Early risks of a liver transplant

Between 80 to 90 in 100 patients will need a blood transfusion within the first week of surgery.

With any operation, there is a risk of bleeding. When this happens during the operation, the surgeon can usually stop it with extra stitches or special medications. Sometimes, it may necessary to return to the operating theatre for more surgery to stop the bleeding, as well as having a blood transfusion. Liver transplant surgery is major surgery, so the risk of bleeding is high.

Your own blood will be re-circulated during the operation and you will commonly require a blood transfusion as well. Re-circulating is when blood lost during the surgery is saved and put back into your body.

Patients who take blood-thinning medications (for example, warfarin) have a higher risk of bleeding.

A blood transfusion carries risks such as fluid overload or (very rarely) disease transmission. Your liver transplant team will discuss these with you, and will give you a leaflet that explains these in more detail.

Rejection happens in up to 30 in 100 patients during the first year after a transplant.

Rejection is when your body’s immune system starts to ‘attack’ your new liver. It happens when your immune system recognises the liver as coming from a different person and thinks it isn’t supposed to be there.

After a liver transplant, patients need to take powerful medications (‘immunosuppressants’) to help stop rejection happening. Even if you take your anti-rejection medications carefully, rejection can still occur. This is why your transplant team will closely monitor your health and liver function after your transplant.

The highest risk of rejection is in the first 6 months after liver transplant. After this, as long as patients remember to take their prescribed immune suppression, at the correct dosage, rejection is much less common

Approximately 80 in 100 patients who experience acute rejection will higher-dose steroids (usually intravenously for 3 days) as treatment and this will resolve the rejection.

The other 20 in 100 patients will need more than one course of steroids or require more powerful anti-rejection treatment. On occasion, antibodies that attack the transplanted organ can develop. This type of rejection may need treatment with a strong medication called anti-thymocyte globulin (ATG).

Learn more about rejection

Between 20 to 30 patients in every 100 will require extra antibiotics for an infection within the few weeks of liver transplant surgery.

Infections are very common after a liver transplant, in part because you will be given immune suppressing medicines. These medicines reduce the risk of you rejecting your liver, but they will also dampen down your immune system’s ability to fight infections.

Most infections can be successfully treated with antibiotics. Infections can occur in your chest, abdomen (tummy), urine, around the plastic tubes inserted through your skin, or in your surgical wound. More serious infections can spread to your blood stream. Sometimes, if there is infected fluid around the liver transplant or in the wound, you might need to go back to the operating theatre to have the fluid washed out.

Learn more about the risk of infections

These occur in between 15-20 out of 100 patients.

There can be problems with your bile ducts (tubes) after a liver transplant. Around 15-20 in 100 patients develop bile duct complications either as a leak or a narrowing (stenosis) of the bile duct.

For leaks, a special tube, called a stent (tube) may need to be placed in the bile duct to allow the leak to dry up.

Stretching or a stent can often be used to fix narrowing of the bile ducts. This can be done without surgery.

Sometimes a return to theatre is required for bile duct reconstruction.

Learn more about bile duct complications

This occurs in around 10 in 100 patients.

Your transplanted liver may not work very well to begin with. This is seen most often with higher risk transplants (e.g. fatty donor livers or livers from donation after circulatory death donors). Poor function of the transplanted liver may delay your recovery and increase the risk of further complications such as infection.

This occurs in up to 6 in 100 patients.

The hepatic artery supplies oxygenated blood to the liver and bile ducts. During or after a liver transplant, a clot may occur within this artery. This is called as hepatic artery thrombosis. This prevents oxygen getting through to the transplanted liver. Lack of oxygen will eventually result in irreversible damage to the bile ducts, resulting in infections and jaundice (yellowing).

If this occurs in the first 21 days after surgery, you may be suitable to be placed on the super urgent list for re-transplantation. At this time, you can become very unwell. This complication can result in life-threatening infections and liver cell death, which will require antibiotics, drainage, and time in intensive care.

Having a clot in your liver artery early on is more commonly associated with organs that have multiple arteries needing to be joined together. 

Clots in the liver artery that happen after 21 days may be associated with liver abscesses and problems with the bile ducts (tubes) in the transplanted liver. You may need further surgery or a re-transplant to fix the problem.

Approximately 3 to 5 in every 100 patients will need to have a second liver transplant.

This is known as re-transplantation. Re-transplantation can be needed for a number of reasons including the donor liver not working properly or problems with blood supply to the liver. Sometimes these problems can appear within hours or days after the transplant.

