Liver Transplant

A liver transplant replaces a failing liver with a whole or partial liver from a deceased or living donor, and is the gold standard treatment for advanced liver disease. Dr. Ashish George, Principal Consultant & Unit Head Liver Transplant, Fortis Hospital, Shalimar Bagh, New Delhi, India, says it offers excellent long-term survival and a marked gain in quality of life, provided it reaches the right patient at the right time.

That last condition is the substance of this guide: which liver diseases lead to transplant, how the MELD-sodium score sets the timing, which patients should not be transplanted, and how viral hepatitis and alcohol change the assessment. The deeper questions of liver cancer, living donation and life after the operation each have their own article in this series.

Is a liver transplant a cure?

Yes. Dr. George calls liver transplantation a cure because the patient's symptoms completely abate once the new liver is working, and the disease that destroyed the old liver goes away. It is not, however, the end of medical care. The recipient takes immunosuppressants (drugs that stop the immune system from rejecting the new organ) for life and stays in contact with the transplant team for life.

He attributes the steady improvement in results to continuous gains in surgical expertise and in care during and after the operation. The list of conditions in which transplant helps is, in his words, expanding and evolving all the time.

Which diseases need a liver transplant?

Transplant becomes the answer when the liver can no longer sustain the body's functions, whether it fails over weeks or over years. Dr. George groups the indications into six families.

Acute liver failure

In acute liver failure, a liver that was normal at baseline deteriorates so fast, within about a month in Dr. George's description, that it cannot sustain the body. The definition used by the American Association for the Study of Liver Diseases (AASLD) allows up to 26 weeks from the onset of illness, and requires both impaired blood clotting and hepatic encephalopathy (confusion caused by liver failure) in a person with no previous liver disease.

The causes he listed are:

• viral infection, notably hepatitis A and some cases of hepatitis B
• certain drugs
• autoimmune hepatitis
• Wilson's disease, an inherited disorder of copper handling that can first appear as acute liver failure

Deciding which of these patients need an urgent transplant is a question of prognosis, and the tool most commonly used is the King's College criteria: a set of laboratory and clinical markers that identify patients unlikely to survive with medical treatment alone.

Chronic liver disease

Chronic liver disease is the most common indication. An injuring agent damages the liver continuously, and over months to years the organ loses its ability to function, usually through cirrhosis (replacement of healthy tissue by scar). The common causes Dr. George named are chronic hepatitis B or C infection, alcohol and autoimmune hepatitis, and fatty liver disease has become a major cause in its own right.

Metabolic liver disease

Less common are metabolic liver diseases, in which an inherited enzyme defect either drives the liver to cirrhosis or causes illness even without cirrhosis. These patients may also need a transplant.

Vascular disease

When the blood vessels of the liver are diseased, the organ can fail. In Budd-Chiari syndrome, the veins that drain blood out of the liver are blocked, and the congestion that follows can lead to liver failure.

Autoimmune disease

Sometimes the body's own immune system injures the liver. Dr. George listed autoimmune hepatitis, primary biliary cholangitis and primary sclerosing cholangitis, the last two of which damage the bile ducts. When these conditions progress to liver failure, they too can require a transplant.

Cancers confined to the liver

Primary liver cancers, and cancers confined only to the liver, are the sixth family. Hepatocellular carcinoma (HCC) is the most common. Less common indications include cholangiocarcinoma, neuroendocrine tumours, haemangioendothelioma and colorectal cancer that has spread only to the liver. The selection criteria and the downstaging treatments that bring patients within them are covered in liver transplant for liver cancer: HCC, the UCSF criteria and downstaging.

MELD-sodium score: when to refer for a liver transplant

Dr. George's threshold is clear: a patient with cirrhosis whose MELD-sodium score is 15 or more should be offered a liver transplant. Timing is decided by the MELD score (Model for End-Stage Liver Disease), calculated from three blood tests: serum creatinine, serum bilirubin and the INR, a measure of blood clotting. Adding the serum sodium level, as is now done, gives the MELD-sodium score.

