Liver transplant gives a second chance at life, but recovery after the surgery is not always straightforward. Most patients recover well, start walking early, and gradually return to their normal routine. However, the first few weeks and months require careful attention. Small symptoms can hold important clues, and ignoring them may delay treatment at the right time.
This guide explains the major warning signs after a liver transplant. Whether you are a patient, caregiver, or someone preparing for a transplant, understanding these signs will help you recognize what needs quick action.
Why Complications After Transplant Should Be Taken Seriously
A transplanted liver is a living organ adjusting to a new body. The body responds to it, medicines control that response, and multiple systems work together to protect the graft. When something is slightly off, the body gives signals—through symptoms, blood tests, or general discomfort.
The difficult part is that early signs of complications are subtle. Many patients feel tired or have mild pain and think it is “normal after surgery.” But certain symptoms are not normal and require immediate medical review.
The goal is simple: recognise problems early, fix them early, protect the new liver.
Key Warning Signs to Watch For
Fever That Doesn’t Settle: A Common Yet Important Sign
Fever is one of the earliest signs that something is wrong. After a transplant, fever may indicate:
- Infection (most common in the first month)
- Acute rejection (typically within the first 3 months)
- Bile duct complications
- Medication side-effects
- Vascular complications
A mild fever for one or two days can happen. However, a fever above 100.4°F (38°C) or a fever that keeps recurring should not be ignored. Infections are extremely common after liver transplant—approximately 55% of patients develop at least one clinically relevant infection within the first year, with the highest risk in the first month.
Report fever immediately if:
- It comes with chills, worsening fatigue, or increased pain near the incision area
- It accompanies abdominal pain, severe headache, or shortness of breath
- It persists despite over-the-counter medications
Many patients try paracetamol and wait 24–48 hours. This delay can allow infections to spread faster. In transplant patients, infections progress quickly because immunity is deliberately kept low to prevent rejection.
Sudden Increase in Tiredness or Weakness
Feeling tired is normal during recovery. However, a sudden drop in energy—where even standing feels heavy—is not routine. This may point to:
- Infection spreading
- Low blood counts or hemoglobin
- Electrolyte imbalance
- Acute rejection in the early stage (typically 5–30 days after transplant)
- Dehydration or poor nutrition
- Kidney dysfunction from immunosuppressive medicines
If tiredness comes with loss of appetite, poor sleep, or body aches, it needs attention. Sometimes, tiredness is the only symptom before liver tests start rising. Marked fatigue can also signal early signs of hepatic encephalopathy or neurological complications.
Yellowing of Eyes or Skin (Jaundice)
Many patients observe slight yellowing after surgery and worry immediately. Mild colour changes in the initial stage can happen. However, new jaundice appearing after the first few weeks is a major warning sign.
It may signal:
- Bile duct narrowing or ischaemic cholangiopathy
- Bile leakage or biloma formation
- Acute or chronic rejection
- Viral infections (including CMV)
- Medication-related liver stress
- Hepatic artery thrombosis
Watch for: If stools become pale or urine becomes darker, it confirms bile-related issues. These problems are treatable, but delaying evaluation can damage the graft. Around 15–20% of patients develop bile duct complications after liver transplant, with the median presentation at 6 months, though early leaks can appear within weeks.
Pain or Swelling in the Upper Abdomen
Some discomfort is expected after surgery. However, new pain, especially sharp or worsening pain in the right upper abdomen, can be linked to:
- Bile leakage or biloma formation
- Fluid accumulation (abscess)
- Organ rejection
- Ascending cholangitis from bile duct problems
- Portal vein or hepatic vein complications
Another important sign is persistent abdominal bloating or tightness that doesn’t reduce. This may indicate fluid build-up (ascites). After a transplant, ascites is not expected, so if it returns, inform your surgeon immediately.
Important note: Fever combined with abdominal pain should raise suspicion for biloma or intra-abdominal infection, which account for 27–47% of early bacterial infections after transplant.
Sudden Weight Gain or Swelling in Legs
Rapid weight gain is not always from eating more. After a transplant, it can be due to:
- Fluid retention from kidney dysfunction
- Kidney stress due to immunosuppressants (especially calcineurin inhibitors like tacrolimus)
- Heart-related issues
- Low albumin levels from poor graft function or nutrition
- Steroid-related fluid retention
If swelling begins in the feet and gradually moves upwards, it usually means the body is retaining fluid. This must be checked early because kidney function plays a critical role post-transplant. Renal dysfunction affects up to 78% of patients in the immediate post-transplant period and is one of the most common long-term complications.
Reduced Urine Output
This is one of the most ignored signs. Patients often think they are not drinking enough water. However, reduced urine output may signal:
- Kidney dysfunction caused by tacrolimus or cyclosporine
- Dehydration due to vomiting or fever
- Infection or sepsis
- Rejection-related changes in blood supply to the kidney
- Hepatorenal syndrome carryover from pre-transplant
If urine output suddenly drops—or becomes darker consistently—it is not something to ignore. Kidneys and liver work closely, and kidney problems can indirectly stress the transplanted liver. Dark urine or oliguria needs urgent evaluation to prevent irreversible kidney damage.
