Liver transplant is followed by a very peculiar kind of silence.
On paper, it looks like a triumph of restoration. The yellow tint fades from the skin, the laboratory markers march back into their healthy ranges, and the failing organ is replaced by one that works. For the team, it is success. But for the person living inside that body, recovery is more than biochemical. What happens is a fundamental shift in how the body talks to itself.
The native liver is much like a gossiper. It is a sensory powerhouse, constantly whispering to the brain through a web of nerves about glucose levels, nutrient flux, and metabolic status. Processing is not its only job. It runs a courier agency, reporting signals.
Transplantation cuts those wires.
The new liver is a denervated organ. The hepatic nerves are inevitably transected during surgery, and there is no evidence of sympathetic reinnervation in the first years. It performs its chemical duties with clinical perfection, but it is sensory silent. It processes, but it does not speak. Function is not significantly impaired - substrates and circulating hormones take over regulation, but the conversation has changed.
In the first year after the graft stabilizes, a strange transition occurs. We move from the emergency phase, where we eat aggressively just to survive the hypercatabolic storm of surgery, to a phase of metabolic drift.
In the first year the new tenant will be stabilizing. I remember eating aggressively just to overcome that hypercatabolic storm of surgery. I was weighing regularly and taking measurements, as advised by my transplant team. I didn’t like the looks of the scale or my reflection in the mirror. All those enormous meals I took showed in a pretty unattractive way.
And then a strange transition occurred. Something about my metabolism drifted.
Because the liver wasn’t sending the brain any feedback, it was missing some landmarks. My hunger was - belated. My feeling of satiety was - belated. Somnolence - I forgot what that word even meant as I started playing zombie at 2.00 a.m. and ironing a pile of laundry or even worse - vacuuming my kitchen at that unheavenly hour.
The drugs, of course, contributed to this disarray. Tacrolimus, which I take at 4 mg extended-release once at 8 a.m., impairs insulin synthesis, secretion and sensitivity. It also reduced insulin secretion. It also lowers butyrate, spikes glucose and satiety feel like a thing from another world.
If the liver has gone silent, how does the body find its North Star?
Some voices disappeared, others became louder. I got better acquainted with how ghrelin works. Unlike the liver’s complex neural feedback, it is a creature of habit. It’s quite predictive and in timed meals it will rise just before meal, even if the stomach isn’t empty. It learns when I eat and starts shouting at those specific times. You can’t miss its trumpet calling for food.
After transplantation I needed an anchor for my appetite and nutrition overall. And my intermittent fasting schedule became a therapeutic tool. Eating at the same intervals ghrelin peaks sharpened and the brain acquired a reliable external structure to replace the signals lost in the OR.
In the absence of hepatic nerves, ghrelin became a more audible time cue in the body's new metabolic rhythm. So, my stomach will start issuing those loud noises at specific hours. I don’t make any appointments in that window. It would be quite embarrassing.
I’ve dealt with the rhythm by set feeding window. I also need stability, so that’s where macronutrients stepped in.
In this sensory silent state, the goal is to reduce metabolic noise. This is where a specific nutritional architecture; a lean, protein-anchored model - changed the game for me:
Protein as the anchor. It stimulates satiety hormones PYY and GLP-1 that provide the off signal the liver can no longer help with. But not just any kind of protein. Fish 3x a week, chicken breast, low carb desserts prepared with gelatin. It keeps me stable and tacrolimus isn’t complaining either. It holds at ideal concentration.
Controlled carbohydrates. This is to prevent glucose from spiking and tacrolimus loves to do that. I gave it a mean look and kept processed carbs at bay to prevent feeding the corrupt mechanism it is prone to inducing. I am doing a variant of lean low carb, moderate sodium. But it's me, because of everything I know about myself. Everyone should check what their body is telling them and clear any pattern with their transplant team, especially since tacrolimus already affects kidney function, blood pressure, and potassium.
Moderate fats. Just enough to slow gastric emptying and prolong that sense of being full. The fat my metabolism reacts best to comes from juicy chicken thighs cooked in a multitude of root veggies and two kinds of lentils. My bowels aren’t complaining, either, and labs tell a wonderful story, too.