He explained the logic in the discussion that followed his lecture. Take a patient with chronic liver disease that has not decompensated: little or no ascites (fluid in the abdomen), no encephalopathy, kidneys not significantly affected and jaundice not very high. If that patient's MELD-sodium score is 14 or less, he should continue on medicines and regular follow-up, because his risk of dying from the operation or from the long-term effects of transplant medication is higher than his risk from the disease at that stage.

At 15 or more the balance reverses. If these patients are kept on medical management rather than transplanted, more of them die than of those who receive a transplant. Dr. George cited a study of more than 16,000 patients behind this threshold. For a referring physician, the implication is that a MELD-sodium score of 15 is a trigger for referral to a transplant centre rather than a number to watch.

Liver transplant contraindications: who should not be transplanted

Dr. George named three absolute contraindications:

1. Poor cardiopulmonary reserve. If the heart and lungs are so weak that the patient may not tolerate the surgery, transplant should not be done.
2. Cancer outside the liver. A patient whose cancer has spread beyond the liver should not be transplanted.
3. Active alcohol or substance abuse. Patients who are actively drinking or using other substances should not be offered a transplant.

These three exclusions share a logic. Each describes a patient in whom the operation would carry the full risk without delivering the lasting benefit: the patient would not survive the surgery, the cancer would continue elsewhere, or the new liver would be injured by the same cause as the old one.

Can patients with hepatitis B or C have a liver transplant?

Yes. Chronic viral hepatitis, in Dr. George's assessment, poses no major challenge to offering a liver transplant. A patient with chronic hepatitis B or C who develops chronic liver failure and decompensates should undergo transplant.

The two viruses are managed differently afterwards:

• Hepatitis B: the patient is kept on antiviral medication for life after transplant. This keeps the virus suppressed and protects the new liver from injury.
• Hepatitis C: the infection is now completely treatable with directly acting antivirals, a class of oral drugs that clear the virus. They can be given before transplant and, in a few cases, after it.

The concern that an ongoing infection will damage the new liver is answered by this treatment, given before or after the operation as the case requires.

Alcohol-related liver disease: the abstinence period before transplant

For a patient whose liver failure is due to alcohol, the ideal interval between the last drink and the offer of a transplant is six months of abstinence. Dr. George accepts that this can be reduced to three months.

Some patients are too sick to wait. Where there has been no period of abstinence at all, the decision is discussed openly with the family: the transplant is lifesaving, but its success depends on the patient never returning to alcohol, because the new liver cannot sustain the metabolic stress of drinking. Those conversations, and the zero-alcohol rule that applies for life after transplant, are part of the assessment itself. The rule is explained in liver transplant survival rates and life after surgery.

Living donor or deceased donor liver transplant?

A transplanted liver comes from one of two sources. A deceased-donor liver is the whole organ, taken from a donor who is brain dead. A living-donor liver is part of a healthy relative's liver, and because the liver regrows, both the donor and the recipient end up with a functioning organ. Who can donate, how donors are assessed and how quickly the donor's liver regrows are set out in who can donate a liver: eligibility, safety and regrowth.

What survival can a patient expect?

Dr. George put survival at more than 90 percent at one year and more than 75 percent at five years. The full figures, the long-term effects of immunosuppression, diet and the possibility of a second transplant are covered in liver transplant survival rates and life after surgery.

The liver transplant programme at Fortis Shalimar Bagh

At the time of the session, Fortis Hospital, Shalimar Bagh was a 262-bed hospital with 78 intensive care beds. Its transplant programme had a separate intensive care unit for patients after liver transplant, dedicated operating theatres, and its own nurses, intensivists and anaesthetists, alongside senior and experienced transplant surgeons.

Dr. George's separate 2026 masterclass covers the diagnosis and treatment of primary liver cancers, including when resection or ablation is preferred to transplant, in the complete guide to the management of primary liver cancers. Doctors' questions from this session, on survival, donor eligibility, COVID-19 and alcohol, are answered in the Live Discussion. Indicative figures for liver transplant costs are published separately, and other specialists are listed under hepatobiliary and liver transplant surgery.