4. Clinical Guidelines for Liver Transplantation (PDF) - British ...

______________________________ 

4 Clinical 

Guidelines 

For Liver 

Transplantation 

Program 

______________________________ 

REVISED July, 2010 

The Clinical Guidelines are a statement of consensus of BC Transplant professionals regarding their views of currently 

accepted approaches to treatment. Any clinician seeking to apply or consult the Guidelines is expected to use 

independent medical judgment in the context of individual clinical circumstances to determine any patient's care or 

treatment. Use of these guidelines and any information on it is at your own risk, and is subject to our Terms of Use. 

AMB-GEN.08.005 Rev 01

4.1.1 INTRODUCTION 

Guidebook for the Solid Organ Transplant Programme Chapter 4 

4.1 Transplant 

Clinical liver transplantation was first performed in 1963 by Thomas Starzl and is now an 

established therapy for end-stage liver disease in selected patients. Since the introduction of 

Cyclosporine by Sir Roy Calne in 1978, outcomes have improved significantly so that the oneyear 

survival is approximately 80 to 90%. Most people return to a normally functioning life, 

although lifelong monitoring and immunosuppressive therapy is required. Liver transplantation 

was first performed in British Columbia in 1989. At present, about 30 to 40 adults undergo 

liver transplantation annually in B.C. 

4.1.2 INDICATIONS AND REFERRAL GUIDELINES 

Liver transplantation should be considered for patients with decompensated chronic liver 

disease for which all other therapeutic options have been exhausted. Such patients generally 

have one or more of the following: 

 

 

 

 

 

 

Jaundice 

Decreased synthetic function (decreased albumin, increased INR) 

Encephalopathy 

Ascites 

Variceal bleeding 

Hepatocellular carcinoma (selected) 

Such patients will have an anticipated survival of less than three or four years due to liverrelated 

complications without liver replacement. Transplantation is also appropriate therapy for 

some patients with fulminant acute liver failure. 

Special Considerations: 

Hepatitis C: Hepatitis C has become the most common indication for liver transplantation in 

most programs in North America. While results are fairly good, there is a high risk of recurrent 

hepatitis C in the new liver. The recurrence disease may be mild, but often leads to significant 

scarring in the liver after 5 years and many patients will have progressed to cirrhosis after 10 

years post-transplant. In about 10% of cases, the recurrent disease is rapidly progressive and 

may lead to graft failure within the first few years. Unfortunately there are few treatment 

options in this circumstance and the results of retransplantation for early graft loss from 

recurrent hepatitis C are too poor to make this a viable option. Antiviral therapy with Interferon 

and Ribavirin is offered to selected patients with recurrent hepatitis C, but the effectiveness in 

preventing graft failure is unknown and there is a theoretical risk that Interferon may trigger 

rejection. 

Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 1 

See Page 1 for disclaimer


4.1.2 INDICATIONS AND REFERRAL GUIDELINES CONT. 

Hepatitis B: With the advent of effective strategies for preventing allograft reinfection with 

hepatitis B, patients with hepatitis B can now be considered for liver transplantation. The HBV 

DNA level must be at the lowest level possible in order to meet transplant criteria. Those who 

have high HBV-DNA levels will be treated with Lamivudine at 100 mg daily. This results in 

HBV-DNA becoming undetectable after approximately four to six weeks in about 90% of such 

patients. Patients who do not respond may be treated with Adefovir, Tenofovir or Entecavir. 

Those who remain HBV-DNA at a titer greater than 500,000 copies/mL cannot be activated for 

transplantation. Patients with HBV who are identified, as possible transplant recipients should 

only be started on Lamivudine or Adefovir, after discussion with the transplant team. Although 

Lamivudine is well tolerated, there is a high rate of resistance by the development of mutant 

hepatitis B virus. This is approximately 50% per year for the first three years and the emergence 

of a mutant virus will render the patient HBV-DNA positive and makes transplantation more 

problematic as high-dose HBIG is then required to reduce the risk of allograft reinfection. Even 

HBV-DNA negative patients with hepatitis B are at risk of allograft reinfection. Fortunately, 

this can be prevented using a combination of antiviral drugs and immunoprophylaxis. We are 

currently using long-term prophylaxis with Lamivudine combined with low dose hepatitis B 

immune globulin (HBIG). Although patients can also develop HBV escape mutants that are 

resistant to the HBIG, at present the combination of Lamivudine and immune globulin appears 

to be very effective at preventing HBV recurrence. 

Alcoholic Liver Disease: Patients with liver failure due to or associated with alcohol abuse 

can be considered for transplantation provided that they have demonstrated full and sustained 

rehabilitation from alcohol and other substance abuse and that social supports and an abstinence 

maintenance program are in effect. The minimal criteria are at least 6 months verifiable 

abstinence, willingness to sign abstinence and monitoring contract, a satisfactory report from an 

independent alcohol and drug counsellor and favourable assessments from the transplant 

program staff members who have expertise in evaluation of patients with a history of substance 

abuse. 

Metabolic Diseases: Liver transplantation is occasionally offered as therapy for patients 

with genetic disorders that can be corrected by liver transplantation. Examples include familial 

amyloidosis, or metabolic conditions such as oxaluria, glycogen storage disease and urea cycle 

defects. 

Hepatocellular Carcinoma: Patients with hepatocellular carcinoma can be considered for 

liver transplantation. However, they must be carefully selected to minimize the chance of 

recurrence of metastatic disease, because the progression of hepatoma is accelerated by 

immunosuppression. Patients with one lesion at 5 cm or up to 3 lesions, none greater than 3 cm. 

Patients with solitary tumors up to 6 cm could be considered if they showed a good response to 

pretransplant cytoreduction. All patients with single tumor should be offered pretransplant 

cytoreductive therapy. Smaller tumors will be treated with RFA or alcohol ablation and large 

ones with chemoembolization or combination therapy. Patients who have larger lesions are 

occasionally considered if they have a good response to chemoembolization. A “good response” 

is shrinkage of the tumour, with a needle biopsy of the area that is negative and a significant 

improvement in the alpha-fetoprotein. Chemoembolization is rarely used in patients who have a 

portal vein thrombosis or a previous shunt procedure. 





HIV Guidelines: 

Undectable HIV viral load. 

CD4 count ≥ 200 but in individual cases, may consider < 200. 

HAART medications on wait list (no minimum duration, HAART medications may be 

changed by HIV specialist at anytime, i.e. no specific duration “stable dose” required). 

Each case will be assessed on an individual basis. HIV guidelines are recognized to be on 

going, dynamic in nature and they are subject to change based on future research outcomes. The 

Liver Transplant Program has an on-going dialogue with the HIV Centre for Excellence on 

these issues. 

Age: Although there is no absolute age limitation, post-operative complications are more 

common in patients over 60 and long-term outcomes are often disappointing. Candidates older 

than 60 are screened carefully for concomitant disease and many will not be suitable for 

transplantation due to comorbid conditions. 

General Health: Although secondary organ dysfunction may be present, it is not necessarily a 

contraindication if it can be expected to improve after transplantation. 

Compliance: Patients must be capable of following a complex medical regimen. Those with a 

history of noncompliance cannot be accepted. 

Emotional Stability and Motivation: Patients should be emotionally stable, have realistic 

attitudes towards their illness and have a strong will to live and return to productive lives. 

Support: Transplant candidates must identify a person or persons (usually a spouse or family 

member) who can provide comprehensive support before and after transplantation. The 

demands on support persons can be high and some patients may be unable to identify an 

individual who is able to meet the program’s requirement in that respect. Unfortunately, in such 

cases the program must defer activation for transplantation. 

Financial Resources: Patients should be prepared to stay in the Vancouver area for several 

months. Social services may be helpful in identifying sources of support. 

Expectations: Patients should have an understanding of what is involved in transplantation 

and should realize that they will be assessed by numerous members of the transplant team to 

determine if transplantation is a feasible treatment option. The decision on the appropriateness 

of transplantation is not made until after the assessment is completed. 

Physician Support: After consultation, patients are returned to the care of their referring 

specialist and family physician. The referring physician should be prepared to assist in 

arranging investigations required for the transplant assessment. Throughout the assessment 

process, the Clinical Coordinator will communicate with the referring physician, the patient and 

the transplant physicians regarding the assessment process and the patient’s clinical condition. 





After transplantation, patients will be seen by the transplant team through the Transplant 

Outpatient Clinic but are also expected to be followed by the referring physician and the family 

practitioner. The role of the transplant team is limited to monitoring graft function, prescribing 

immunosuppression and assisting with management of transplant-related complications. The 

family physician should be prepared to provide non-transplant care. 

Contraindications: The following are generally considered to be contraindications to liver 

transplantation: 

 

 

 

 

 

 

Active or chronic infection outside the biliary tree 

Extensive malignancy 

Systemic disease which significantly limits life expectancy or quality 

Refusal to accept blood transfusions or blood products 

Ongoing or recurrent alcohol or substance abuse 

Inability to follow a complex medical regimen 

Patients may be referred directly to the Clinical Liver Coordinator at BC Transplant (604-877- 

2240 or 1-800-663-6189). 

(See Appendix A: Liver Transplant Referral form) 

4.1.3 ASSESSMENT 

Patients are usually seen on an outpatient basis at BC Transplant unless they are too ill and need 

to be hospitalized. Critically ill patients may be transferred to Vancouver General Hospital for 

assessment. Following assessment, they are transferred back to their referring physician 

whenever possible for ongoing management. Patients should be referred when they are still 

relatively stable to minimize the likelihood of death or complications that preclude 

transplantation before the evaluation is completed or a suitable donor organ can be obtained. 

At the time of the initial assessment, patients will be seen by the Clinical Coordinator, a 

Transplant Hepatologist and Surgeon. All referred patients will be discussed at a weekly 

meeting of the liver transplant team. At that time, a recommendation will be made about the 

most appropriate management of the patient’s liver disease. Patients deemed to require 

transplantation will then have further investigations, including a CT scan of the abdomen. They 

will be seen by an Anaesthetist and by the team’s Psychologist, Social Worker and Dietician. In 

some cases, consultation with other specialists may also be sought. During the assessment 

phase, the transplant team provides patients and families with information about transplantation, 

including the risks and benefits of the procedure, medication regimens and the transplant 

process. 




4.1.3 ASSESSMENT CONT. 

Routine Investigations 

The following tests are typically done during the assessment phase: 

Complete blood count 

INR 

PTT 

Electrolytes 

Creatinine 

Liver function tests 

Glucose 

Protein 

Alpha fetoprotein 

CEA 

Urinalysis 

PSA to male patient 

Stool for occult blood 

TB skin test 

Virology markers for Hepatitis B, Hepatitis C, CMV, EBV, Hepatitis A, HSV, VSV, 

and HIV 

(Where indicated), ferritin, TIBC, Iron, Fraction Saturation, (ceruloplasmin, alphato1 

antitrypsin), ANA and antimitochondrial antibody and antismooth 

Blood group 

ECG 

Echocardiogram 

Chest X-Ray 

Ultrasound (Doppler) 

CT scan / MRI 

Mammogram (women) 

Selected patients may require gastroscopy, ERCP, colonoscopy 

Dental Examination 

Anaesthetic consult 

4.1.4 ACTIVATION 

Patients referred for liver transplant are assessed and, if necessary, appropriate consultation is 

made with specialists in the areas of Medicine, Surgery, Social Work, Psychiatry/Psychology 

and Drug and Alcohol Addiction. All candidates for liver transplantation who have been 

referred are then discussed at the weekly liver transplant activation rounds. This is a 

multidisciplinary rounds including representation from transplant hepatology, surgery, nursing, 

nutrition, pharmacy, psychology and social work. The decision to place a patient on the waiting 

list is made in accordance with current accepted Canadian Guidelines for Liver Transplantation. 




4.1.4 ACTIVATION CONT. 

Indication for liver transplantation shall be documented in the physician and surgeon consult 

notes and in the coordinator’s progress notes. Patients are supplied with educational material 

including Living with Liver Transplant Manual which includes risk factors relevant to 

successful transplantation. 

