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Liver transplant complications
From WikEM
Contents
Background
- 2nd most frequently transplanted solid organ
- May be from living or deceased donor
- Most common causes of liver failure necessitating transplant include hepatitis C or B infection, alcoholic cirrhosis, idiopathic/autoimmune liver disease, primary biliary cirrhosis, primary sclerosing cholangitis, and acute liver failure (e.g. drug/toxin induced, acute hepatitis, etc.)
Immunosuppressant Medications
- Balance between immune suppression, rejection and susceptibility to infection
- Typical regimen includes: calcineurin inhibitor + antimetabolite + steroid
- Calcineurin inhibitor
- Steroids
- +/- Antimetabolite
Clinical Features
- Signs/symptoms of infection
- Fever and localizing symptoms may be blunted due to immunosupression
- GI bleed
- RUQ pain, especially with biliary complications
- Neurologic findings
- focal neuro deficits or altered mental status due to bleed, infarct, thrombosis, osmotic demyelination, abscess, etc.
- Jaundice
- may indicate rejection or biliary leak/stricture
- Nausea/vomiting
Differential Diagnosis
Most common problems in liver transplant patients involve:
- Acute graft rejection
- 1 in 5 have rejection during first year, usually within <1 mo
- Vascular thrombosis
- Biliary leak or stricture
- Infection
- Malignancy (squamous cell carcinoma, lymphomas, post transplant lymphoproliferative disorder)
- Adverse effects of immunosuppressant drugs[1]
Evaluation
- CBC
- Infection may cause leukocytosis or leukopenia
- LFTs
- Elevated in biliary, vascular, and rejection complications
- BMP
- Hyperglycemia, sodium, and potassium derrangements not uncommon
- Coags
- Tacrolimus/cyclosporine levels
Additional work up will depend on presentation, but may include:
- Infectious workup
- Blood and urine cultures
- +/- PCR and other studies for viral/fungal pathogens as indicated
- diagnostic paracentesis if evidence of SBP
- Abdominal CT or ultrasound with doppler, if concern for rejection, biliary obstruction, or thrombosis
- Biliary complications may need ERCP
Management
- Consult transplant team
- High-dose steroids for rejection
- See immunocompromised antibiotics
- See upper GI bleed
- See Spontaneous Bacterial Peritonitis
- See Graft-vs-host disease
Disposition
See Also
External Links
References
- ↑ Liver Transplants: Practice Essentials, Orthotopic Liver Transplantation, Immunosuppression Agents. Emedicinemedscapecom. 2016. Available at: http://emedicine.medscape.com/article/776313-overview#a1. Accessed September 23, 2016.
