Longer-term risks of a liver transplant

Infections are very common, even many months or years after a liver transplant.

The most common infections are chest or urine infections. These are usually fairly straightforward to treat with antibiotic tablets. Infections inside the liver transplant itself can be harder to treat.

Some infections come from the donor liver

The most common of these is a virus called CMV (cytomegalovirus). This virus infects more than half of healthy people and, after the initial infection, remains dormant in the body for the rest of your life.

Learn more about the risk of infections

Learn the risks from the donated liver

This happens in 40 to 80 patients in every 100 transplants.

Many liver transplant patients develop high blood pressure (hypertension). Being overweight and steroid medicines increase the risk. This often requires medicine to lower blood pressure.

A majority of liver transplant patients develop hypertension. The risk of post-operative hypertension is increased by obesity, corticosteroids and immunosuppressants. This often requires anti-hypertensive medical therapy.

This affects up to 40 in 100 patients.

A liver transplant can affect your kidney function. A small number of patients may require temporary dialysis in the early days after the operation.

Chronic or long-term kidney problems can occur in up to 40% of patients. This may be due to the immunosuppressant medication you need to take. In particular, ciclosporin and tacrolimus can cause kidney damage.

Occasionally, kidney function can deteriorate to the point of requiring a kidney transplant.

Many patients develop high cholesterol. Being overweight and steroid medicines can contribute to this. This may require medicine to lower your cholesterol levels.

This occurs in up to 9 out of 100 patients who have had a liver transplant.

Up to 9 out of 100 patients who have a liver transplant may require a second transplant (known as a re-transplant). This is often a result of disease recurrence, complications resulting from the first transplant or chronic deteriorating liver function.

Chronic rejection happens in 2 in 100 patients.

The risk of rejection is highest in the 6 months after a transplant. After this time, your body’s immune system is less likely to recognise the liver as coming from another person. 

However, chronic rejection can occur after 6 months. Chronic rejection refers to long-standing, and sometimes irreversible, worsening of the transplanted liver function. It is caused by the recipient’s immune system reaction to the transplanted organ.

Chronic rejection occurs in only a small number of liver transplant recipients (around 2 in 100). It can lead to the loss of bile ducts (ductopenia). 

While we do not fully understand what causes it, the strongest risk-factor for its development is repeated episodes of acute rejection, and/or acute rejection which doesn't respond well to treatment. 

It is important to take immune suppression as prescribed and have regular monitoring of your transplanted liver function and immune suppression levels. If identified early, it may be possible to treat chronic rejection. However, sometimes the only way to treat this condition is to have another liver transplant. Some patients are not suitable for another liver transplant and chronic rejection can lead to progressive liver failure and death.

Learn more about rejection

You will need to take powerful medicines after a liver transplant.

You may experience side effects to your transplant medicines. Different liver transplant centres use different medicines to prevent rejection and infection in their patients. Your own transplant centre will tell you about the medicines they will prescribe after your transplant, and the most common and most important side effects that you need to know about.

In general, medicines for liver transplant patients include:

Immunosuppressants

To reduce the risk of liver rejection.

The doses of these medicines usually reduce over time, but some medicines will be needed for the lifetime of the liver transplant. All immunosuppressants increase the risk of infection, and of some cancers.

Antibiotic and antiviral medicines

To reduce the risk of infection.

These usually stop between 3 and 12 months after a transplant, but your transplant team will advise you about this.

• Medicines to lower blood pressure, reduce blood sugar levels, or reduce the risk of blood clots.
• Medicines to protect the lining of your stomach, as some immunosuppressants and blood thinners can cause stomach irritation 
• Medicines to protect your bones
• Medicines that you may need for other health issues

Learn more about medicines after a liver transplant

There is a higher risk of some types of cancer following a transplant.

Cancer is a significant cause of illness and death in liver transplant patients. Following liver transplant, the risk of developing cancers rises for nearly all types of cancers, but more commonly skin cancer, lymphoma and smoking-related cancers.

After liver transplant, the risk of skin cancer is around 40 in 100 patients over a lifetime. The risk of post-transplant lymphoproliferative disease (PTLD), a type of white blood cell cancer, is around 2 to 4 in 100.

Symptoms of PTLD include night-sweats, fevers and weight loss. Depending on the severity of PTLD, treatment can range from minimising immune suppression to chemotherapy. PTLD can be life threatening.

What you can do:

• Avoid staying out in the sun for long periods, and wear factor 50 sunblock and a long-sleeved shirt and a hat if you are in the sun.
• It is strongly recommended that you attend any cancer screening tests, such as a mammogram, cervical smear or bowel cancer screening.
• If you notice a lump, something unusual on your skin or anything else that you’re worried about, please let your transplant team know.

Recurrent disease is when your original liver disease comes back and damages your new liver.

It is possible for your original liver disease to come back in the transplanted liver (‘recurrent disease’). This chance of this happening depends on the cause of your original liver disease. For some diseases this is common, for others very rare. Your liver transplant team will tell you whether your liver disease is likely to come back and damage your liver transplant. 

This is commoner in patients with immune-mediated liver diseases (Primary Sclerosing Cholangitis, Autoimmune Hepatitis, Primary Biliary Cholangitis) or Non-alcoholic fatty liver disease/Non-alcoholic steatohepatitis.

Primary Sclerosing Cholangitis (PSC) can recur in up to 30 in 100 patients. There is no specific medical therapy to prevent this. Sometimes, PSC recurrence can be severe enough to cause progressive liver disease which may lead to consideration of re-transplantation.

PBC can recur in up to 25 in 100 patients after a liver transplant. Ursodeoxycholic acid is now recommended to prevent this. Progressive disease requiring re-transplantation is unusual.

Non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH) can return, or even develop for the first time, especially in those who are obese, have high blood pressure, high cholesterol, or type 2 diabetes after transplantation.

Heart problems can happen many months or years after the liver transplant operation.

These problems may be due to a blockage in the blood supply to the heart. This is called a heart attack. A heart attack happens when there is a blockage in the blood supply to the heart muscle. This usually happens when there is thickening of the walls of the heart arteries.

Good treatments are available for a heart attack. These include blood thinning medication and medication to improve the blood flow to the heart muscle. Sometimes heart specialists (cardiologists) may need to place tubes into the heart arteries through blood vessels in your groin, wrist or elbow in order to inspect the heart arteries and try to unblock them.

What you can do to reduce the risk of a heart attack:

• Remain a non-smoker
• Take regular exercise
• Keep a healthy body weight
• Maintain healthy blood sugars and blood pressure

Approximately 7 in 100 patients will die within year of having a liver transplant.

There is a risk of dying following a liver transplant. But the majority of liver transplants do very well, with 93 out of 100 patients alive after a year.

It is important to remember that your transplant team won’t recommend that you have a liver transplant if they believe that the risk of the operation is higher than the benefits. For most patients, the risk of dying after a transplant is lower than the risk due to their original liver disease.

The risk of dying is different for different patients. The risk is higher in older patients, and in those who have serious heart, liver, blood vessel or liver disease and those who have previously had cancer or major infections. If your liver transplant team think that you have a higher than average risk of dying following a liver transplant, they will talk to you about this.