The date of activation is documented on the Recipients Activation Sheet and on the active list. 

Patients accepted for transplantation will be placed on the active list and will be given a pager 

and instructions to communicate any change in their location or health status to the transplant 

coordinator. A letter is also sent to the referring physicians by the coordinator. While on the 

active list, they will be followed closely by the transplant team. Patients living outside the 

Lower Mainland have urgent transportation to Vancouver arranged by the transplant 

coordinator when a donor organ is available. Air Ambulance costs are not covered by Medical 

Services Plan, however, they may be covered by extended health benefits. 

Patients in whom a contraindication for transplantation exists or those who are felt not to be 

candidates for other reasons are returned to their referring physicians for ongoing care. Some 

patients may not require transplantation at the time of assessment. These patients will be 

periodically reviewed by the transplant team, with follow-up clinical and laboratory 

investigations. These are done at three to twelve month intervals and will vary from individual 

to individual. 

When a patient is activated, the Program Assistant copies the following information as well as 

any other pertinent information and places it in a brown envelope in the patient's BCT chart. 

These copied reports are transported to the hospital by the Clinical Coordinator and the 

information from the envelope becomes part of the in-hospital chart at the time of transplant. 

Copies of: 

Patient demographics 

Social work consult 

Psychologist consult 

Anaesthesia consult 

Initial and most recent Dietician consult 

All recent physician's consults 

Summary blood sheet 

Most recent virology results 

VGH ABO report 

Imaging Reports 

Alcohol and Drug Contract and Consult (See Appendix O: Contract For Abstinence) 

Original surgical consent form signed by both surgeon and patient. (cc: BCT patient chart) 

(See Appendix M: Consent for Surgical care and Transfusion of Blood Products) 




4.1.4 ACTIVATION CONT. 

All preoperative investigations become a permanent part of the BCT Chart. A letter outlining 

the assessment and plan for follow up is written by the transplant hepatologist and the surgeon 

and sent to the referring specialist with copies to the family doctor and to the BCT chart after 

each visit to the BCT clinic. Nursing Assessment is charted on the progress notes of the BCT 

chart. When a patient is ready for activation a Recipient Activation form is filled out (See 

Appendix N) and remains in the BCT chart. A letter is sent to the referring specialist, with 

copies to the family doctor and the patient informing them of the activation. When patient is 

placed on Active Liver Transplant list, the Clinical Coordinator reviews the updated active list 

to ensure accuracy. 

Critical recipient-specific listing items are documented in the BCT patient chart as well as on 

the Active Liver List. The Active List is updated as necessary to change status, weight, etc. The 

Active Liver List is discussed and reviewed at the weekly Liver Team rounds. Any changes to 

the Active List shall be made under the direction of the transplant physician and/or surgeon on 

call. 

A copy of the Active Liver List is kept in Recipient Coordinator’s On-Call Binder. Each 

member of the Liver Transplant team receives an updated list at weekly Liver Team meetings. 

An updated list shall be distributed to the on call transplant physician, transplant surgeon and 

Clinical Coordinator as changes occur. 

In addition to other information, patient's home address, phone number, contact number, 

referring specialist and family doctor are found on the “Extra-Renal Transplant Waiting List 

Demographic” form, which is located in the Clinical Coordinators on call book. 

(See Appendix Q: When a Liver Becomes Available) 

4.1.5 PATIENT DEEMED NOT TO BE TRANSPLANT CANDIDATE 

Patients who are considered unsuitable for transplantation and therefore discharged from BC 

Transplant's follow-up care are informed of the decision by the Clinical Coordinator and 

offered the opportunity to meet with the liver transplant team members for a face to face 

meeting. The Medical and Surgical Director of the Liver Transplant Program writes a letter to 

the referring physician and the patient’s primary care physician informing them of the decision. 

Patients in whom a contraindication for transplantation exists or those who are felt not to be 

candidates for other reasons are returned to their referring physicians for ongoing care. 




4.2.1 DONOR COORDINATION 

4.2 Transplant 

When a donor liver becomes available, the transplant surgeon on call and hepatologist review 

the list of activated patients with compatible blood type to the donor and select the recipient 

based on medical urgency, size compatibility and waiting time on the list. 

Patients on the waiting list are discussed at the weekly activation rounds. Changes in status are 

in accordance with the accepted Canadian Society of Transplantation (CST) criteria (i.e., status 

1 to 4). 

Patients who are assigned a higher priority status are given preference for transplantation (if an 

organ becomes available) compared to patients who have lower CST priority status listing. 

4.2.2 RECIPIENT COORDINATION 

(See Appendix R: VGH Transplant Checklist) 

4.2.3 PRE-OPERATIVE PROTOCOL 

When a suitable donor organ has been identified, the recipient will be admitted to Vancouver 

General Hospital and assessed by the hepatologist on call. Pre-op blood work and a chest X-ray 

is done. If no contraindications to transplantation have arisen, the patient is prepared for 

surgery. 

(See Appendix B: Pre-Liver Transplant - Adult) 

4.2.4 BACK-UP 

Occasionally a second potential recipient is prepared for transplant in the event the first 

recipient is found to be unsuitable. 



4.2.5 TRANSPLANT PROCEDURE 


The technical aspects of liver transplantation are complex. The procedure has been modified in 

many ways over the years to account for concerns regarding physiological stability during the 

transplant procedure and has been further modified to accommodate split liver, partial liver and 

living-related liver transplantation. The procedure is described as an orthotopic liver 

transplantation, which means replacing the liver in the same location in the body. 

The liver transplant actually requires four surgeries. These are listed as follows: 

i. Donor hepatectomy 

The liver is removed along with other organs, such as the heart, lung, pancreas and kidneys. 

Occasionally, the liver is split into two during this process and usually a portion of the organ 

goes to a child and the remaining liver goes to an adult. During this procedure, the anatomy of 

the donor is assessed and the liver is assessed for fat content, size and the presence of any 

tumors or abnormalities, which may affect the recipient operation. The organ can be kept in ice 

for up to 24 hours. However, the longer the storage time, the more likely there is going to be an 

ischemic reperfusion injury due to lack of nutrients and oxygen to the liver. Therefore, it is 

desirable to keep the cold ischemic time, i.e., the time the liver is stored on ice, as short as 

possible, preferably under 12 hours. 

ii. Recipient hepatectomy 

The recipient surgery is divided into three procedures: 

a. On entering the abdomen, the surgeon performs a careful assessment of the liver and 

other intra-abdominal structures. 

b. Rarely, an unexpected abnormality such as an advanced malignancy is found that 

precludes transplantation. A back-up recipient may then be brought in. 

c. The diseased organ is removed in a way that preserves vessels and the bile duct to 

permit re-anastomosis to the graft. 

The anesthesia for this particular procedure is quite complex. The patient requires intensive 

monitoring during the procedure. This requires a catheter in the radial artery at the wrist, in the 

central vein near the heart for monitoring pressures and for rapid infusion of fluids. The patient 

generally has compression devices on the legs to prevent blood clots from forming in the legs 

during the prolonged procedure. The entire chest and abdomen, armpit and groin are prepared 

should a venous bypass be required. Venous bypass allows flow of the blood from the inferior 

vena cava below the liver, which is normally clamped off during the operation, to leave the 

body, go through a pump and enter the body again above the liver. Patients who have heart 

disease or metabolic conditions, such as amyloidosis may not tolerate vena cava clamping 

during the procedure and may require a venous bypass. The venous bypass catheter takes blood 

from the saphenous vein in the groin and replaces it through the axillary vein in under the 

armpit. Therefore, incisions may be necessary in the groin and armpit when this procedure is 

performed. 




4.2.5 TRANSPLANT PROCEDURE CONT. 

iii. Back table preparation 

Before the liver is transplanted into the recipient, it is prepared in a separate location in the 

operating room. This is called the “back table preparation". The liver is inspected, perhaps 

biopsied, the anatomy is confirmed and any abnormalities, injuries or unusual findings detected 

and dealt with. The liver is modified to fit the recipient’s anatomy if necessary and the vessels 

and bile duct are optimized for transplant. 

iv. Transplantation 

Once the liver has been prepared in the back table, the diseased liver is removed and the 

transplant itself begins. There are two commonly used recipient procedures. One is the 

standard orthotopic procedure, which is generally used for patients with tumors and whole 

organ transplants, where the vena cava, the large vein that goes to the heart, is removed with the 

diseased liver. A second technique, termed “piggyback” technique is when the recipient’s vena 

cava is left intact, the liver is removed from the cava and the hepatic veins are sewn to the 

hepatic veins of the donor liver, leaving the patient’s vena cava as well as the transplanted vena 

cava intact. The first step of the recipient procedure is the anastomosis, the suprahepatic vena 

cava first, followed by the infrahepatic vena cava. 

The liver can be either washed out with cold lactated Ringers solution or some IV solution that 

washes out the potassium and preservative solution, or the patient’s portal blood can be run 

through the liver and allowed to run out the vena cava from below through a vent until such 

time that the liver has been washed out with the patient’s own blood. This blood is usually 

saved in a cell saver system, which scavenges any blood that is allowed to leave the body and is 

re-transfused once the red cells have been washed. This cuts down the need for allogeneic blood 

transfusions. 

Once the vena cava has been reconstructed, the portal vein is reconstructed, which when 

completed allows for reperfusion of the liver. The next procedure is to reconstruct the hepatic 

artery, which is done is various ways, generally not leaving too short of an artery or too 

redundant an artery. Good flow through the portal vein and hepatic artery is mandatory for 

survival of the organ. The quality of the storage can be assessed by the stiffness of the liver, the 

rapidity of preservation and the fact that the liver may make bile in the early reperfusion period. 

Livers that contain a lot of fat or were in storage for a prolonged period of time may function 

poorly at first. In the third stage of the operation, the bile duct is reconnected. If the biliary 

system of the recipient is adequate an intraoperative cholangiogram may be done to assess for 

major bile leaks or obstruction. 

The donor bile duct is sewn to the recipient bile duct so that the sphincter mechanism in the 

distal end is still intact. Sometimes a small stent is placed across the sphincter of Oddi to reduce 

the chance of a bile leak. The stent usually floats out on its own in the postoperative period but 

may have to be removed endoscopically. 




4.2.5 TRANSPLANT PROCEDURE CONT. 

iv. Transplantation cont. 

If the recipient’s bile duct is diseased or if a split liver is being transplanted Rouxtoentoy 

choledochojejunostomy may be performed. In this case, a loop of bowel is sutured to the 

intrahepatic bile duct to serve as conduit for bile drainage. Once the bile duct is reconstructed, 

the gall bladder is removed and the liver is checked for any bleeding. 

If no bleeding is detected, up to three drains are placed into the abdominal cavity, usually one 

under each leaf of the diaphragm and one by the bile duct. The abdomen is then closed and the 

patient goes into the Intensive Care Unit for early postoperative management. 

Immunosuppressive treatment is started in the operating room to minimize the risk of rejection. 

The transplant surgeon is responsible for completing the BC Transplant Cooler sheet (Part B) 

and returning it to the BCT Organ Donation and Hospital Development (ODHD) Department. 




4.3.1 IN-HOSPITAL CARE 

4.3 Post-Transplant 

After the transplant operation, the patient is transferred to the Intensive Care Unit (ICU). 

Management in the ICU specifically relates to the identification of early post-transplant 

complications such as bleeding, metabolic abnormalities, perfusion abnormalities, ventilatory 

support and sepsis. The patient is carefully monitored with tests, hemodynamic monitoring and 

clinical examination. Most patients will spend 24 to 48 hours in the ICU before being 

transferred to the Transplant Unit. Occasionally, patients with serious complications or 

respiratory problems may have a more prolonged ICU stay. 