Confusion, Sleepiness, or Behavioural Changes
Any change in mental clarity must be taken very seriously. These signs include:
- Confusion or disorientation
- Irritability or personality changes
- Slow thinking or difficulty concentrating
- Excessive sleepiness or difficulty staying awake
- Forgetfulness or memory issues
- Tremors or unusual movements
These may occur due to:
- Infections or sepsis
- Electrolyte issues (sodium, potassium, magnesium)
- High tacrolimus or cyclosporine levels (common immunosuppressive drugs)
- Hepatic encephalopathy from graft dysfunction
- Kidney failure leading to toxin build-up
- Hepatic artery thrombosis affecting brain oxygenation
- Post-transplant encephalopathy from various causes
Even mild confusion should not be dismissed. Many families think the patient is “just tired,” but in transplant care, mental changes can be the earliest sign of a serious condition. Cognitive impairment is common after liver transplant and requires prompt investigation.
Vomiting, Nausea, or Not Tolerating Food
Post-transplant medicines can irritate the stomach. However, persistent nausea or vomiting is not expected.
Warning signs include:
- Vomiting more than 2–3 times a day
- Not being able to hold even liquids
- Feeling full after very little food
- Severe gut cramps or abdominal discomfort
These symptoms could happen due to infections (especially intra-abdominal), bowel issues, medication side effects, immunosuppressive drug toxicity, or liver graft dysfunction. Candida infections of the digestive tract are common in liver transplant recipients and can present as nausea or abdominal discomfort.
Poor intake also leads to dehydration and kidney strain, creating a chain reaction. Early correction is important. Persistent vomiting within the first month should raise suspicion for bile duct complications or ascending cholangitis.
Dark Urine, Pale Stools, or Itching
These symptoms point strongly to bile-duct-related complications or cholestasis.
Why they matter:
- They often appear before blood tests rise
- They indicate the bile is not flowing properly
- They can mean blockage, narrowing, ischaemic injury, or leakage
- Itching is one of the earliest signs of bile accumulation in the blood
If itching becomes severe at night, spreads quickly, or is accompanied by dark urine and pale stools, it is a signal that the liver needs urgent evaluation. These symptoms require imaging (ultrasound or MRCP) to rule out bile duct obstruction or stricture.
Sharp Pain in Right Shoulder or Back
This may look like a muscle issue, but in transplant patients, it can indicate:
- Bile duct pressure or ischaemic injury
- Fluid collecting under the diaphragm (biloma or hematoma)
- Right subphrenic abscess
- Hepatic artery thrombosis affecting the capsule
This pain usually increases with deep breathing or sitting upright for long periods. It is not a classic “emergency” symptom, but definitely one that needs medical review. Combined with fever or abdominal pain, this warrants urgent imaging.
Bleeding, Easy Bruising, or Black Stools
These signs point towards:
- Graft dysfunction affecting clotting factor production
- Blood-thinning complications
- Ulcers due to medications or immunosuppressants
- Low platelets (thrombocytopenia is extremely common after transplant, with 60% average platelet reduction by post-operative days 3–5)
- Internal bleeding
Any sudden bruise without injury or any black, tar-like stool should be reported quickly. Even small nosebleeds that keep recurring may mean the blood-clotting system is affected. These findings suggest either portal hypertension development or early liver dysfunction and require urgent liver function tests and imaging.
Increased Blood Sugar Levels
High blood sugar is common after transplant because steroids and immunosuppressants affect glucose control. However, when sugar levels rise too much or suddenly fluctuate, it becomes dangerous.
High glucose can:
- Increase infection risk (immunosuppression already increases this risk significantly)
- Slow healing
- Affect kidney function
- Stress the new liver
- Trigger post-transplant diabetes mellitus (PTDM)
Patients should monitor sugar levels regularly, especially in the first few months. New-onset diabetes after transplant is associated with worse long-term outcomes and requires early intervention.
Rising Blood Pressure
Blood pressure often increases due to medications like calcineurin inhibitors and steroids. However, very high readings, headaches, or dizziness should not be taken lightly.
Uncontrolled BP may cause:
- Stroke risk
- Kidney damage (tacrolimus-induced kidney injury is accelerated by hypertension)
- Stress on the liver graft
- Risk of intracranial complications
If BP is consistently above the recommended range (usually above 130/80 mmHg for most transplant patients, or as advised by your doctor), the medication dose may need adjustment. Monitor BP regularly and report sudden spikes.
Signs of Rejection—The Most Important Category
Rejection does not always mean the liver is failing. It simply means the body is reacting to the graft. Early recognition makes treatment simple and highly successful. Acute cellular rejection occurs in 15–25% of patients on modern immunosuppression regimens and most cases respond well to steroid therapy.
