For Australians living with Alpha-1 Antitrypsin Deficiency (AATD or Alpha-1), liver transplantation can become a necessary treatment when liver disease has progressed to an advanced or end-stage condition. Unlike many other causes of liver disease, Alpha-1 affects the liver through a fundamentally different mechanism — and transplantation offers a highly successful outcome, including a notable benefit unique to Alpha-1. This article explains the full transplant process in the Australian context, from referral and eligibility through to long-term care after surgery.

How Does Alpha-1 Cause Liver Disease That Requires Transplantation?

In people with Alpha-1, the most common reason for liver transplantation is cirrhosis caused by a build-up of abnormal alpha-1 antitrypsin protein that becomes trapped in liver cells rather than being secreted into the bloodstream. Over time, this accumulation causes inflammation, scarring, and ultimately cirrhosis. Unlike most other forms of solid organ transplantation, tissue matching beyond basic ABO blood group compatibility has little impact on outcomes for liver transplant recipients — which simplifies the matching process compared to other organ transplants.

Is Liver Transplantation Publicly Funded in Australia?

Yes. Liver transplantation in Australia is publicly funded, with transplant units supported by the government. Recipient listing criteria and organ allocation criteria have been agreed nationally, meaning the process is consistent across states. A timely referral to a specialist transplant centre is important for achieving the best possible outcome.

Where Are Liver Transplants Performed in Australia?

Liver transplantation units across Australia include both adult and paediatric centres:

New South Wales

• Royal Prince Alfred Hospital, Sydney (adult)
• Children’s Hospital Westmead (paediatric)

Victoria

• Austin Hospital, Melbourne (adult)
• Royal Children’s Hospital, Melbourne (paediatric)

Queensland

• Princess Alexandra Hospital, Brisbane (adult)
• Lady Cilento Hospital, Brisbane (paediatric)

South Australia

• Flinders Medical Centre, Adelaide (adult)

Western Australia

• Sir Charles Gairdner Hospital, Perth (adult)

Who Is Eligible for a Liver Transplant?

Liver transplantation is generally considered when a person’s liver disease is so severe that their estimated risk of dying within the next two years without a transplant exceeds 50%, or their quality of life has become intolerable due to liver-related complications.

In adults, eligibility is largely guided by the Model for End-Stage Liver Disease (MELD) score — a numerical measure of liver failure severity calculated from blood test results. A MELD score greater than 15 typically indicates a level of disease where transplant may be warranted. In children, the equivalent measure is the Paediatric End-Stage Liver Disease (PELD) score, with a PELD score greater than 17 used as a comparable threshold.

Other clinical indications for transplant listing include:

• Diuretic-resistant ascites (fluid accumulation in the abdomen that does not respond to medication)
• Recurrent hepatic encephalopathy (episodes of confusion caused by liver failure)
• Recurrent spontaneous bacterial peritonitis (repeated serious infections of abdominal fluid)
• Recurrent or persistent gastrointestinal haemorrhage
• Intractable itch (pruritus) secondary to cholestatic liver disease

What Can Prevent Someone from Being Listed for Liver Transplant?

Several factors may make a person unsuitable for transplantation. These contraindications include:

• Untreatable problems with other major organs, including active cancer
• Coronary artery disease or cerebrovascular disease with a poor prognosis
• Severe metabolic syndrome (including morbid obesity, uncontrolled type II diabetes, hypertension, and hyperlipidaemia, with or without obstructive sleep apnoea)
• Hepatopulmonary syndrome or portopulmonary hypertension
• Behavioural risk factors including inability to adhere to medical treatment or active substance misuse
• Extreme frailty, or age over 70 with significant comorbidities
• Neurocognitive impairment (which requires close assessment)
• Poor social support or poor rehabilitation potential

Importantly, if you are assessed as unsuitable for transplant listing, you have the right to seek a second opinion from another transplant unit.

How Do You Get Referred for a Liver Transplant?

Referral for liver transplant assessment is made by your treating specialist — typically a gastroenterologist or hepatologist. Once referred, you will undergo a comprehensive set of consultations and investigations to assess your suitability for transplantation. If found suitable, you will receive detailed education about the procedure and its expected short- and long-term outcomes before being listed.

What Does the Pre-Transplant Assessment Involve?

The pre-transplant workup is thorough and covers every body system. Maintaining a healthy body weight — neither too low nor too high — is important throughout this period. You will be assessed by a multidisciplinary team that may include an immunologist, dietitian, dentist, dermatologist, and psychologist or psychiatrist.

Assessments typically include:

• Full head-to-toe physical examination
• Blood tests and kidney function tests
• Lung function testing
• Cardiac assessments including echocardiogram, cardiac catheterisation, and coronary angiogram
• CT scans of the chest and abdomen to screen for cancer
• Bone density scans
• Gender- and age-specific screening such as mammography or prostate assessment

How Long Is the Wait for a Liver Transplant in Australia?

Wait times vary and depend on several factors, including donor availability, the size compatibility of the donor liver, and the relative clinical urgency of other candidates on the waiting list. Sicker patients are prioritised when a suitable liver becomes available. Your transplant coordinator can give you the most accurate guidance based on your centre and clinical situation.

What Are the Risks of Liver Transplantation?

Liver transplantation is major surgery and carries significant risks that your transplant team will explain in detail before you consent to the procedure. Risks include:

• Rejection — your immune system may identify the donor liver as foreign and attempt to reject it
• Infection
• Hepatic artery thrombosis — a blood clot in the artery supplying the liver
• Bile duct narrowing (strictures)
• Kidney failure requiring temporary dialysis
• Cardiac complications
• Unexpected transmission of diseases from the donor
• Death — there is approximately a one percent risk of dying during the operation itself
• Long-term medication side effects, including diabetes, kidney damage, high blood pressure, skin cancers, and osteoporosis

Despite these risks, survival after liver transplantation is good, with five-year survival exceeding 80%.

What Happens After a Liver Transplant?

Recovery varies between individuals, but most people take three to six months to fully recover from liver transplant surgery. During this period, you will be monitored closely for acute rejection and will need frequent medical follow-up appointments, particularly during the first year.

You may be asked to live near the transplant hospital during early recovery. If you live more than approximately 100 kilometres away, you may be eligible for travel or accommodation assistance through your state government — ask your transplant coordinator about available support.

One important benefit specific to Alpha-1: after a successful liver transplant, the new healthy donor liver will produce normal alpha-1 antitrypsin protein. This means the underlying cause of Alpha-1-related liver disease is effectively corrected by transplantation.

What Medications Are Required for Life After Liver Transplant?

Lifelong immunosuppression is required after liver transplantation to prevent rejection of the donor liver. Most recipients receive triple immunosuppression medication, with dosages typically reduced during the first year as the risk of acute rejection decreases. Infection prophylaxis is also routinely prescribed. You must take your medications reliably as directed, and avoid foods and supplements known to interfere with immunosuppressant medications.

What Is Retransplantation?

In some cases, the transplanted liver may itself develop organ failure over time. Organ transplant recipients in Australia who experience failure of a transplanted organ are entitled to be assessed for a subsequent transplant. This is known as retransplantation, and eligibility is assessed in the same way as the initial transplant process.

Can I Speak to Someone Who Has Had a Liver Transplant?

The Alpha-1 Organisation Australia can connect you with members of the community who have undergone liver transplantation. Contact A1OA at contactus.a1oa@gmail.com.