Liver transplant complications

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
    • Cyclosporine
    • Tacrolimus
  • Steroids
    • Prednisone/Prednisolone
  • +/- Antimetabolite
    • Azathioprine
    • Mycophenolate mofetil (MMF)

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
• Malignancy (squamous cell carcinoma, lymphomas, post transplant lymphoproliferative disorder)
• Adverse effects of immunosuppressant drugs

Infections

Time from transplantation affects the risk and type of infection.

• Early (within the first month)
  • Donor-derived - bacterial, fungal, parasitic
  • Nosocomial & surgical-site - C. diff, aspiration Pneumonia, UTI, surgical-site, superinfection of graft tissue
• Intermediate (1-6 months after)
  • Highest risk for opportunistic infections - PCP, TB, fungal (cryptococcus, histoplasma), viral (BK virus, hepatitis B/C, CMV)
  • Dormant host infection reactivation - HSV, VZV, EBV
• Late (more than 6 months after)
  • Community-acquired infection

Evaluation

• CBC
  • Infection may cause leukocytosis or leukopenia
• LFTs
  • Elevated in biliary, vascular, and rejection complications
• BMP
  • Hyperglycemia, sodium, and potassium derangements 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

• Admit in consultation with transplant team

See Also

• Transplant complications
• Neutropenic fever
• Immunocompromised antibiotics