Common signs of rejection:
- Increase in liver enzymes (AST, ALT, alkaline phosphatase)
- Jaundice
- Fatigue and malaise
- Fever (typically 5–30 days after transplant, though can occur later)
- Abdominal discomfort or right upper quadrant pain
- Dark urine
- High INR (blood clotting time)
- Nausea or vomiting
The tricky part is that many of these signs overlap with infection. This is why transplant centres usually advise patients not to self-treat fever or symptoms—always check with the transplant doctor. A liver biopsy may be needed to confirm the diagnosis of rejection versus infection.
Early Hepatic Artery Thrombosis—A Vascular Emergency
Early hepatic artery thrombosis (eHAT) occurs within the first 2 weeks after transplant and is a severe but rare complication (0.5–4.8% incidence). It demands urgent detection because it leads to biliary complications and graft failure.
Warning signs:
- Sudden deterioration in liver function tests
- Persistent fever unresponsive to antibiotics
- New jaundice appearing abruptly
- Septic picture with chills and hemodynamic instability
Early diagnosis via Doppler ultrasound is critical because early intervention (thrombolysis or thrombectomy) can save the graft. This is why daily ultrasound screening is recommended in the first 2 weeks post-transplant at specialized centres.
Wound-Related Changes
The surgical wound should gradually heal. However, the following signs need attention:
- Redness spreading around the incision
- Pus or fluid discharge
- Bad smell from the wound
- Opening of wound edges
- Increasing warmth at the site
- Dehiscence (separation of wound edges)
- Persistent drainage beyond 2 weeks
Any of these could mean surgical site infection, especially in patients on immunosuppressants. Surgical site infections occur in approximately 10% of liver transplant patients and require prompt antibiotic therapy or wound care.
Why Blood Tests Cannot Be Ignored
Even if you feel fine, blood tests may detect complications earlier than symptoms. After a transplant, tests are frequent for a reason:
- Liver enzymes show graft health and rejection status
- Kidney tests (creatinine, GFR) show how medicines are affecting the system
- Tacrolimus levels need tight control to balance rejection prevention with toxicity
- Clotting tests (INR, PT) reveal early liver stress
- Bilirubin and albumin indicate synthetic liver function
- Blood counts detect infection or medication toxicity
Skipping tests or delaying report review is one of the biggest causes of late detection. Most complications appear in laboratory abnormalities before clinical symptoms become obvious. This is why routine follow-up is non-negotiable.
How to Keep Yourself Safe After a Liver Transplant
Here are simple but powerful habits every patient should follow:
Never skip immunosuppressant doses. Even one missed dose can trigger rejection in some patients. Set phone reminders if needed.
Maintain proper hydration. It protects both the kidney and liver. Drink adequate water unless advised otherwise by your transplant team.
Report symptoms early. Even mild symptoms matter in transplant care. Do not wait to see if symptoms resolve on their own.
Keep a small diary of symptoms and medicines. It avoids confusion and helps the doctor see patterns. Note fever, unusual tiredness, pain, or appetite changes.
Follow food and hygiene guidelines. To reduce infection risk, avoid raw or undercooked foods, unwashed vegetables, and unsafe water sources.
Avoid over-the-counter medicines without permission. Many common painkillers (NSAIDs), antibiotics, and herbal supplements can harm the liver or interact with transplant medicines.
Attend all scheduled lab appointments and clinic visits. This is where early problems are caught, often before you feel sick.
Smart Ways to Catch Problems Before They Become Serious
Many complications can be prevented simply by staying alert.
Track daily weight. Sudden gain (more than 1–2 kg in a day or 2–3 kg in a week) can reveal hidden fluid.
Monitor urine colour and quantity. Kidneys reflect liver health. Reduced output or very dark urine needs investigation.
Check temperature once daily for the first few weeks. Early morning temperature is most reliable.
Keep medicine timings strict. Delays or inconsistencies affect drug levels and increase rejection risk.
Follow your lab schedule exactly. Most problems appear in tests before symptoms develop. Liver function can change rapidly.
Note any medication side effects. Report them to your transplant team rather than stopping medicines on your own.
Maintain a list of all medicines and supplements. Including doses and timing. Show this to any new doctor to check for interactions.
These habits act like an early-warning system for the transplanted liver.
Final Thoughts
Liver transplant recovery is a partnership between the patient and the doctor. Most complications can be managed if recognised early, but they require attention, honesty about symptoms, and regular follow-ups. No patient should feel nervous about reporting small changes—sometimes a small clue can protect the new liver from major harm.
The first year after transplant is the most critical period. Infections are most common in the first month, rejection typically peaks between 5 and 30 days (though can occur later), and bile duct complications may appear anytime but often within 3–6 months. Vigilance during this window significantly improves long-term outcomes.
If you or your family member has undergone a liver transplant and you want expert guidance, advanced monitoring, or a trusted second opinion, connect with a specialist liver transplant surgeon for accurate evaluation and long-term care support.