(See Appendix C: Liver Transplant Post-operative Orders in ICU) 

From the ICU, the patient will be transferred to the transplant unit. Postoperative care of the 

patient involves standard surgical nursing care, nutritional support, mobilization, medical and 

immunosuppressive therapy, monitoring for rejection, sepsis, or biliary tract complications and 

education for the patient and his/her family. Psychological interventions are available to assist 

the patient in coping with inevitable stresses and for anxiety, mood and pain management. 

The drains are removed in the early postoperative period except for the one by the bile duct, 

which is usually left for about a week or until the patient is on a regular diet and no bile leak is 

detected. 

4.3.2 EARLY COMPLICATIONS 

The early complications after a liver transplant fall into four major categories. 

The first includes surgical complications: which include intra-abdominal bleeding, vascular 

thromboses and bile leaks or bile strictures. A bile leak is an occasional but serious 

complication of transplant operations. Patients typically have abdominal pain, ongoing jaundice 

and sepsis. Diagnosis may be made by HIDA scan or cholangiogram. Sometimes patients can 

be managed by the placement of a stent at the time of an ERCP. Patients may require reoperation 

for bile duct reconstruction. 

The second category is primary non-function: which is another complication that the liver 

itself may not work adequately postoperatively. This is termed primary non-function and may 

be due to multiple factors, both patient and graft. Complete primary non-function is life 

threatening and occurs in only 2% of transplants. The only option is retransplantation on an 

urgent basis. 

The third category is infection: Bacterial, fungal or viral. These are treated with appropriate 

antimicrobial agents (See Appendix I & J for treatment guidelines). 




4.3.2 EARLY COMPLICATIONS CONT. 

The fourth category is rejection: Acute rejection occurs in approximately 30 to 40% of the 

patients. This is usually suspected by an increase in liver enzymes. A liver biopsy is performed 

to confirm the diagnosis. Treatment is with Methylprednisolone (SoluMedrol ® ) 10mg/kg per 

day for three days. Patients with steroid resistant rejection may require antibody treatment 

(ATG) and/or alternate immunosuppressive regimens. 

Anti-rejection Protocols and Target Levels: 

Anti-rejection: medications for liver transplant recipients include: 

1. Tacrolimus: Initial oral dose is 0.03 mg/kg/ dose given every 12 hours for the first few 

days post-transplant. Once liver function has been established increase dose to 0.12 to 

0.15 mg/kg/day divided every 12 hours to achieve therapeutic concentrations 

(See Appendix D: Table - Target Cyclosporine/Tacrolimus Blood Concentrations) 

2. Azathioprine: 1 mg/kg PO daily 

3. Methylprednisolone: IV daily 

a. Day 0 – 500 mg 

b. Day 1 – 200 mg 

c. Day 2 – 160 mg 

d. Day 3 – 120 mg 

e. Day 4 – 80 mg 

f. Day 5 – 40 mg followed by 

4. Prednisone: 20 mg (or 0.3 mg/kg) PO daily. Dose is tapered over 6 months so patient is 

steroid free by 6 months 

Guidelines for Use of Other Immunosuppressive Agents: 

1. IL-2 Receptor Blockers: Basiliximab (Simulect ) 

The use of Basiliximab is restricted to patients who are heading into a liver transplant with 

renal impairment. For patients with renal impairment the use of a calcineurin inhibitor for 

induction may aggravate renal impairment and hinder post-transplant renal recovery. Under 

these circumstances, our program prefers to use an induction with an IL2 receptor 

antagonist, followed by either delayed low-dose Tacrolimus or, if renal recovery does not 

occur, continued avoidance of Tacrolimus with the use of Mycophenolate Mofetil 

plus/minus Sirolimus. 





2. Mycophenolate Mofetil (CellCept ) 

In the maintenance phase, Mycophenolate Mofetil (MMF) use is restricted to the following 

indications: 

a. Renal dysfunction: Under these circumstances, in order to allow the use of low-dose 

calcineurin inhibitors or, in some cases, no calcineurin inhibitor. Mycophenolate 

Mofetil is used. 

b. Graft rejection: In circumstances in which graft rejection occurs despite the use of 

Tacrolimus at therapeutic levels, Mycophenolate Mofetil will be used. Once graft 

function has stabilized, Mycophenolate Mofetil use may be discontinued after three 

to six months. 

c. Calcineurin neurotoxicity: In circumstances where neurotoxicity has occurred to a 

calcineurin inhibiting agent, Mycophenolate Mofetil use will be indicated on an 

indefinite basis. 

d. Mycophenolate Mofetil use as a steroid-sparing agent: There may be circumstances 

in which patient’s should be weaned off maintenance Prednisone, i.e. osteoporosis, 

osteopenia, diabetic mellitus, etc. and for which patients are either intolerant of 

Azathioprine or the continued use of Azathioprine is inadequate to maintain a 

rejection-free allograft. Under these circumstances, Mycophenolate Mofetil may 

have to be used on an indefinite basis. 

The goal is for all patients that are clinically stable and have reached one year on initial 

immunosuppression with Mycophenolate to switch to Azathioprine 1 mg/kg/day PO except 

patients with the following: 

 

 

 

Calcineurin inhibitor nephrotoxicity or neurotoxicity despite therapeutic 

calcineurin inhibitor concentrations 

Calcineurin inhibitor hypersensitivity reactions or microangiopathy 

Multiple rejection episodes (≥ 2 rejections within the first year post transplant), 

despite adequate maintenance immunosuppression, including the inability to 

discontinue steroids 

3. Sirolimus (Rapamune ® ) 

The use of Sirolimus by the Liver Transplant Program is on a case by case individualized 

basis. Due to an increased risk of hepatic artery thrombosis (HAT) in de novo transplant 

recipients, Sirolimus should not be used within the first 3 months of transplantation. The 

risk/benefit ratio of Sirolimus use in any liver transplant recipients must be discussed with 

the liver transplant team and the patient. Sirolimus has a long half-life (around 72 hours) 

and takes about 7 to 10 days to reach therapeutic level. Therefore it should be used with 

another agent until therapeutic level is reached. (See Appendix E: Target Sirolimus 

Therapeutic Blood Concentrations) 





To date, Sirolimus has been used when immunosuppression is required with low-dose 

Tacrolimus levels. The circumstances in which this drug may be used would be in patients 

who are suffering from ongoing renal dysfunction or calcineurin inhibitor toxicity and 

Mycophenolate Mofetil use alone is inadequate either because the patient cannot tolerate 

MMF or because of the risk of ongoing rejection 

(See Appendix F: Application for Sirolimus) (Also in Chapter 7, Section 7.9) 

4.3.3 Exceptional Distribution - Follow-up of Recipients 

It is recognized that in exceptional circumstances and compassionate reasons, a liver may be 

transplanted even when there may be a contraindication during donor assessment (e.g., 

incomplete donor screening). If these conditions exist, an organ may be released for transplant 

only under exceptional distribution as per Health Canada requirements. The process is 

documented on an Exceptional Distribution Form by the BCT Organ Donation Coordinator. 

The transplanting physician must authorize the exceptional distribution including obtaining 

informed consent of the recipient. Copies of the exceptional distribution form are to be 

included in the Recipient chart. 

It is important that in all cases, appropriate follow-up of recipients is performed by the posttransplant 

medical care team. Each exceptional distribution is to be reviewed and assessed by 

the team for any follow-up treatment and diagnosis. 

Risk for Viral Mediated Disease Transmission 

In Exceptional Distribution cases involving risk for viral mediated disease transmission, the 

following will be faxed from BCT Quality Assurance to the transplant hospital or outpatient 

location: 

1) Fax Coversheet - Required Medical Follow-up for Transplant Recipient(s) 

(See Appendix S) 

2) Copy of the Exceptional Distribution Form 

3) Reference - Recommended Follow-up Testing for Recipients Transplanted under 

Risk for Viral Mediated Disease Transmission (See Appendix S) 

The post transplant Coordinator at VGH will ensure the above documents are reviewed by the 

post-transplant medical care team and the recommended follow-up is performed at the required 

intervals. 




4.4 Outpatient Follow-up 

4.4.1 AMBULATORY CARE PHASE 

Patients typically remain in the hospital for less than two weeks. After discharge from hospital, 

they are usually seen in the Post Transplant Clinic on a daily basis until their wounds are well 

healed and the staples and drains have been removed. The physician sees them twice weekly for 

the first four weeks and weekly for the next few months. For patients with no major 

complications, frequency of visits is gradually reduced to monthly for the remaining part of the 

first year and approximately every two to three months for the next two years. Psychological 

services are available to assist patients with their emotional adjustment issues. 

Blood tests are done twice weekly for the first few months and if stable, biweekly and then 

monthly by the end of the first year. The blood tests are to monitor liver and renal function, 

blood counts, blood levels of immunosuppressive medication and screening for common 

complications of immunosuppression such as CMV disease. Patients who had a hepatoma are 

also followed with alpha-fetoprotein levels and chest X-rays every four months for the first 

three years. 

At six months, twelve months and every year thereafter, patients have more extensive 

investigations, which include hepatitis serology, cholesterol, hemoglobin A1C and ultrasound 

of the abdomen. The purpose of these tests is to monitor possible side effects of 

immunosuppressive medications and screen for new or recurrent viral infection. 

Patients develop a close relationship with the transplant team and have an understandable 

tendency to call on the transplant team for all their health concerns. However, the transplant 

physicians and nurses are neither able to nor necessarily the best qualified to advise on general 

health concerns or routine follow-up and it is expected that the family physician and referring 

specialist will continue to take primary responsibility for their general medical care. The 

laboratory investigations that are done prior to each clinical visit and also the “mini” blood 

work performed for routine interval monitoring. 

(See Appendix G: VHHSC Standing Lab Orders) 

Hepatitis B protocol: 

(See Appendix H: Protocol for Hepatitis B) 




4.4.2 IMMUNIZATION 

Immunization in Immunocompromised Hosts: 

General Principles: 

 

 

 

 

 

 

Maximize benefit while minimizing harm 

Make no assumptions about susceptibility or protection 

A history of childhood infection or previous immunization may be irrelevant 

Immunize at the time when maximum immune response can be anticipated 

Immunize early, when immunologic decline is predictable 

Delay immunization if the immunodeficiency is transient (if this can be done 

safely) 

Stop or reduce immunosuppression to permit better vaccine response 

Consider the immunization environment broadly 

Spread of vaccine strain varicella to family members of the vaccine 

Avoid live vaccines, unless 

Data are available to support their use 

The risk of natural infection is greater than the risk of immunization 

Monitor vaccines carefully and boost aggressively 

The magnitude and duration of vaccine-induced immunity are often reduced 

Some vaccine strain organisms can persist for years in compromised hosts 

Source: Canadian Immunization Guide, 6 th Edition 




4.4.2 Immunization Cont. 

Solid Organ Transplant Candidate 

The number of immunocompromised people in Canadian society is steadily increasing for a variety of reasons, 

including the accumulation of long-term survivors after organ transplantation. Apart from the importance of 

providing protection to the individuals, the increasing number of susceptible immunocompromised persons may also 

be of public health importance. One general principle of immunization of immunocompromised individuals is to 

immunize at a time when maximum immune response can be anticipated. Our goal is to have every Solid Organ 

Transplant Candidate within British Columbia complete all of their recommended vaccine series BEFORE they 

have their transplant. This will maximize benefit while minimizing harm. 

Organ 

Tdap/ 

Td 

IPV 

Hepatitis A 

Hepatitis 

B 

Meningococcal 

Quadrivalent 

Conjugate 

Pneumococcal 

(polysaccharide 

only) 

Hib Influenza MMR Varicella 

Kidney 

 

Liver 

Pancreas 

 

Lung 

Heart 

 

 

Live Vaccines: 

MMR Vaccine for susceptible adults born after 1956 - 2 doses minimum 1 month apart 

Varicella Vaccine for any susceptible (test for VZIgG) adult - 2 doses minimum 1 month apart 

Live Vaccines must be given at least 4 weeks BEFORE transplantation 

Booster Doses: 

Td every 10 years for life 

Influenza every year for life 

Pneumococcal - a once only revaccination after 5 years 

References: Canadian Immunization Guide 7th Edition, BC Centre for Disease Control Immunization Program Manual, 

Loutan, L. Vaccination of the Immunocompromised Patient. Biologicals, 1997,25, 231-236., Avery Rk and 

Ljungman, P. Prophylactic Measures in the Solid-Organ Recipient before Transplantation: CID 2001;33:S15- 

S21. 



