Liver Transplant Survival Rates and Life After Surgery

The liver transplant survival rate is more than 90 percent at one year after surgery and more than 75 percent at five years, according to Dr. Ashish George, Principal Consultant & Unit Head Liver Transplant, Fortis Hospital, Shalimar Bagh, New Delhi, India. Long-term survival depends on what follows the operation: lifelong immunosuppression managed with care, a diet adapted to a weakened immune system, and no alcohol.

This article sets out the survival figures Dr. George gave, why he says a transplanted liver has no expiry date, the long-term risks of anti-rejection medication and how they are kept down, COVID-19 in transplant recipients, nutrition before and after the operation, the alcohol rule, and the possibility of a second transplant. Who needs a transplant and when is covered in the complete guide to liver transplant.

What is the survival rate after a liver transplant?

Dr. George gave the following survival figures for patients who undergo liver transplant:

• 1 year: more than 90 percent alive
• 3 years: more than 80 to 85 percent alive
• 5 years: more than 75 percent alive
• 10 years: more than 65 to 70 percent alive

These figures describe recipients as a group. Individual results vary with the reason for the transplant and the patient's condition at the time of surgery.

Why a transplanted liver has no expiry date

A liver transplant, in Dr. George's words, does not have an expiry date. The reason is the organ's capacity to regenerate: a small insult will not harm the transplanted liver, because the cells that die are replaced. Patients who undergo a transplant and follow their treatment properly, he said, live for a very long time.

That is why he describes the operation as a cure: the patient's symptoms completely abate and the disease goes away. The condition attached to that cure is lifelong medication and lifelong contact with the transplant team.

Immunosuppression after liver transplant: the side effects

Anti-rejection drugs are taken for life, and they carry long-term risks. The body treats a transplanted liver as foreign and would reject it without treatment. Immunosuppressants, the anti-rejection drugs, prevent this.

Dr. George was direct about the costs. The medication given after transplant carries a risk of:

• heart problems
• high blood pressure
• diabetes
• kidney dysfunction
• cancer, at a rate higher than in the general population but, in his words, not very high overall

How the risks are kept down

Two practices reduce these risks. First, because the patient remains in contact with the transplant team, the doses are kept at a level at which the complications either become less likely or do not arise. In standard practice, doses are highest in the first months after transplant, when the risk of rejection is greatest, and are reduced over time to the lowest level that protects the graft. Second, if a complication does occur, there is the option of switching from one drug to another.

The risks of the drugs against the risks of the disease

The question Dr. Nasoro, an attendee, put to Dr. George was whether these side effects mean patients are worse off after a transplant. Dr. George's answer turned on comparison. Take 100 patients with advanced liver disease who are transplanted and 100 who are not. At one year, three years and five years, more of the transplanted patients will be alive.

The comparison holds only when transplant is offered at the right stage. For a patient whose disease is still compensated and whose MELD-sodium score is 14 or less, the balance favours continued medical treatment; at 15 or more it favours transplant. The reasoning behind that threshold is set out in the complete guide to liver transplant.

COVID-19 after a liver transplant

There is now significant data on COVID-19 in transplant recipients, and Dr. George described two patterns. Many patients who develop COVID-19 after transplantation have only a mild illness, perhaps no more than a flu, probably because the suppressed immune system cannot mount a very severe response against the virus.

Patients who develop severe COVID-19, however, may have poor survival. Because they are immunosuppressed, they are at risk of superadded secondary infections on top of the viral illness.

Diet before and after a liver transplant

Before transplant the aim of the diet is to protect muscle; after it, the aim is food safety for a suppressed immune system. Dr. George treats the two as separate problems.

Before transplant: protecting muscle

Patients with liver cirrhosis usually lose a great deal of muscle mass, a condition called sarcopenia. While they wait for a transplant, they are put on a high-protein, high-calorie diet to reduce that muscle loss as far as possible.

After transplant: food safety for a suppressed immune system

After the transplant, sarcopenia usually reverses quickly, because the underlying disease has been addressed. The new constraint is the immune system. Because the patient is on immunosuppressive medication, Dr. George places a few restrictions on diet:

1. Freshly cooked meals only. Food kept in the refrigerator and reheated may carry infections that are harmful to a patient on immunosuppressants.
2. Clean drinking water. The patient must make sure the water they drink is clean.
3. Raw fruit and vegetables that can be peeled. Uncooked fruit and vegetables should be ones that can be washed, peeled, cut and eaten immediately. Anything that cannot be peeled is ideally avoided, because bacteria or parasites may remain on the surface even after thorough cleaning.
4. Less red meat. Recipients carry a long-term risk of heart disease, so they are asked to eat red meat less often where possible.

These rules follow directly from the medication: the same drugs that protect the liver lower the body's defences against food-borne infection and add to cardiovascular risk.

Alcohol after a liver transplant: the limit is zero

For patients transplanted for alcohol-related liver disease, Dr. George's prescribed limit is zero. An attendee asked whether a patient long used to drinking might be allowed a small amount. The answer was no, for two reasons.

The first is physiological: the new liver will not be able to sustain the metabolic stress of alcohol after transplant. The second is behavioural. There is no natural stopping point once drinking resumes: one drink becomes two, two become four, and the habit returns. The best course, he advises, is to stop completely and not think of alcohol again.

The rule connects to the assessment before transplant, where an abstinence period of ideally six months, reducible to three, is expected. A return to drinking puts the new liver under exactly the stress it cannot sustain and, as the next section explains, weighs against a second transplant.

Liver re-transplantation: can a liver transplant be repeated?

Yes. Re-transplantation is possible, and Dr. George estimates that perhaps 5 to 7 percent of patients who undergo liver transplant may need a second one. The reasons include recurrence of the original disease, chronic rejection (gradual immune damage to the transplanted liver over months or years) and other causes.

A re-transplant is technically more challenging than a first transplant, but it is feasible, and results are good when it is done by a skilled team. Survival after re-transplantation is, however, somewhat lower than after a first transplant, particularly when the second operation is done early or in a very sick patient. How many times a transplant can be repeated is debatable: there are case reports of patients who have had two, three or even four transplants over the years, for example after repeated chronic rejection.

Additional conditions for a second transplant

For most patients the same rules apply as for the first transplant, and those whose disease has recurred for other reasons need no major evaluation beyond what the first transplant required. What changes is the scrutiny of why the first liver failed. Dr. George described two situations that demand rethinking:

• Stopping immunosuppressants. If a patient lost the first liver because he stopped taking his anti-rejection medication, the team must be confident he will take it the second time before offering another transplant.
• Recidivism. If the liver failed again because the patient went back to drinking, the team must consider whether he will maintain the abstinence a transplant requires.

Life after a liver transplant: the long view

The figures Dr. George gave describe a cure with lifelong terms: survival above 65 percent at ten years, and the option of a second transplant for the 5 to 7 percent who need it. Those terms are the medication, the follow-up with the transplant team, the food-safety rules and the absence of alcohol. Patients who keep to them, in his experience, live for a very long time.

How the donor's liver regrows and how a living donor's recovery compares is covered in who can donate a liver: eligibility, safety and regrowth. Doctors' questions on these topics are answered in full in the Live Discussion, and indicative liver transplant costs are published separately.