Up to 3 in 100 of all liver transplants may not work.

This is called primary non-function (PNF).

This complication is more common with livers donated from donors who are more than 60 years old and have mild liver abnormalities, or livers from donation after circulatory death (DCD) donors.

If your liver transplant doesn’t work, the transplant team may decide that you need another transplant (re-transplantation).

If a liver transplant doesn’t work within 7 days of transplantation, you may be suitable to be listed on what is called the ‘super-urgent’ transplant list. This would mean having extra priority to receive a donated liver. In the majority of these cases, a new liver is transplanted successfully. However, you may become very sick with liver failure before a new liver is available and die before re-transplantation is possible.

This occurs in 1 or 2 in every 100 patients.

The portal vein carries blood from the stomach and intestines to the liver, and the hepatic veins carry blood from the liver back to the heart. During the liver transplant the surgeons make joins between the liver veins and your veins. Sometimes these joins can become blocked or narrowed.

The portal vein supplies the largest volume of blood to the liver. Sometimes, there can be a narrowing at the join between your portal vein and the one on the donated liver. Sometimes, a clot can develop in the portal vein (portal vein thrombosis - PVT). 

A clot in the liver veins is less common than in the liver artery, but can occur if you had clots in these veins before surgery. Development of a PVT may require blood-thinning medication (anticoagulation) with tablets or injections and, in some cases, breaking down the clot by interventional radiology (thrombolysis).

More commonly, a portal vein narrowing (stenosis) may occur that may require radiological stenting. In both circumstances, re-transplant may be necessary.

Interventional radiology treatments may be performed under sedation with local anaesthesia, or under general anaesthetic. These involve inserting a wire through the skin into the vein, under x-ray guidance.

Similar problems can occur with the hepatic veins, with similar treatments.

About 1 in 100 patients experience deep vein thrombosis.

Blood clots can form within the deep veins of the leg. These clots can break off and travel in the bloodstream to the livers, causing liver and heart problems. Blood clots in the deep leg veins are called a deep vein thrombosis (DVT). If they travel to the liver it is called a pulmonary embolus (PE).

How your care team aim to prevent DVT:

• You will be encouraged to get out of bed as soon as you can after a liver transplant to reduce the risk of these blood clots forming.
• Tight stockings help reduce the risk of DVTs and PEs. These should be worn while you are in hospital, and until the transplant team tell you that it is safe to remove them. Some patients should not wear tight stockings, for example if you have major blood flow problems in your leg arteries.
• Blood-thinning medication is usually given to patients after a liver transplant to reduce the risks of DVTs and PEs. However, these blood thinners can increase the risk of bleeding after surgery so a balance needs to be found.

Heart problems affect 1-3 in 100 patients.

Cardiovascular (heart) problems can occur soon after a liver transplant. This is the same for any type of surgery. Heart problems can be an irregular heart rhythm, heart attack or stroke. This may need specialist input from other doctors and additional medications. The risks of these complications are higher if you have had similar problems in the past

This might happen in about 1 in every 400 attempted liver transplant operations.

Sometimes the liver transplant operation can start, but the surgeon is unable to finish the liver transplant. This is uncommon.

Reasons include:

• Serious anaesthetic complications that mean it would be dangerous to proceed with surgery (for example, reactions to the anaesthetic or other medications, or serious heart problems)
• Major bleeding that cannot be controlled
• Severe diseases of the arteries or veins that mean that connecting them to the liver transplant is dangerous
• Serious problems with the blood flow within the liver transplant that mean the liver has to be removed during the same operation
• New information about the deceased donor or liver that was not available before the operation started (for example, finding a cancer in the donor)
• Discovering unexpected cancer

Fewer than 1 in 1000 patients will get cancer from a donated liver.

It is very rare for cancer to be transmitted with the donated liver. Donors are screened as carefully as possible, to minimise the risk of transmitting any disease. Although extremely rare, donor-transmitted cancer has been known to occur on a very small number of occasions. 

You may be offered a liver transplant team from a donor known to have had cancer. This will only happen if the transplant team think that the risk of the donor’s cancer having spread to the liver is low. You do not have to accept a liver from a donor who has had cancer. This will be discussed in detail with you.

This happens in fewer than 1 in 1000 patients.

It is rare to get a serious infection such as hepatitis B, hepatitis C or HIV from a liver transplant. It is more common that less serious infections such as cytomegalovirus (CMV) are passed on – this infection is usually easy to diagnose, treat and monitor.

Learn about the risks from a donated liver

Learn more about infections