4.4.2 Immunization Cont. 


Solid Organ Transplant Recipients 

There is potential for serious illness and death in both the under immunization and over immunization of 

these people. Immunization of those with significant immunodeficiency should be performed only in 

consultation with experts. 

Organ 

Tdap 

/Td 

IPV 

Hepatitis 

A 

Hepatitis 

B 

Meningococcal 

Quadrivalent 

Conjugate 

Pneumococcal 

(polysaccharide 

only) 

Hib 

Influenza 

Kidney 

Liver 

Pancreas 

Lung 

Heart 

 

Booster Doses 

Td every 10 years for life 

Influenza every year for life 

Pneumococcal - a once only revaccination after 5 years 

ALL Live Vaccines (such as MMR and Varicella) are Contraindicated after transplantation 

References: Canadian Immunization Guide 7th Edition, BC Centre for Disease Control Immunization Program 

Manual. 




BCCDC - Communicable Disease Control Immunization Program - Immunization of Special Populations 

January 2010 VACCINES RECOMMENDED FOR IMMUNOSUPPRESSED CLIENTS 

IMMUNE- 

SUPPRESSING 

CONDITIONS 

Asplenia (anatomic or 

functional), including 

sickle cell disease 

Congenital 

immunodeficiency 

(e.g., Complement, 

properdin, or factor D 

deficiency) 

Hematopoietic Stem 

Cell Transplant 

(HSCT)recipient 

Meningo 

 

Pneumo 

 

VACCINES 

Special Indications 

Hib 

Hep A Hep B Influenza 

 

Routine 

Inactivated 

x x x x x 

x x x x x C 

x x x x x x x 

HIV + adult x x x x x x 

Immunosuppressive 

therapy 

x x x x C 

Islet cell transplant 

candidate or recipient 

x x x x x 

Kidney 

disease(chronic) (predialysis 

and dialysis 

clients) 

x x x x 

Liver disease 

(chronic) 

x x x x x x 

Hepatitis B (chronic) x x x x x 

Hepatitis C (chronic) x x x x x x 

Malignant neoplasm x x x x C 

Solid organ (liver, 

heart, lung, kidney) 

transplant candidate 

or recipient 

x x x liver liver kidney x x 

Meningo = Meningococcal conjugate vaccines 

Pneumo = Pneumococcal conjugate and/or polysaccharide vaccine 

Yearly influenza immunization is indicated for all immunosuppressed individuals ≥ 6 months of age. 

Special considerations exist. 

C = Contraindicated 

This table is intended as a guideline only. For more information, refer to the appropriate health condition 

in this Section or BC Communicable Disease Control Manual, Chapter 2, Section VII Biological Products 

Live 




4.4.3 PROPHYLACTIC ANTIBIOTIC DENTAL COVERAGE 

As a general rule, we believe that all teeth should be preserved if at all possible. If this includes 

root canal or periodontal work, this should be done when the patient is well and ideally after 

transplantation. 

Pre-Transplant Patients 

These patients differ fundamentally from heart valve patients in two ways. The first is that it’s 

very easy to develop spontaneous bacterial peritonitis with dental procedures. Most of these 

patients will have ascites and therefore are at risk of this. The second problem is that because of 

their blood clotting abnormalities, things as simple as teeth cleaning can lead to progressive 

bleeding. Our major concern with cleaning and dental extractions, is that the patient will 

develop discomfort related to this and therefore will require some analgesia which could 

precipitate encephalopathy. Secondly, they can bleed from this and the swallowed blood and 

protein can also precipitate encephalopathy. Thirdly, they can become infected and not only 

can this also cause spontaneous bacterial peritonitis (SBP) but can also lead to encephalopathy. 

Therefore, as a general rule, patients and dental staff should follow these general guidelines. 

1. Pre-transplant patients should generally not undergo either cleaning or any periodontal 

work unless they are very early in the course of their disease. The patient usually will be 

informed as to whether or not he/she could proceed with aggressive dental work. 

2. Fillings above the gum line should be treated only with Amoxicillin 2 grams PO one hour 

prior to the dental procedure. 

3. Fillings below the gum line, including root canals, should be performed in pre-transplant 

patients only when necessary. These patients should receive Amoxicillin 2 grams PO one 

hour before their dental procedure and Penicillin V 300 mg PO four times daily for four 

days. 

4. Patients requiring standard extractions should receive Amoxicillin 2 grams PO one hour 

prior to dental procedures and Penicillin V 300 mg PO four times daily for ten days 

thereafter. 

5. As mentioned above, we try to preserve every tooth. In the event that extraction is required 

of teeth 36, 37, 38, 46, 47 and 48, the addition of Decadron is usually of benefit. This helps 

to reduce swelling and therefore decreases analgesia requirement. The dosage is 4 mg on 

the morning of their procedure, 2 mg on the morning of post op day 1 and 1 mg on each of 

the subsequent two days. All of this of course is in addition to the Amoxicillin and 

Penicillin V as mentioned in number 4 above. 

6. Patients who are allergic to Penicillin (non skin rash only) should receive a single dose of 

Clindamycin 600 mg PO instead of the 2 grams of Amoxicillin PO and should receive 

Clindamycin 300 mg PO three times a day instead of the Penicillin V. 




4.4.3 PROPHYLACTIC ANTIBIOTIC DENTAL COVERAGE CONT. 

7. Patients undergoing an elective root canal with localized abscesses should receive 48 hours 

of Penicillin V PO prior to their dental procedures at 300 mg four times a day which should 

then be continued for at least four days thereafter. 

Post Transplant Patients 

The American Heart Association Guidelines for the Prevention of Infective Endocarditis 

recommend antibiotic prophylaxis before dental procedures ONLY for patients who have a 

history of previous infective endocarditis, or who have had cardiac valve replacement, or 

surgically constructed pulmonary shunts, or conduits (1) . 

Prophylactic antibiotic coverage for dental procedures is recommended ONLY for the 

following transplant recipients: 

 

 

 

 

Prosthetic cardiac valve 

Previous infective endocarditis 

Congenital heart disease (CHD) 

Unrepaired cyanotic CHD 

months following repair of CHD with any prosthetic material or 

device 

Repaired CHD with residual defects 

Cardiac transplant recipients who develop cardiac valvulopathy 




4.4.3 PROPHYLACTIC ANTIBIOTIC DENTAL COVERAGE CONT. 

Recommended Antibiotic Regimens for a Dental Procedure (1) 

SITUATION ANTIBIOTIC REGIMEN: SINGLE DOSE 30 TO 60 

MIN PRIOR TO PROCEDURE 

Adults 

Children 

Oral Amoxicillin 2 grams 50 mg/kg 

Unable to take Oral 

Medication 

Ampicillin 

OR 

Cefazolin* or 

2 grams IV or IM 

1 gram IV or IM 

50 mg/kg IV or IM 


Ceftriaxone * * 

True Allergy to 

Penicillin Allergic 

to Penicillins or 

Ampicillin - Oral 

Cephalexin* 

OR 

Clindamycin 

OR 

Azithromycin or 

Clarithromycin 

2 grams 

600 mg 

500 mg 

50 mg/kg 

20 mg/kg 

15 mg/kg 

Allergic to 

penicillins or 

ampicillin and 

unable to take oral 

medication 

Cefazolin or 

Ceftriaxzone * * 

OR 

Clindamycin 

1gm IV or IM 

600 mg IV or IM 

50 mg/kg IM or IV 


* Or other first or second generation oral cephalosporin in equivalent adult or pediatric 

dosage 

** 

Cephalosporins should not be used in an individual with a history of anaphylaxis, 

angioedema or urticaria with penicillins or ampicillin 



4.4.4 LATE COMPLICATIONS 


Rejection is less common after nine months, although acute rejection can occur at any time 

after transplantation. Rejection is almost always confirmed by liver biopsy before treatment is 

instituted. Patients then are treated the same as they are in the immediate perioperative period, 

with Methylprednisolone (Solu Medrol ® ), at a dosage of approximately 10 mg/kg IV daily for 

three days. Patients with severe rejection or steroid-resistant rejection may require treatment 

with a polyclonal antibody (ATG) IV for 7 to 10 days. In addition, they may have their 

maintenance immunosuppressive treatment intensified. 

CMV infection is common 3 weeks to 6 months after transplantation. Typically, this occurs 

in patients who are already CMV positive by CMV PCR testing, as the immunosuppression 

decreases the body’s immune surveillance of the virus. Patients may develop generalized 

malaise, low-grade fever and often, upper GI complaints. To permit prompt initiation of 

therapy, CMV PCR tests are performed routinely according to the CMV Prophylaxis and 

Treatment Regimens for Liver Transplant Recipients (See Appendix I). 

These tests are not 100% reliable and diagnosis may have to be confirmed by upper GI 

endoscopy or some other method of demonstrating tissue invasion. Patients who are a CMVmismatch, 

meaning the donor is positive and the recipient is negative, are at very high risk of 

CMV disease. 

(See Appendix I: CMV Prophylaxis and Treatment Regimens) 

Renal Dysfunction is one of the common complications of long-term immunosuppression. 

This is typically associated with calcineurin inhibitors (Cyclosporine and Tacrolimus). Patients 

with decreased renal function may need to have their immunosuppressive regime modified. 

Those whose serum creatinine continues to rise will be referred to a nephrologist. Occasional 

patients may eventually require dialysis. 

Hypertension is common after transplantation. This may be related in part to unmasking of 

essential hypertension. However, Cyclosporine and Tacrolimus can cause hypertension, partly 

through direct effects on blood flow in the kidney. There is a view that calcium channel 

blockers may be of benefit, as they cause vasodilatation and preserve renal function. In general, 

hypertension in these patients should be treated similarly to that in the non-transplant setting. 

Bile duct disease is a common complication of liver transplantation, occurring in up to 15% 

of patients. This is typically related to ischemic injury but may be associated with strictures 

occurring at the area of anastomosis. Usually patients are asymptomatic and these problems are 

detected only on the basis of increasing liver enzymes, however, they may also present with 

jaundice or episodes of cholangitis. Rapid identification of the problem is paramount. Patients 

require immediate assessment with blood tests, blood cultures and ultrasound. They will often 

require an ERCP or percutaneous transhepatic cholangiogram (PTC). Patients with evidence of 

biliary tract stenosis may require stenting at the time of the ERCP or placement of a 

percutaneous catheter at the time of their PTC. These stents are typically left in place for a 

period of a few months and exchanged. 




4.4.4 LATE COMPLICATIONS CONT. 

Some patients will benefit from this and require no further therapy after their stents are 

eventually removed six months later. Not infrequently, patients will ultimately require 

reconstructive surgery with the revision of their anastomosis or conversion to Rouxtoentoy. 

Patients with significant intrahepatic strictures who continue to develop recurrent cholangitis 

may eventually require retransplantation. Initial treatment of patients who develop cholangitis is 

usually with a combination of broad spectrum antibiotics with gram negative enterococcal 

coverage. The antibiotics are adjusted when culture and sensitivity results are available. If the 

patient develops cholangitis and is treated for cholangitis at a hospital other than VGH, it is 

important that the transplant team be notified. 

Diabetes is present in approximately 10% of patients prior to liver transplantation. This is 

worsened with the use of Prednisone and calcineurin inhibitors in the post-transplant period. 

While in hospital, patients may require insulin, although insulin-dependent diabetes typically 

presents several weeks after transplantation. This is particularly true in patients who receive 

Tacrolimus. Ten to twenty percent of patients may develop de novo diabetes post-transplant 

secondary to steroids and calcineurin inhibitors. 