The point is not so much dieting as providing the brain with clearer, more consistent data points.
Regulation, Rebuilt
Metabolism doesn’t just happen in the background. It was reorganized abruptly by the surgery and now I’m reorganizing it again by scheduling, measurements and balancing.
I’ve taken command because that connected nervous system is gone and I have my esthetic criteria. I am prone to excessive weight and I don’t want it under my roof. The hierarchy of control has shifted. The internal perfection of a connected nervous system is gone, replaced by a new reliance on gut-derived signals, behavioral patterns, and nutritional precision. The stomach's rhythm. The clock on the wall. The fuel in the tank.
The liver is a peripheral clock with its own timekeeping. It governs glucose, lipids and bile, and it also clears melatonin — the hormone that tells the brain it is night.
In cirrhosis, clearance slows. Melatonin that should peak at night gets delayed into the day, producing markedly elevated daytime melatonin when it is normally absent. That daytime signal causes an internal phase shift and explains the classic pattern: insomnia at night and excessive sleepiness by day, even before overt encephalopathy appears. Before transplant, I was sleepy because melatonin lingered during the day.
After transplant the problem flips.
First, a new peripheral clock. The graft brings its own molecular clock, but its nerves are cut and its timing cues are gone. In the first weeks it learns timing mainly from what reaches it by blood: food, light-driven hormones from the brain, and drugs.
Second, drugs that do not let you sleep. Immunosuppressants, especially corticosteroids and calcineurin inhibitors like tacrolimus, may affect sleep. Mild neurotoxic effects including headache, tremor and sleep disturbances are listed as common.
Third, the ICU effect. Days of artificial light, alarms, pain, and the 12-hour and now 24-hour dosing schedules entrain the brain to be awake at drug times. My awakenings were not random. They were learned.
Fourth, food becomes the time giver. With hepatic nerves silent, ghrelin's meal-anticipatory rise becomes a stronger synchronizer for hunger and activity. Regular meal timing gives the brain a reliable external cue while the central clock in the suprachiasmatic nucleus and the new liver clock resynchronize. I didn't introduce structure as lifestyle. What I did was chronotherapy.
In an earlier draft I wrote that my 2:00 a.m. drug-induced awakenings showed signs of withdrawal and that sleep was finding its way into a normal rhythm. That was wishful.
The truth two and a half years later is more stubborn. I still have characteristic abrupt awakenings around 2 a.m. with incredible mental clarity. It is impossible to go back to sleep, so I read, write and journal. I compensate with long afternoon sleeps. I told my team more than once. They prescribed Zonotte as needed. I take one a week for fear of addiction and sleep well that night. I don't see it as a solution.
I have tried to use that clarity. Husserl at 2 a.m. to fall back asleep. Honestly, I tried. But then a sentence brings up butterflies and the deal is off.
So now I keep the dullest possible political speeches by the bedside. From communist times. Good heavens, those would kill an elephant.
I live five minutes from the sleep clinic where I lecture part-time. The next step is retraining. I have to learn to reschedule the butterflies from the night shift to the day shift, to make 2 a.m. unproductive again, to shorten the afternoon sleep that keeps the split schedule alive. The clinic calls it KBT-I. I call it teaching the body that bed is for sleep, not for philosophy.
The transplanted liver learned to listen differently. By using structure, timing, and lean nutrition — noon biggest meal, MCT after, 20:00 closure with a small sausage or a few cubes of hard cheese — I am helping a silent organ find its voice in a new metabolic symphony. It's much more than feeding my ever hungry stomach. That symphony is still rehearsing at 2 a.m. But it is playing.
And that rehearsal is only possible because someone, somewhere, said yes to donation.
On European Organ Donation Day, that yes is the only reason there is any rhythm at all.
Draft and lived experience © Ljerka Kovačić Tot, 2.5y post PBC transplant, Zagreb. Edited with AI for clarity. Original draft preserved.