Liver Transplantation: Eligibility, Surgery, and Immunosuppression Explained

When your liver stops working, there’s no backup. No second chance. No pill that can replace it. That’s where liver transplantation comes in - not as a last resort, but as the only real path back to life for people with end-stage liver disease. It’s not simple. It’s not quick. But for thousands each year, it’s the difference between dying and living.

Who Gets a Liver Transplant?

Not everyone with liver disease qualifies. The system is strict, and for good reason. Organs are scarce. Every one saved is someone else’s chance. The Model for End-Stage Liver Disease, or MELD score, is the key. 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 mildly ill. A score of 40? You’re in critical danger of dying within three months. That’s priority one.

But MELD isn’t the whole story. If you have liver cancer - specifically hepatocellular carcinoma - you have to 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) blood marker is above 1,000 and doesn’t drop after treatment, you’re typically ineligible unless your case gets special review. This isn’t about being punitive. It’s about making sure the transplant has a real chance of working.

Then there’s the psychosocial side. Do you have a place to live? A support system? Are you still drinking or using drugs? Most centers require at least six months of sobriety before listing. But here’s the real issue: that rule isn’t applied the same everywhere. Some centers accept three months. Others won’t budge. One Reddit user in November 2023 shared how the six-month rule cost them their chance - and got over 200 upvotes. That’s not an outlier. It’s a system in flux.

Donors face their own rules. Living donors must be between 18 and 55, have a BMI under 30, and be free of heart, lung, kidney, or liver disease. They can’t smoke, drink, or use illegal drugs. Their liver must be healthy enough to give away 55-70% of it - and still grow back. The remnant liver must be at least 35% of the original volume. If it’s not, they won’t be approved. The graft-to-recipient weight ratio must be over 0.8%. These numbers aren’t arbitrary. They’re based on survival data.

What Happens During the Surgery?

The surgery itself is a marathon. Six to twelve hours. Three phases. First, the diseased liver is removed - that’s hepatectomy. Then comes the anhepatic phase: no liver. No detox. No clotting. No protein production. The body survives on machines and IV support. Finally, the new liver is stitched in. Most surgeons use the “piggyback” technique - leaving the inferior vena cava in place - which happens in about 85% of cases. It reduces bleeding and speeds recovery.

For living donors, the process is just as intense. The right lobe - about 60% of the liver - is taken for adult recipients. For kids, it’s the left lateral segment. Donors usually stay in the hospital for 5-7 days. Full recovery? Six to eight weeks. And yes, there’s risk. About 0.2% of donors die. About 20-30% have complications: bile leaks, infections, hernias. But for many, the reward is worth it. One 58-year-old donor in March 2023, slightly over the age limit, was approved because his liver anatomy was perfect. The transplant center called it a “rare exception.” But it happened.

Deceased donor livers come from two sources: brain-dead donors (DBD) and those who died after circulatory death (DCD). DCD livers used to be considered high-risk. Bile complications were common. But now, with machine perfusion - a device that keeps the liver alive and pulsing with oxygenated fluid - those rates have dropped from 25% to 18%. That’s a 28% improvement. The University of Pittsburgh’s protocol is now being adopted across the U.S.

Life After the Transplant: Immunosuppression

The new liver isn’t yours. Your body sees it as an invader. So you take drugs - every day, for life - to stop your immune system from attacking it. This is immunosuppression. And it’s not gentle.

Right after surgery, you get induction therapy. Low-risk patients get basiliximab: two IV doses on day zero and day four. High-risk patients? Anti-thymocyte globulin - five days of IV treatment. Then comes maintenance: triple therapy. Tacrolimus, mycophenolate mofetil, and prednisone. Tacrolimus is the backbone. Doctors keep its blood level between 5-10 ng/mL in the first year, then drop it to 4-8. Too high? Kidney damage. Too low? Rejection.