Hyperlipidemia is another long-term complication. Lipid profiles are checked for this at the 

time of annual post-transplant assessments. Sirolimus is associated with an increased risk of 

hyperlipidemia. 

Hyperkalemia is another common side effect of Cyclosporine and Tacrolimus. This is usually 

readily treated with a potassium exchange resin. Fifteen grams of Kayexalate ® given two to 

three times a day is usually sufficient. Patients with peripheral edema are also treated with 

Furosemide. It should be noted that those patients who are also receiving sulfa/trimethoprim 

(Septra ® ), are at increased risk of hyperkalemia, as trimethoprim has an amiloride - like effect. 

Osteoporosis is another important metabolic complication of transplantation. Supplemental 

calcium and vitamin D is part of the standard protocol. High-risk patients are evaluated further 

with bone densities and if abnormal, are referred to an endocrinologist and bisphosphonates 

may be recommended. 

Infection with fungus such as Candida is common in the post-transplant setting. Patients who 

are colonized with fungus, as demonstrated by routine cultures of body fluids, are treated 

prophylactically with Fluconazole at a dosage of 200 mg a day for ten days. This usually results 

in eradication and it is rare to develop systemic fungemia. Rarely, patients can develop 

Cryptococcal meningitis. This is manifest by subtle neurological complaints, variable physical 

findings and mild fever. These patients need to be aggressively assessed and treated. 

Pneumocystis carinii is an organism, which occasionally causes pneumonia. This occurs in 

approximately 2 to 3% of patients. Some transplant programs prophylaxis against pneumocytis 

pneumonia (PCP) with the use of Cotrimoxazole. In our experience, the incidence of PCP has 

been too low to justify routine prophylaxis. 

(See Appendix J: Treatment for Other Opportunistic Infections) 




4.4.4 LATE COMPLICATIONS CONT. 

Recurrence of Hepatitis C is essentially universal after transplantation and typically 

manifests approximately three months after transplantation. It is characterized by mild to 

moderate elevations of the transaminase levels, with a normal alkaline phosphatase and a 

gamma GT less than 200 units. The diagnosis should be confirmed by liver biopsy to be sure 

there are no other causes of the abnormal liver tests. While some patients have a fairly benign 

outcome, most patients develop gradually progressive liver disease that leads to cirrhosis over a 

decade or so. Although no treatment has been clearly shown to be effective in the transplant 

recipient, patients with aggressive hepatitis should be considered for treatment with Pegylated 

Interferon and Ribavirin. Occasional patients will develop rapidly progressive liver disease, 

with jaundice, accelerated fibrosis and progression to liver failure. This can occur at any time, 

but often within a few years of their transplant. Results of retransplantation are poor and the 

prognosis of this form of recurrent Hepatitis C is dismal. 

Immunologically mediated liver diseases including primary biliary cirrhosis (PBC), 

autoimmune chronic hepatitis and primary sclerosing cholangitis can all recur after 

transplantation despite immunosuppression. Patients with PBC can be treated with 

ursodeoxycholic acid (UDCA). The risk of recurrence is thought to be increased after 

discontinuation of steroids; so low-dose Prednisone is sometimes continued in such patients. 

Post-transplantation autoimmune hepatitis may require Prednisone for prolonged periods. 

Finally, some transplant recipients may experience protracted psychological adjustment 

problems. Individual and group interventions are available to facilitate long-term emotional 

adjustment. 




4.5 Pediatric Transplantation 

4.5.1 INTRODUCTION 

While the general principles of liver transplantation are similar in children and adults, a number 

of additional factors must be considered for the pediatric patient. First, the size of the pediatric 

patient may affect the transplant outcome. Candidates weighing less than 10 kg may be at high 

risk for transplant complications and the nutritional status of any young patient with liver 

disease is a major concern. Second, the immunization status of a child referred for liver 

transplant evaluation requires thorough review. Children who are potential transplant candidates 

should receive an accelerated immunization schedule whose goal is to complete as many of the 

primary immunizations as possible prior to the transplant. Third, the vessels that supply blood 

to the liver may be quite small in caliber, especially in young infants. Abnormalities of the 

hepatic vasculature are relatively common in children and the risk for post-transplant vessel 

blockage is higher for those infants with small caliber vessels. A thorough radiological 

assessment of the liver vessels is crucial for the pediatric patient prior to undergoing a liver 

transplant. Finally, particular attention must be paid to the child’s environment. The 

psychosocial needs of the child, the reliability of the child’s caregivers, the stability of the home 

environment and religious or cultural beliefs need to be assessed to ensure adequate and 

responsible care of the transplanted child after discharge. 

4.5.2 WHEN TO REFER 

As part of the liver transplantation protocol, potential pediatric candidates will undergo a 

thorough preoperative evaluation of their liver disease to determine their eligibility for 

transplantation. We prefer to see potential candidates early in their disease course as this 

enables us to anticipate any problems as well as to correct any disease associated complications. 

In addition, it affords the transplantation team an opportunity to become familiar with the 

patient and their family. 

In a child with liver disease, the presence of one or more of the following features indicates 

significant hepatic dysfunction and warrants a referral for transplant evaluation: 

 

 

 

 

 

 

 

Progressive jaundice 

Diminishing hepatic synthetic function (hypoalbuminemia, coagulopathy unresponsive 

to vitamin K, hypoglycemia) 

The onset of encephalopathy 

Progressive cholestasis/pruritus/refractory cholangitis 

Portal hypertension with its complications (variceal bleeding, ascites, hypersplenism) 

Growth retardation despite aggressive nutritional therapy 

Poor quality of life 




4.5.2 WHEN TO REFER CONT. 

The ultimate goal of the transplant evaluation process is to: 

 

 

 

 

 

 

 

 

Confirm the diagnosis 

Evaluate alternative therapies 

Determine potential disease complications 

Decide if there are any contraindications for transplant 

Initiate aggressive nutritional therapy 

Review medications 

Ensure appropriate immunization schedule 

Educate and prepare patient and family 

4.5.3 WHAT HAPPENS DURING ASSESSMENT 

All pediatric candidates are evaluated by members of the pediatric transplantation team 

following which a decision is made as to whether the candidate is suitable for transplant. 

This pediatric multidisciplinary team includes the following consultants: Surgeon, 

Gastroenterologist, Intensivist, Microbiologist, Radiologist, Anaesthesiologist, Pathologist, 

Psychiatrist, Clinical Nurse, Ethicist, Social Worker, Dietician and Transplantation 

Coordinator. Other consultants whose expertise may be needed include Nephrologists, 

Hematologists, Neurologists, Respirologists, Immunologists, etc. 

During the assessment, a complete history and physical examination is performed and a number 

of tests are obtained to assess the extent of the liver disease and confirm the diagnosis. The 

patient is screened for a variety of viruses and the immunization schedule is reviewed. A 

complete nutritional assessment with aggressive dietary management to maximize the growth of 

infants with liver disease is an integral part of the pediatric transplant evaluation. During the 

assessment phase, the transplant team also provides patients and their families with information 

about liver transplantation, including the risks and benefits of the procedure and the 

transplantation process. 

The following tests are routinely completed during this assessment phase: 

Complete blood count 

Assessment of liver function: AST, ALT, gamma GT, alk phos, total and direct 

bilirubin, total protein albumin, PT, PTT, Factor V 

Assessment of renal function: serum electrolytes, BUN, Ca, creatinine, PO4, Mg, U/A, 

urinary electrolytes, GFR 

Other biochemistries: glucose, amylase, immunoglobulins, cholesterol, triglycerides 

Viral screen: serology for CMV, Hep A IgM, HBsAg, HBcAb, HBsAb, HIV, EBV, 

Hep C 

PPD 

Blood group and match 




4.5.3 WHAT HAPPENS DURING ASSESSMENT CONT. 

 

 

 

 

 

 

Other diagnostic tests: alphato1 antitrypsin level, ceruloplasmin, CEA, alpha-fetoprotein 

Imaging studies: abdominal ultrasound with doppler, CXR 

ECG 

Dentistry consult if needed 

Ophthalmology consult if required 

Immunology consult if indicated 

4.5.4 ACTIVATION 

Once this extensive evaluation is completed, the pediatric multidisciplinary transplant team will 

meet and review each candidate to determine eligibility for transplantation. 

If the candidate has been deemed eligible for transplantation, he/she will be placed on the active 

list and the family will be given a pager and instructions to communicate any change in their 

location or health status to the transplant coordinator. While on the waiting list, the patient and 

family will be closely followed by the transplant team. 

4.5.5 TRANSPLANT OPERATION 

The technical aspects of liver transplantation are complex. Several modifications have recently 

occurred which have advanced the procedure and its outcome, especially for the pediatric 

patient. The ability to divide a deceased donor liver and use only a small part of it for 

transplantation into a young infant has had a significant impact in pediatric transplantation. This 

procedure is known as a reduced liver transplant. The development of living related liver 

transplantation where a parent can donate a part of their liver to the affected child has been 

another major achievement in the field. 

The operation itself is essentially the same as the adult operation described in section 4.2.5. The 

main difference is that infants and small children will usually receive split livers. 

4.5.6 POST-TRANSPLANT CARE AND FOLLOW-UP 

See sections 4.3 and 4.4 




4.6 Appendices 

Appendix A 

Appendix B 

Appendix C 

Appendix D 

Appendix E 

Appendix F 

Appendix G 

Appendix H 

Appendix I 

Appendix J 

Appendix K 

Appendix L 

Appendix M 

Appendix N 

Appendix O 

Appendix P 

Appendix Q 

Appendix R 

Appendix S 

Liver Transplant Referral Form 

Pre-Liver Transplant Assessment - Adult 

Liver Transplant Post-operative Orders in ICU 

Table for Target Tacrolimus / Cyclosporine Blood Concentrations/Assays 

Table for Sirolimus Target Therapeutic Concentrations 

BCT Fax Form: Application for Sirolimus, Liver Transplant Recipients 

VHHSC Standing Lab Orders for Liver Transplant Program 

Protocol for Hepatitis B Liver Transplant Recipients 

CMV Prophylaxis and Treatment Regimes for Liver Transplant Recipients 

Treatment for Other Opportunistic Infections in Liver Transplant Recipients 

Authorization for Release of Information 

Consent to Diagnosis, Treatment and Care 

Consent for Surgical Care and Transfusion of Blood Products 

Recipient Activation Form 

Contract for Abstinence 

Liver Transplant Baseline Assessment 

When a Liver Becomes Available 

VGH Transplant Checklist 

Fax Coversheet and Recommended Follow-up Testing for Recipients 

Transplanted under Risk for Viral Mediated Disease Transmission 




LIVER TRANSPLANT REFERRAL FORM 

APPENDIX A 

Referral Date:__________________________ 

Last Name: _____________________ First Name:__________________ Initial: ___________ 

Street Address:___________________________________________________________________ 

City:________________________ Province: _____________ Postal Code: ________________ 

DOB: __________________ Age: ________ Sex: _________ Race: ________________________ 

Home Phone: __________________Other Phone: _____________________________________ 

Contact Name: ___________________ Phone: _____________Relationship: ______________ 

GP: ____________________________ Phone: _______________ Fax: _____________________ 

Address: ______________________________________________________________________ 

Ref. MD: ________________________ Phone: ________________Fax: _____________________ 

Address: ______________________________________________________________________ 

Health Plan: ______________________ Insurance #: __________________________________ 

Diagnosis: Primary _____________________________________________________________ 

Secondary ___________________________________________________________ 

Does patient/family speak and understand English? Yes______ No ______ 

If No, what language: ___________________ Height:______________Weight: _______ 

Previous Surgery ___________________________________________________ 

Is this patient VRE+________ 

Is this patient MRSA+_________ 

*PLEASE SEND PERTINENT MEDICAL HISTORY AND DOCUMENTATION – INCLUDING 

LAB TESTS AND OTHER PROCEDURAL TESTS AND CONSULTATION NOTES. 

