Liver Transplantation

An organ transplantation treatment performed in patients with end-stage liver disease, acute liver failure, and some liver cancers.

Liver Transplantation

Overview

Liver transplantation is a treatment that replaces a liver that has lost function with a liver or part of a liver from a healthy donor. It has become established as standard treatment that prolongs life and restores quality of life in end-stage cirrhosis, acute liver failure, some hepatocellular carcinomas, and congenital metabolic diseases. The shortage of donor organs and long-term management of immunosuppressive therapy remain core challenges.

Main Content

Indications and Evaluation

Liver transplantation is mainly indicated for end-stage liver disease that is difficult to recover from with conservative treatment. Representative examples include decompensation of compensated cirrhosis, recurrent variceal bleeding, refractory ascites, hepatic encephalopathy, and hepatorenal syndrome. In acute liver failure, emergency transplantation is considered when the likelihood of spontaneous recovery is low or the risk of cerebral edema is high. For hepatocellular carcinoma, transplant suitability is determined by comprehensively assessing tumor size, vascular invasion, tumor markers, and liver function, and some metabolic diseases and pediatric biliary atresia are also important indications. On the other hand, active severe infection, uncontrolled cardiopulmonary disease, conditions in which it is difficult to tolerate post-transplant immunosuppression, and some advanced malignancies are evaluated as contraindications or high-risk factors. Before transplantation, MELD or MELD-Na score, nutritional status, infection screening tests, cardiovascular evaluation, and psychosocial evaluation are comprehensively considered.

Donor Types and Organ Allocation

Donors are divided into brain-dead donors and living donors. Brain-dead donor whole-liver transplantation uses the entire liver or a split liver from a donor declared brain-dead, and allocation follows the national organ allocation system, considering urgency and expected survival benefit. Living donor liver transplantation is a method in which a healthy adult family member or other donor donates part of the liver; in adults, the right lobe is mainly used, and in children, the left lateral section is used. Living donors undergo detailed preoperative evaluation of liver volume, vascular and biliary anatomy, degree of fatty liver, and general health, and donor safety is an ethical prerequisite of transplantation. Split liver transplantation, graft reconstruction, and ABO-incompatible transplantation are also used as strategies to alleviate organ shortage.

Surgical Procedure

Recipient surgery consists of removing the diseased liver, connecting the donor liver to blood vessels, and reconstructing the bile duct. Anastomosis of the hepatic vein, portal vein, and hepatic artery and bile duct-to-bile duct or bile duct-to-intestine anastomosis are key, and management of intraoperative bleeding and hemodynamic stability is important. The cold ischemia time and preservation status of the graft affect initial functional recovery. Living donor surgery imposes invasive risk on a healthy person, so precise preoperative evaluation and postoperative follow-up at experienced centers are essential.

Immunosuppression and Rejection

After transplantation, immunosuppressants are used so that the recipient immune system does not attack the donor liver. Typically, calcineurin inhibitors such as tacrolimus, mycophenolate, steroids, and mTOR inhibitors are used in combination, and induction therapy is applied depending on the situation. Acute cellular rejection is diagnosed by elevated liver enzymes and biopsy findings and treated with steroid pulse therapy, etc. Antibody-mediated rejection is evaluated together with donor-specific antibodies and clinical findings. Because immunosuppression must be balanced against infection, nephrotoxicity, metabolic complications, and malignancy risk, the goal is the minimum effective dose for each patient.

Complications and Long-term Prognosis

Early complications include bleeding, hepatic artery thrombosis, portal vein thrombosis, biliary leakage or stricture, primary graft dysfunction, and bacterial, viral, and fungal infections. In the long term, immunosuppressant-related renal dysfunction, diabetes, hypertension, dyslipidemia, osteoporosis, neurotoxicity, and post-transplant lymphoproliferative disorder can become problems. Recurrence of the underlying disease, especially hepatitis C reinfection and hepatocellular carcinoma recurrence, is managed through regular imaging tests and tumor marker tracking. Recently, with advances in surgical techniques and immunosuppression management, 1-year survival rates have increased considerably, and in long-term survivors of 5 years or more, chronic disease management and restoration of quality of life have become important treatment goals.

Ethics and Systems

Organ transplantation is an area with strict bioethical and legal procedures. Brain death determination, donation consent, fairness of organ allocation, voluntariness and non-commerciality of living donors, and transparency in recipient selection are important. In Korea, an organ transplantation management system and a brain-dead organ donation registration and allocation system are operated, and medical staff must sufficiently explain surgical risks, the long-term burden of immunosuppressive treatment, and alternative treatments to recipients and donors.

Recent Trends

In 2024-2025, machine perfusion technology is expanding. Hypothermic oxygenated perfusion and normothermic perfusion are increasingly being studied and clinically applied as methods to evaluate the function of marginal donors or extended-criteria organs and increase preservation potential. Transplantation using direct-acting antivirals from hepatitis C-positive donors, improvement of selection criteria for fatty liver donor organs, and improvement of accessibility to split liver transplantation and pediatric transplantation are also major trends. Minimization of immunosuppression, biomarker-based rejection monitoring, donor-specific antibody management, and prevention of post-transplant metabolic disease are being emphasized. In living donors, evidence on the safety and learning curve of laparoscopic and robot-assisted donor hepatectomy is accumulating. Nationally and internationally, activating brain-dead organ donation, fairness of waiting-list priorities, and an integrated care system for long-term survivors remain policy tasks.