What is a liver transplant? When do I need one? How do people do after one? Who pays for it?

A liver transplant is a medical procedure that may be recommended by your doctor if you have a significant chance of dying from liver disease in the next 1-3 years. We are born with a liver that has many functions needed to maintain our health. Sustained injury, over time, can lead to decreased function and ultimate failure of the liver. There are many causes for this, with hepatitis C and alcohol being the most common. Patients are typically considered for transplant when the liver is working at roughly 10-20 percent of what is considered normal functioning. A few patients each year are referred for liver transplant on an emergency basis for "acute liver failure" — a condition that causes the liver to suddenly stop working and can lead to death in 1-2 weeks.

As you will read, evaluation for a liver transplant, receiving a liver transplant, and recovering from the procedure takes time, commitment, and is unique to each patient. The key to a successful transplant is the Transplant Team, which consists of you (the recipient), your caregiver/support person, family and friends, and the group of committed health care professionals working with you.

Definitions

A liver transplant replaces a sick (referred to as cirrhotic) liver, or a liver with a tumor, with a healthy one from someone else. Most of the time, a liver is donated from someone who has died. This was once called a cadaveric donor but is now known as a deceased donor. When an organ donor dies, the liver is removed by a surgeon and sent to the transplant recipient as quickly as possible. Livers for transplant are matched for body size and blood type. In some cases, a living person donates a portion of their liver (called a living donor). Within VA, living donor transplantation is now being considered on a case by case basis.

Statistics

According to the Organ Procurement and Transplantation Network (OPTN), nationwide in 2018:

• Over 8,000 liver transplants took place
• Largest recipient age group is 50-64 years old

The Organ Procurement and Transplantation Network (OPTN) also reports:

• Survival rate for primary liver transplant (2008-2015):
  • 1 year after transplant is 89.6%
  • 3 years after transplant is 80.8%
  • 5 years after transplant is 72.8%
• As of February 2019, there are over 13,000 people nationwide waiting for a liver transplant.

There are currently 6 VA Transplant Centers that perform liver transplants: Nashville, Madison, Pittsburgh, Richmond, Houston, and Portland. Learn more about the VA National Transplant Program.

When is a liver transplant considered?

A liver transplant is considered when you might die from liver disease within the next 1-3 years. In some situations, very severe liver disease may exclude you from receiving a liver transplant if you are too sick to tolerate the surgery and recovery. You may also be excluded if other parts of your body are too sick or have cancer. If cancer starts in the liver and is found early enough, a transplant can still be done and offers the best chance at a cure.

Your medical provider may think you need a liver transplant if you have symptoms of severe liver disease, which may include:

• Yellowing of skin or whites of eyes (jaundice)
• Fluid in your belly (called ascites) or in your legs (called edema)
• Vomiting blood or passing blood in your stool from dilated veins (varices) in your esophagus or stomach
• Unclear thinking or confusion (called encephalopathy) related to the build-up of toxins which affect the brain
• Changes in your liver tests that suggest your liver is working poorly
• Life-threatening bleeding
• Thinning of your muscles, especially in your face, neck, and arms
• Easy bruising or bleeding (due to low platelet count or decrease in "clotting" protein levels)

To treat these symptoms, you may be prescribed a diuretic (or "water pill," which decreases the ascites and edema by increasing urination), lactulose or rifaximin (which gives you diarrhea as it helps you get rid of toxins that make you encephalopathic) or a beta-blocker (which lowers your heart rate and blood pressure in order to prevent bleeding from varices). Occasionally, an antibiotic is given to prevent infection in the ascitic fluid. Your provider may do procedures like paracentesis (tap) to remove excess fluid from your belly or transjugular intrahepatic portosystemic shunt (TIPS) where a stent is inserted in the liver.

These medications may seem like unusual ways of controlling liver failure, but they are vital and may extend your pre-transplant life. Stopping these medications can lead to a rapid decline in health, hospital admission, or even death.

Cost

The VA covers the cost of evaluation, transplant, and medications for eligible Veterans, as well as travel to and from the transplant center for the Veteran and their support person. Some patients whose income level exceeds a certain threshold may be billed a co-pay for medications and/or services. In certain circumstances, patients receive a transplant outside the VA system and then return to the VA for follow-up care and medications. This service (follow-up appointments/labs and medication costs) is covered by the VA for eligible Veterans.