Please mail to: 

Clinical Coordinator 

British Columbia Transplant 

West Tower, 3 rd Floor 

555 West 12 th Avenue 

Vancouver, BC V5Z 3X7 Phone: (604) 877-2240 Fax: (604) 877-2111 

Toll Free: 1-800-663-6189 

The completion of this form will expedite your patient’s investigations and subsequent 

consideration for transplantation. Thank you for your cooperation in providing this material. 




Appendix B 




Appendix B (cont.) 




































Appendix C 




Appendix C (cont.) 




Appendix D 

Target Cyclosporine Blood Concentrations for Liver Transplant Recipients 

As of June 2010, in British Columbia there are two different types of assays used for the determination of 

Cyclosporine blood concentrations: 

1. Immunoassay (Abbott TDX ® ) 

2. Mass Spectrometry Assay. 

Mass spectrometry results are 24% lower than the Abbott TDX Assay. 

You must know which assay was used for measuring the Cyclosporine concentrations to interpret the 

result. There is a chart below which lists the assays used to monitor Cyclosporine concentrations at different 

hospitals in the province. 

Time Post 

Transplant 

(Months) 

Cyclosporine 

Trough 

Concentration 

(ng/mL) 

Immunoassay 

Cyclosporine C 2 

(ng/mL) 

Immunoassay 

Cyclosporine Trough 

Concentration 

(ng/mL) 

Mass Spectrometry 

Assay 

Cyclosporine C 2 

(ng/mL) 

Mass 

Spectrometry 

Assay 

0 to 3 300 to 350 1000 250 to 275 750 

3 to 6 250 to 300 800 200 to 250 600 

6 to 9 200 to 250 600 150 to 200 450 

9 to 12 150 to 200 600 125 to 150 450 

Greater than 12 125 to150 600 100 to 125 450 

Prepared by Nilu Partovi, Pharm D. March 10, 2004 

Target Trough Tacrolimus Blood Concentrations for Liver Transplant Recipients 

As of June 2010, in British Columbia there are two different types of assays used for the determination 

of Tacrolimus blood concentrations: 

1. Immunoassay (Abbott TDX ® ) 

2. Mass Spectrometry Assay. 

Mass spectrometry results are 24% lower than the Abbott TDX Assay. 

You must know which assay was used for measuring the Tacrolimus concentrations to interpret 

the result. There is a chart below which lists the assays used to monitor Tacrolimus concentrations at 

different hospitals in the province. 

Time Post- 

Transplant 

(Months) 

Tacrolimus Trough 

Blood Concentration 

(ng/mL) 

12 hours Post-Dose 

Immunoassay 

Tacrolimus Trough Blood 

Concentration (ng/mL) 

12 hours Post-Dose 

Mass Spectrometry Assay 

Less than 1 10 to 15 8 to 12 

1 to 3 8 to 12 6 to 9 

Greater than 3 5 to 10 4 to 8 

For Liver Transplant Patients With Hepatitis C or Renal Failure 

Less than 1 8 to 12 6 to 9 

1 to 3 5 to 10 4 to 8 





Cyclosporine and Tacrolimus Assays Used in British Columbia 

Appendix D (cont.) 

HOSPITAL LABORATORY 

Vancouver General Hospital 

St. Paul’s Hospital 

B.C.’s Children’s Hospital 

Royal Jubilee Hospital, Victoria 

Prince George Regional Hospital 

Penticton Regional Hospital 

Kootenay Boundary Hospital 

Royal Inland Hospital 

Kelowna General Hospital 

LifeLabs 

TYPE OF CYCLOSPORINE 

ASSAY AS OF JUNE 2010 



Abbott TDX Immunoassay 


Abbott TDX Immunoassay 


Sent to Penticton Regional Hospital 




The different Mass Spectrometry Assays used at Vancouver General, St. Paul’s Hospital, 

Royal Jubilee Hospital and Penticton Regional Hospital produce very similar results. 




Appendix E 

Target Whole - Blood Sirolimus Trough Concentrations 

For LIVER Transplant Recipients 

HPLC-TMS Assay * 

TIME POST-TRANSPLANT 

(MONTHS) 

TROUGH SIROLIMUS 

CONCENTRATIONS (NG/ML) 

(WHEN USED WITH 

TACROLIMUS OR 

CYCLOSPORINE +/- 

MYCOPHENOLATE AND 

STEROIDS) 

TROUGH SIROLIMUS 

CONCENTRATIONS (NG/ML) 

(WHEN SIROLIMUS IS USED AS 

A SINGLE AGENT +/- STEROIDS) 

Less than 1 10 to 15 12 to16 

1 to 3 months 8 to 12 10 to 12 


Prepared by Nilu Partovi, Pharm D, Nov 2008 

* HPLC-TMS: High performance liquid chromatography - Tandem mass spectrometry 

Assay is only done at Vancouver General Hospital. Samples must be sent to Vancouver 

General Hospital for testing. 




Appendix F 

BCT FAX FORM: APPLICATION FOR SIROLIMUS LIVER TRANSPLANT 

RECIPIENTS 

Please complete & fax to Dawn Strong for Dr. YOSHIDA at B.C. Transplant (604)- 877-2111 

DATE: 

TO: 

FROM: 

Dr. Eric Yoshida 

Medical Director, Liver Transplant Program, BCT 

BCT #:_______________________ 

Name: Last: _________________________________ First: ______________________ 

Hospital: _________________________ Hepatologist: _________________________ 

Indications for Sirolimus Use: 

1. Patient has developed calcineurin toxicity despite blood concentrations within therapeutic range. 

Cyclosporine concentration _________ng/mL (date________) 

Tacrolimus concentration __________ng/mL (date________) 

a) biopsy-proven severe nephrotoxicity. Increase in serum creatinine must be 50% above baseline. 

Biopsy result ____________________________________(date_________) 

Baseline serum creatinine ____________________µmol/L (date_________) 

Current serum creatinine ____________________µmol/L (date_________) 

b) Neurotoxicity (describe reaction) ______________________________________ (date______) 

2. Patient has developed calcineurin inhibitor intolerance: hypersensitivity reaction or microangiopathy 

Cyclosporine (date_________) Tacrolimus (date______) 

3. Recurrent (≥ 2) biopsy-proven, acute rejection, while on calcineurin inhibitors despite blood 

concentrations within the therapeutic range. 

Biopsy result: ___________________________ (date_______) 

Biopsy result: ___________________________ (date________) 

Cyclosporine concentration: _________________mol/L (date_________) 

Tacrolimus concentration: _________________mol/L (date_________) 

4. Maintenance immunosuppression following steroid-resistant rejection. ATG use __________(date) 

5. Renal dysfunction due to: hepato-renal syndrome or post transplant acute tubular necrosis 

6. Acute rejection not requiring ATG, but sirolimus is necessary for maintenance 

immunosuppression. 

Physician’s Signature: __________________________ Date: ____________ 

Approval by BCT: _____________________________ Date: ____________ 

FEB/2010 




Appendix G 

VANCOUVER HOSPITAL & HEALTH SCIENCES CENTER 

DOCTOR’S ORDERS 

STANDING LAB ORDERS FOR LIVER TRANSPLANT PROGRAM 

Date: 

Full BLOOD WORK 

CBC with differential 

PTT, INR 

Na, K, C1, PO4, Mg, Ca, CO 2 

BUN, Cr, Glucose (random), uric acid, 

Total/direct bilirubin, Alk. phosphatase, GGT, AST, ALT 

Amylase, albumin, total protein 

Cyclosporine level, Sirolimus level or FK506 (Tacrolimus) level 

Mini BLOOD WORK 

CBC with differential 

PTT, INR 

K, BUN, Cr, 

Total/direct bilirubin, Alk. phosphatase, GGT, AST, ALT 

Cyclosporine level, Sirolimus level or FK506 (Tacrolimus) level 

ANNUAL BLOOD WORK 

Same as full blood work plus the following tests: 

HgAIC: 

Done at 3 months post transplant. 

If the values are abnormal and/or diabetic patient, repeat q 3 months and consult doctor. 

If the values are normal, then annually thereafter. 

Lipid studies: (Cholesterol, triglycerides, HDL, LDL): 

Done at 6 months and annually thereafter. 

If the values are elevated, follow level and consult doctor. 

Hepatitis Screening: 

Done at 1 year post-transplant and as ordered thereafter. 

Hepatitis B positive patient/or donor: HBV DNA, HCV Ab 

*HBV DNA annually thereafter. 

Hepatitis C positive patient: HBsAg, HBc Ab(total) 

Non Hep B & Hep C: HBsAg, HBc Ab(total), HCV Ab 

AFP test: Every 4 months x 3 years and annually thereafter on patient who has any one of the 

following conditions: Hep B, Hep C and/or malignancy. 

CA19to9: Every 4 months x 3 years and annually thereafter on patient who has gallbladder 

malignancy. 

Abdominal ultrasound with Doppler 

____________________ 

Physician Signature 

________________________________ 

Printed Name/PIC 




Appendix H 

PROTOCOL FOR HEPATITIS B LIVER TRANSPLANT RECIPIENTS 

Protocol: 

1) Lamivudine 100 mg PO daily and 

2) HBIG 

{HBIG is available as: 

Bay-Hep ® 5ml (1085 units) given IM 

- must only be given IM (no IV administration) 

A. Induction phase (Intra-operatively) 

Bay-Hep ® 10ml (2170IU) IM as 5ml into each deltoid muscle 

B. HBIG protocol for week 1 to week 52: 

1. Post-transplant Week 1 to 6: Bay-Hep ® 10ml (2170IU) IM as 5ml into each gluteal muscle until Hep 

B titer is > 1000 U/L. Then, Bay-Hep ® 10ML IM (as 5ml into each gluteal/deltoid muscle) Twice 

weekly (Q Mon, Thurs) for 6 weeks (maintain trough Hep B titer > 500 U/L). 

2. Post-transplant weeks 7 to 10: if Hep B titer is > 500 U/L, then give Bay-Hep ® 10ml IM (as 5ml 

into each gluteal muscle) weekly. 

3. Post-transplant weeks 11 to 24: give Bay-Hep ® 10ml every 2 to 4 weeks to maintain Hep B titer 

> 500 IU/L 

4. Post-transplant week 25 to 52: give Bay-Hep ® 10ml every 4 weeks to maintain Hep B titer > 

250 IU/L 

C. HBIG protocol for > 1 year post-transplant: 

Dose: BaytoHep ® 10ml IM. (as 5ml into each gluteal muscle) 

Patient to get Hep B AB titer done in the local lab 4 weeks after each injection. The results will be sent 

to outpatient liver transplant clinic. 

Then, the frequency of administration of HBIG will be adjusted based on Hep B Ab titer according to 

the following table 

Hep B Ab titer (IU/L) 

Action 

> 300 Level in 2 weeks 

200 to 300 Injection in 3 weeks* 

150 to 200 Injection in 2 weeks* 

100 to 150 Injection in 1 week* 

< 100 Injection ASAP* 

* Please obtain Hep B titer before each injection 




CMV PROPHYLAXIS AND TREATMENT REGIMENS FOR LIVER TRANSPLANT RECIPIENTS Appendix I 

CMV STATUS 

THERAPY 

DONOR RECIPIENT PROPHYLAXIS PRE-EMPTIVE TREATMENT DISEASE TREATMENT 

Negative Negative No prophylactic Valganciclovir 

If CMV PCR > 1000 cp/mL follow treatment protocol 

CMV PCR testing with bloodwork (maximum q weekly) for 

4 months post-transplant and for 2 months following any 

antiviral treatment. 

Asymptomatic: 

Valganciclovir 900 mg PO bid adjusted for renal function 

for 2 weeks followed by 900 mg PO daily for 4 months. 

