobe of the liver may be needed.

For safety of donor & recipient, the donor assessment is done by transplant team, which normally takes 2-3 days & donor should fulfil following criteria’s

  • Donation should be with independent desire
  • Age should be between 18-55 years and weight should be between 50-85kg
  • Donor must be a close relative
  • Blood group of both donor & recipient should match
  • Liver structure / function, as well as the other systems must be normal
  • Half of the donor liver must be enough in volume for the recipient

Life after Liver donation

After surgery, the donor stays in hospital for 1 week. His diet and activities is started very next day. Next 2-3 weeks donor resume normal activity (except strenuous physical exercise) and return to work 4 weeks after surgery. Sexual activity can be resumed as soon as the donor feels well enough. Avoid heavy physical activity, sports including lifting weights can be resumed 3 months after surgery. Donor lives normal life.

Deceased Donor Liver Transplant Surgery

When a suitable liver from a deceased donor is matched to a person who is ready to receive it, the surgery is scheduled as quickly as possible. The recipient completes pre-surgical testing and is prepared for surgery while the donor liver is obtained, transported to the hospital, and carefully checked to ensure it is suitable for transplantation.

Liver transplant surgery is complex and can take up to 12 hours. The patient receiving the liver requires general anaesthesia given through a breathing tube inserted into the windpipe, intravenous lines to provide medicine and fluids, and a catheter to drain urine.

An incision is made in the upper abdomen, and the surgical team detaches the diseased or injured liver from blood vessels and the common bile duct, clamps the vessels and duct, and removes the liver. The team then attaches the recipient’s blood vessels and common bile duct to those in the donor liver. The donor liver is typically placed in the same location where the diseased or injured liver was. Tubes are sometimes placed around the transplanted liver to allow blood and fluids to drain out of the abdomen.

After surgery, the patient goes to an anaesthesia recovery area and then to an intensive care unit. After the patient is stabilized, the breathing tube used for anaesthesia is removed and the patient moves out of intensive care and into a regular hospital room. Patients usually stay in the hospital from 1 to 2 weeks after a liver transplant.

Living Donor Transplant Surgery

Living donor transplants involve two surgeries performed in the same hospital. In one operating room, a surgical team removes the transplant recipient’s diseased or injured liver. In another operating room, another surgical team removes a segment of the donor’s healthy liver. Then the segment of donor liver is transplanted into the recipient. Otherwise, the surgery and recovery for the recipient is similar to that for a recipient of a liver from a deceased donor. The living donor typically remains hospitalized for about 1 week after surgery.

Complications of liver transplantation

Possible complications of liver transplant surgery include bleeding, damage to the bile ducts, blood clots in the liver’s blood vessels, infection, rejection of the new liver by the body’s immune system & side effects from the immunosuppressive medications liver transplant recipients must take to prevent rejection. In addition, liver diseases can recur in transplanted livers, for example, person resumes drinking alcohol after the transplant.

New liver rejection occurs when a person’s immune system recognizes the transplanted liver as “foreign” and tries to destroy it. Rejection commonly occurs a week or two after a transplant, although rejection can occur at any time that immunosuppressive medications fail to control the patient’s immune reaction.

In general, a transplant recipient needs to take more medications during the first several months after a transplant, and later some medications may be eliminated or doses may be lowered to minimize side effects. One year after transplantation, many patients require only tacrolimus, cyclosporine, or sirolimus.



Life After Liver Transplantation

Most liver transplants are successful. About 80 to 85 percent of transplanted livers are functioning after 1 year.2 People who have a liver transplant are usually able to return to normal activities after recovering for several months.

Liver transplant recipients receive intensive medical follow-up during the first year after a transplant. They have regular blood tests to check whether the liver is being damaged by rejection, infections, or problems with blood vessels or bile ducts.

To help achieve a good outcome after a liver transplant, recipients need to

  • follow instructions for taking medications
  • keep all medical appointments
  • avoid people who are ill and let their doctor know when they are ill
  • learn to recognize the signs of rejection and infection and report them promptly to their doctor
  • maintain a healthy lifestyle by making healthy food choices, exercising, not smoking, and not drinking alcohol


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