Myth: You’ll be on steroids forever. Truth: 45% of U.S. transplant centers now skip prednisone after the first month. Why? Because it causes diabetes in 28% of patients. Drop it, and that number falls to 17%. That’s a game-changer. But not everyone can do it. Some need the extra protection.

Side effects are real. One in three people on tacrolimus develop kidney problems by year five. One in four get diabetes. One in five get shaky hands or headaches. Mycophenolate? One in three gets stomach cramps or diarrhea. One in ten gets low blood cell counts. These aren’t rare. They’re expected. You learn to live with them - or adjust your meds.

Rejection still happens. About 15% of patients have acute rejection in the first year. It’s not always dramatic. Sometimes it’s just a rise in liver enzymes. Doctors respond by tweaking tacrolimus or adding sirolimus. Most cases are caught early. Most are fixed. But you have to know the signs: fever over 100.4°F, yellow skin, dark urine, unexplained fatigue. If you ignore them, you risk losing the transplant.

Cost, Care, and the Hidden Challenges

The surgery isn’t the end. It’s just the beginning. For the first three months, you’re in the hospital or coming in weekly for blood tests. Then biweekly. Then monthly. By year two, it’s every three months. But you’re still on the clock. Every pill. Every appointment. Every lab.

Medication costs? $25,000 to $30,000 a year - just for the drugs. Not counting hospital visits, ultrasounds, or emergency trips. Insurance? 32% of candidates get denied coverage for pre-transplant evaluations. That’s not a glitch. That’s the system.

And then there’s geography. In the Midwest, you might wait eight months. In California? Eighteen. The same MELD score, same urgency, same hospital - but different odds based on where you live. The OPTN regions don’t share organs equally. And it’s not just about distance. In 2023, patients in the Southwest had 40% lower chances of getting a transplant within 90 days than those in the Mid-Atlantic - even with identical scores.

But some centers are changing the game. Those with dedicated transplant coordinators - nurses who manage your meds, remind you of appointments, help you find transportation - have 87% one-year survival. Centers without? 82%. The difference isn’t the surgeon. It’s the support.

What’s Changing Now?

The field is evolving fast. In 2023, the FDA approved the first portable liver perfusion device - a machine that keeps donor livers alive for 24 hours instead of 12. That means better organs. More transplants. Fewer wasted livers.

And what about getting off immunosuppression? In 2023, researchers at the University of Chicago found that 25% of pediatric transplant patients could stop all drugs by age five using a new therapy targeting regulatory T-cells. It’s not ready for adults yet. But it’s a sign. The dream of a “tolerant” transplant - where your body accepts the organ without drugs - might not be science fiction anymore.

Criteria are also shifting. The AASLD will update its guidelines in 2024 to allow donors with controlled high blood pressure and BMI up to 32. That’s a big change. It means more people can help. More lives saved.

Even policy is catching up. In British Columbia, Indigenous patients now get cultural support built into their psychosocial evaluations. Sobriety requirements are being adjusted. This isn’t just medicine. It’s justice.

One thing won’t change: there’s still no artificial liver that can replace a transplant for long-term survival. Machines can buy time - maybe a few days. But they can’t restore function. Not yet. That means the demand will keep rising. Non-alcoholic fatty liver disease (NASH) now causes 18% of transplants. In 2010? Just 3%. The epidemic is here. And the transplant list is growing.

Final Thoughts

Liver transplantation isn’t a miracle. It’s a trade-off. You trade a failing organ for a new one - and then trade your freedom for a daily pill regimen. You trade your health for a chance. And for many, that’s worth it.

But it’s not fair. The system is uneven. Access is unequal. The rules are inconsistent. The cost is crushing. And the burden? It falls hardest on those who are already struggling.

The truth? A liver transplant doesn’t just save a life. It changes everything. Your body. Your routine. Your future. And it demands more than medicine. It demands support. Understanding. And a system that doesn’t leave people behind.