Symptomatic: 

Ganciclovir 5 mg/kg/dose q 12h IV adjusted for renal 

function x 2 weeks followed by Valganciclovir 900 mg PO 

daily adjusted for renal function for 4 months. 

Positive 

(Mismatch) 

Negative 

Ganciclovir 5mg/kg/dose q 12h IV adjusted for renal 

function x 14 days or until hospital discharge, then 

Valganciclovir 900 mg PO daily adjusted for renal 

function until 4 months post transplant. 

During Lymphocyte Depleting Therapies: 


function or Valganciclovir 900mg PO daily adjusted for 

renal function for 2 months. 

If CMV PCR > 1000 cp/mL and patient is asymptomatic 

then: 


function until CMV PCR test is < 1000 cp/mL for 2 

consecutive weeks and patient is clinically stable 

(minimum 1 month therapy) 

Increase Valganciclovir dose to 900 mg PO bid 

adjusted for renal function if CMV PCR is rising 


function x 2 weeks followed by Valganciclovir 900 mg 

PO daily adjusted for renal function for 4 months. 

If no diarrhea, consider: 


x 2 weeks followed by Valganciclovir 900 mg PO daily 

adjusted for renal function for 4 months. 

Positive OR 

Negative 

Positive 




No prophylactic Valganciclovir 

During Lymphocyte Depleting Therapies 


function or Valganciclovir 900 mg PO daily adjusted for 

renal function for 2 months. 




If CMV PCR > 5000 cp/mL and patient is asymptomatic 

then: 


function until CMV PCR test is < 2000 cp/mL and 

decreasing for 2 consecutive weeks and patient is 

clinically stable (minimum 1 month therapy). 

Increase Valganciclovir dose to 900 mg PO bid 

adjusted for renal function if CMV PCR is rising. 


function x 2 weeks followed by Valganciclovir 900 mg 

PO daily adjusted for renal function for at least 2 weeks 

(CMV PCR test should be < 2000 cp/mL and decreasing 

for 2 consecutive weeks and patient clinically stable prior 

to discontinuation of Valganciclovir). 

If no diarrhea, consider: 


x 2 weeks followed by Valganciclovir 900 mg PO daily 

adjusted for renal function for at least 2 weeks (CMV PCR 

test should be < 2000 cp/mL and decreasing for 2 

consecutive weeks and patient clinically stable prior to 

discontinuation of Valganciclovir). 

Hepatitis C positive recipient (donor or recipient CMV +) Follow mismatch protocol 

Oral Valganciclovir tablets are supplied free of charge through the BCT Pharmacy Program for outpatients on the above protocol. 

If total WBC is less than 2.5 x 10 9 /L decrease Valganciclovir dose to 450 mg PO daily. 

If total WBC is less than 1.5 x 10 9 /L hold Valganciclovir until WBC is greater than 3.5 x 10 9 /L, then restart Valganciclovir at 450 mg PO daily. December 11, 2008 




Valganciclovir and Ganciclovir Dose 

Appendix I (con't) 

The Valganciclovir dose depends on patient’s renal function, white blood cell count and whether or 

not the patient is receiving Valganciclovir for CMV prophylaxis, pre-emptive treatment or disease 

treatment. Refer to the tables of Valganciclovir dosing with impaired renal function and CMV 

prophylaxis and treatment protocols for renal, liver and lung recipients on the following pages. 

Valganciclovir is administered with food. 

Ganciclovir IV Dose for Adult Patients with Impaired Renal Function (6) 

Creatinine Clearance 

(mL/min) 

Greater and equal to 70 

Ganciclovir IV Dose 

(mg/kg) 

5 mg/kg/dose q 12h 

50 to 69 5 mg/kg/dose q 24h or 2.5 m/kg/dose q 12h 

25 to 49 2.5 mg/kg/dose q 24h 

10 to 24 1.25 mg/kg/dose q 24h 

Less than 10 

1.25 mg/kg/dose 3 times weekly post dialysis 

Valganciclovir Oral TABLET Dose for Adult Patients with Impaired Renal Function (7) 

Creatinine Clearance (mL/min) Valganciclovir TABLETS PO Dose 


900 mg PO daily 

40 to 59 450 mg PO daily 

25 to 39 450 mg PO every 2 days 

10 to 24 450 mg PO twice weekly 

Valganciclovir Oral SOLUTION Dose for Adult Patients with 

Impaired Renal Function (7) 

Creatinine Clearance (mL/min) 


Valganciclovir SOLUTION PO Dose 

900 mg PO daily 




Less than 10 

100 mg PO three times a week post dialysis 




Appendix I (con’t) 

Valganciclovir Oral Dose for Pediatric Patients with Impaired Renal Function (8) 

Creatinine 

Clearance 

(mL/min/1.73 m 2 ) 

Patient Weight 

< 30 kg 

Greater and equal to 10 to 12 mg/kg PO 

60 

daily 

40 to 59 5 to 6 mg/kg PO 

daily 


every other day 


2 times/week 

Valganciclovir Oral Dose 


30 to 50 kg 


greater and equal 

to 50 kg 

450 mg PO daily 900 mg PO daily 

225 mg PO daily 450 mg PO daily 

225 mg PO every 

other day 

225 mg PO 

2 times/week 

450 mg PO every 

other day 

450 mg PO 

2 times/week 




Appendix I (con't) 

References 

For CMV Prophylaxis and Treatment and Dental Prophylaxis 

1. Wilson W, Taubert KA, Gewitz M et al. Prevention of infective endocarditis. Guidelines from 

The American Heart Association. Circulation 2007; 116:1736-1754 

2. Asberg A, Humar A, Rollag H et al. Oral valganciclovir is noninferior to intravenous 

ganciclovir for treatment of cytomegalovirus disease in solid organ transplant recipients. American 

Journal of Transplantation 2007:7; 2106-2113. 

3. Khoury JA, Storch GA, Bohl DL et al. Prophylactic versus preemptive oral valganciclovir for 

the management of cytomegalovirus infection in adult renal transplant recipients. American 

Journal of Transplantation 2006:6; 2134-2143. 

4. Preiksaitis JK, Brennan DC, Fishman J et al. Canadian society of transplantation consensus 

workshop on cytomegalovirus management in solid organ transplantation final report. American 

Journal of Transplantation. 2005:5; 218-227. 

5. Reischig T. Jindra P. Hes O. Svecova M. Klaboch J. Treska V. Valacyclovir prophylaxis versus 

preemptive valganciclovir therapy to prevent cytomegalovirus disease after renal transplantation. 

American Journal of Transplantation. 2008: 8; 69-77. 

6. Kliem V, Fricke L, Wollbrink T et al. Improvement in long-term renal graft survival due to 

CMV prophylaxis with oral ganciclovir: results of a randomized clinical trial. American Journal of 

Transplantation 2008:8; 975-983. 

7. Cytovene® Product Monograph, Hoffman La Roche Ltd, Canada, revised May 29, 2009 

8. Valcyte® Monograph Roche Hoffman La Roche Ltd, revised March 5, 2008 

9. BCCH Transplant –Sirolimus Study SN-01, Children and Women’s Hospital. 2007 




Appendix J 

TREATMENT FOR OTHER OPPORTUNISTIC INFECTIONS IN 

LIVER TRANSPLANT RECIPIENTS 

Organism Site of Infection Drug of Choice 

Herpes Simplex Virus (HSV) 

Mucocutaneous 

to mild 

Acyclovir 800 mg PO qid for 7 days 

OR 

Valacyclovir 1000 mg PO tid for 7 to 10 days 

Varicella-Zoster Virus (VZV) 

Pneumocytis Carinii Pneumonia 

to severe 

Respiratory 

Encephalitis 

Mild 

Severe 

Prophylaxis 

Treatment 

Acyclovir 5 mg/kg IV q 8h for 7 days 



Acyclovir 800 mg PO for 4 to 5x daily for 7 to 10 

days OR 

Valacyclovir 1g to tid x 7 to 10 days 

Acyclovir 10 to 12 mg/kg IV q 8h for 7 to 14 days 

None 

TMP-SMX 5 mg/kg IV (based on TMP 

component) q 6h for 21 days 

Sulfa allergy: Pentamidine IV 4mg/kg/daily for 21 

days 




AUTHORIZATION FOR RELEASE OF INFORMATION 

Re: ____________________________________________________________ 

(Name of Patient-Print in Full) 

(Date of Birth) 

Address of Patient: ______________________________________________________ 

I, _____________________________________________, do hereby authorize you to 

permit __________________________________to release the following information: 

(Name of institution) 

Appendix K 

(Note approximate dates in hospital and indicate what specific information the records are required) 

_______________________________________________________________________ 

_______________________________________________________________________ 

to, BC Transplant: 

I consent to the use of this information by the authorized recipient only for the purposes of: 

____________________________________________________________ 

I am nineteen years of age or older. 

Dated this _______________________________day of__________________, 20____ 

Signature: _______________________ Witness: _______________________ 

(Patient) 

(Signature of Witness) 

_______________________ 

(Print Name of Patient) 

________________________ 

(Print Name of Witness) 

_______________________ 

(Parent or Guardian) 

Address of witness if not an employee of BC Transplant: 

________________________________________________________________________ 

________________________________________________________________________ 

Relationship to Patient: __________________________________________________ 




Appendix L 

CONSENT TO DIAGNOSIS, TREATMENT AND CARE 

I, the undersigned, do hereby authorize the physician and employees of BC Transplant (and persons 

authorized by such other institutions as may be requested by BC Transplant) to carry out examinations, 

procedures and treatment deemed necessary and advisable for the evaluation, diagnosis, treatment and 

continuing care. I, hereby authorize the release of follow-up information pertaining to my condition and/or 

status (including medical diagnosis and relevant dates). 

Program: ________________________________________ 

Registration Date: _________________________________ 

Name: (Mr., Mrs., Ms.) __________________________________________________________________ 

SURNAME 

GIVEN NAMES 

Date of Birth: _____________________________________________Sex:__________________________ 

MONTH DAY YEAR 

Address: ______________________________________________________________________________ 

NUMBER 

STREET 

Address:_______________________________________________________________________________ 

CITY 

PROVINCE 

Address: ____________________________ 

POSTAL CODE 

Telephone Number (home): (________)__________________ PHN:_____________________________ 

SIGNATURE:_________________________________ 

(PATIENT OR GUARDIAN) 

WITNESS:____________________________________ 

(SIGN) 

_____________________________________ 

(PRINT NAME IF NOT THE PATIENT) 

_____________________________________ 

(PRINT NAME) 

DATE: ___________________________________ 




Appendix M 




Appendix M con’t. 




Recipient Activation Form 

BCT #: Activation Date: 

Appendix N 

dd/mmm/yyyy 

Program: 

Pancreas 

Liver 

Heart 

Heart/Lung 

Single Lung 

Double Lung 

Other: _________________ 

Tx Centre: 

Tx No.: Date of Previous Tx: Previous Tx Prg: 

VGH 

SPH 

CHH 

Patient Name: 

Date of Birth: 

Pager #: 

Home Phone#: 

Work Phone #: Cell #: 

Contact Name 1: Phone #: 

Contact Name 2: Phone #: 

Specialist: Phone #: 

Family Physician: Phone #: 

Activation Status: 

Previous CT Surgery: 

ABO:__________ Rh: ____________ Height (cm): ________ Weight(kg): __________ 

Cytotoxicity (PRA): Current: _____________ Date: _______________ 

Viral Screen: CMV: ______ CMV Tested Date:___________ HCV: ______ HIV: ________ EBV: _______ 

HbsAg(HBV):______ HBV Date Tested: _________ HbsAB: ____ HbcAB (Total): ________ 

VZV:____________ RPR: ____________ HBV DNA:_____ HSV:______ 

Comments: 

Ascites: 

No Small Moderate Large Unknown 

HCV Genotype: ___________ PVR: _____________ X-Match:_________________ 

HCV Genotype Sub-Category: ____ 

TLC (Actual): __________ TLC (Predicted): ____________ 

Completed By: 

Entered into PROMIS By: 

Date: 

Date: 




Appendix O 

CONTRACT FOR ABSTINENCE 

The policy of BC Transplant is that no patient with an ongoing substance abuse problem be accepted 

for liver transplantation. In order to be considered a possible liver transplant candidate, patients with 

a history of alcohol or drug abuse will have to demonstrate at least six continuous months of 

abstinence. 

In order to do everything to ensure a successful outcome to transplantation, 

I, _________________________________________, AGREE TO COMPLETELY ABSTAIN FROM ALCOHOL, 

ILLICIT DRUGS AND OTHER ABUSABLE SUBSTANCES FOR THE REST OF MY LIFE. In addition, I will refrain 

from abusing any prescription medications. 

I may also be required to avail myself of the services of an alcohol and drug (A&D) treatment program to 

help ensure relapse prevention and I will adhere to the recommendations of the A&D counsellor. In addition, 

I will allow random testing of my blood, breath and urine as evidence of my abstinence. 

I give permission to have family members, significant others and relevant health care providers be contacted 

to help verify my continuing abstinence and for purposes of ongoing transplant assessment. 

Following completion of the initial required period of abstinence, I will be re-assessed by the Transplant 

Team to determine my status regarding transplantation. I UNDERSTAND THAT VIOLATING THIS AGREEMENT 

WILL RESULT IN MY FORFEITING MY TRANSPLANT CANDIDACY STATUS. 

I further understand that lifelong abstinence from all abusable substances is an important part of my 

ability to maintain my health and the health of the transplanted liver following surgery. 

Resuming substance use any time following acceptance into the transplant program will result in my 

being removed from the transplant waiting list. 

If I relapse after surgery, I agree to enter a substance abuse program chosen for me by the Transplant Team. I 

ALSO UNDERSTAND THAT IF I RELAPSE TO SUBSTANCE USE FOLLOWING TRANSPLANTATION, I WILL NOT 

BE OFFERED A SECOND TRANSPLANT SHOULD ONE BECOME NECESSARY. 

I have read the above and agree to the conditions set forth and I have a copy of this contract for my records. 

____________________________________ 

Patient Signature 

__________________________________ 

Signature of Witness 

____________________________________ 

Date and Place 

___________________________________ 

Print Name and Relationship to Patient 




Liver Transplant Baseline Assessment 

Appendix P 

Pt. Name 

Blood Type:_______________________ 

Hematology: 

WBC:_____________________________ 

Hgb:______________________________ 

MCV:_____________________________ 

Platelet :___________________________ 

INR:______________________________ 

PTT:______________________________ 

Chemistry: 

Na:_______________________________ 

K:________________________________ 

CL:_______________________________ 

CO2:_____________________________ 

Urea:_____________________________ 

Creatinine:_________________________ 

Est GFR:___________________________ 

Calcium:___________________________ 

Phosphate:________________________ 

AlkPhos:__________________________ 

GGT:_____________________________ 

CK:_______________________________ 

AST:______________________________ 

ALT:______________________________ 

Total Bili:__________________________ 

Direct Bili:_________________________ 

Protein:___________________________ 

Albumin:___________________________ 

Glucose:__________________________ 

Other Results: 

AFP:______________________________ 

CEA:_____________________________ 

PSA:_____________________________ 

Urinalysis:_________________________ 

Stools for OB: #1_____#2_____#3_____ 

TB Skin Test:_______________________ 

Diagnostic: 

Antinuclear Ab:_____________________ 

Antismooth muscle Ab:_______________ 

Antimitochondial Ab:_________________ 

Alpha 1 Antitrypsin level:______________ 

Ceruloplasmin:_____________________ 

Ferritin:____________ Iron:___________ 

TIBC:______Fraction Saturation:_______ 

Genetic Testing: ____________________ 

Date of Blood work: 

Virology: 

DATE 

CMV IgG 

EBV IgG 

HepA Total 

HbsAg 

HbsAb 

HbcAB 

HbVDNA 

Hep C 

Genotpye 

HSV 

VZV 

HIV I &II 

Ancillary Testing: 

CXR:__________________________________ 

EKG:__________________________________ 

ECHO:_________________________________ 

US:____________________________________ 

CT:____________________________________ 

MRI:___________________________________ 

Mammogram:____________________________ 

Dental:_________________________________ 

Anesthesia:______________________________ 

Tumor Rounds:__________________________ 

Tumor Treatment:________________________ 

MISC. Consults:_________________________ 

_______________________________________ 

_______________________________________ 

Team Consults: 

Social Work:_____________________________ 

Psychologist:_____________________________ 

Nutritionist:______________________________ 

Pre-Activation Talk:_______________________ 

Ascites:_____________HE:____________ 

MELD:____________PUGH:___________ 




Appendix Q 

WHEN A LIVER BECOMES AVAILABLE 

Keep your pager with you at all times and call the Clinical Coordinator on call 24 hours a day at 

1-800-663-6189 or (604) 877-2240 anytime your pager goes off. 

It is extremely important that the transplant team be able to reach you as soon as a liver becomes available. 

The transplant team should know where to get in touch with you at all times. 

If an organ becomes available and the transplant team has selected you as the most suitable recipient, the BCT 

Transplant Coordinator will attempt to contact you by first phoning your home telephone number. If there is 

no response, they will attempt paging you via your pager. Even though a donor liver receives special 

handling and will be stored in a special solution to keep it suitable for transplantation, there is a time limit. 

It is very important that if your telephone number changes, you should immediately inform the BCT Liver 

Transplant Coordinator. 

You may also want to get a telephone answering machine and check it often. If you plan on going out of 

town, be sure to leave your travel plans and contact numbers with the transplant coordinator. 

When you do get the call from your Transplant Centre, you will probably feel equal levels of excitement and 

fear. It will seem as if everything is a blur. This is why it is very important for you to make any plans in 

advance, whenever possible. 

Make sure you do not eat or drink anything once you have been called to the hospital. It is important that 

your stomach be empty in order to have surgery. 

If you are waiting at home, the call to come into hospital for transplant may come at any time of the day or 

night. The Transplant Coordinator will identify themselves and ask you a few questions. They will ask: 

How you are feeling 

If you have any colds or fever 

If you have a sore throat or diarrhea 

If you have had any recent infections 

If you are taking any antibiotics 

If they have no concerns regarding your present condition they will ask you to come to the hospital as soon as 

possible. If you live in the Lower Mainland/Vancouver area, it is expected that will arrive at the hospital 

within 2 hours of the telephone call. If you are coming by car, please ensure that you have someone drive 

you. If you are coming from outside of the lower Mainland, the Transplant Coordinator will give you detailed 

instructions regarding the transportation plan. You will either come by air ambulance, commercial flight, or 

charter flight. The Transplant Coordinator will make the travel arrangements. 

If you are coming by commercial flight or charter flight, you will need money for a taxi from the airport to 

Vancouver General Hospital (around $20.00). BC Transplant will cover the cost of commercial flight or 

charter flight. If you come by air ambulance, you can be billed up to $240.00 depending on where you live. 




Appendix Q (con’t) 

Once you have been admitted to hospital you will be prepared for surgery on the Transplant Unit. 

Once admitted, you can expect: 

 

 

 

 

 

 

Not to eat or drink anything 

To have blood work drawn 

To have an intravenous (IV) started 

To be asked for a urine specimen 

To have a chest x-ray and ECG 

To have your bowels cleared/prepped 

WHAT SHOULD I BRING TO THE HOSPITAL? 

 

 

Your Care Card/PHN number 

An accurate list of all medications (names, doses, frequency) that you take, or bring the 

medications with you. 

After your surgery, once you are transferred to the Transplant Unit, your family can bring: 

1. The “Living With Transplantation Manual” 

2. A credit card which you can use to pay for a television 

3. Any walking aid or cane you may be using 

4. Small change to cover the cost of newspaper, coffee shop, pay phone etc. 

5. A small overnight bag 

6. All needed toiletry items: soap, shampoo, comb/brush, toothbrush etc. 

7. Lip and skin moisturizer (the air in hospital tends to be very dry) 

8. Mouthwash (if you use it on a regular basis) 

9. Bathrobe which opens all the way down the front 

10. Slippers with closed-in heel and rubber soles, or running shoes. 

11. A good book or magazine 

12. BRING YOUR PAGER with you to return to the BCT after your transplant. 

Do NOT Bring 

 

 

 

 

Any valuables such as rings, watches or jewellery 

A large amount of cash (a maximum of $20.00 may be locked up on the ward.) 

Any large electrical equipment, which needs to be plugged in (you may bring an electrical 

razor or hair dryer or a small portable radio) 

A cellular phone (you cannot use this in the hospital) 




VGH Transplant Checklist-Liver, Kidney, P/K 

Appendix R 

Patient 

Name 

DOB 

PHN 

CMV 

ABO 

Chart to ward 

Patrick Helton 

604-715-6693(24hr) 

250-629-3257 

604-270-6101 

EHS 

1-800-561-8011 

872-5151 L.Mainland 

Date:________________; CC Start time:___________Finish time:___________ 

Donor Info: ABO _____; CMV _____; Retrieval Time _____ 

Liver P/K Kidney 1 Kidney 2 

On call Nephrologist 

to contact patient 

N/A 

On call Nephrologist 

to contact patient 

ETA to hosp N/A N/A 

Emerg Admit 

Nephrologist to call Nephrologist to call 

875-4311 

VGH access director: P. 

675to6056 (local 55145) 

Any Infection 

Precautions? VRE, MRSA 

Inform Admitting, ward, 

OR, ICU 

T4D 875-4822 

Extrarenal: 2ACD,1 clot 

Nephrologist to call 

ICU 875-4275 N/A N/A N/A 

OR 875-4472 N/A N/A 

Recip. OR start time N/A N/A 

Blood Bank 

875-4420 (tell if HepB) 

Emerg. X-Ray 

875-5555 Local 62520 

Clinical Trials 

Liver Tx. Dr. on-call: 

Yoshida 875-5371 (O) 

872-9858 (P) 

Steinbrecher 

220-3273 (BB) 

Erb 

875-5039 (O) 

875-5618 (O) 

707-1397 (P) 

574-6360 (H) 

N/A 

N/A 

N/A 

Nephrologist to call 

N/A 

N/A 

N/A N/A N/A 

Program Coordinators Each program to notify Allied staff, Specialists & GP 

Linda Leung lleung4@bcts.hnet.bc.ca 604-877-2182 

Andrea 

aoshaughnessy@bcts.hnet.bc.ca 604-877-2134 

O’Shaughnessy 

Jan Emerton Jan_emerton@bcts.hnet.bc.ca 604-877-2120 

Wynne Chiu wchiu@providencehealth.ca 604-806-8887 

Sharon Duncan sharon_duncan@bcts.hnet.bc.ca 604-877-2110 

Reminders: Notify Transplant surgeon, retrieval, transplant physician, T4D if patient 

delayed. 




AMBULATORY DEPARTMENT 

BC Transplant (BCT) 

3 rd Floor, West Tower, 555 West 12th Ave. 

Vancouver, BC 

CANADA V5Z 3X7 

Telephone (604) 877-2240 

Toll Free 1-800-663-6189 

FAX (604) 604-877-2111 

Appendix S 

FAX COVERSHEET 

REQUIRED MEDICAL FOLLOW-UP 

FOR TRANSPLANT RECIPIENT(S) 

FROM:_____________________________ 

Date:___________________ 

Number of Pages _________________ [Attach copy of Exceptional Distribution] 

(including this page) 

SPH Heart Clinic Fax: 604-806-8763 Attention: 

SPH Kidney Clinic Fax: 604-806-8076 Attention: 

BCCH Fax: 604-875-2943 Attention: 

VGH SOT Clinic Fax: 604-875-4088 Attention: 

OTHER Fax: Attention: 

Please note that the organ recipient listed below requires Medical follow-up as 

a result of Exceptional Distribution of Organs: 

Date of Transplant:__________________________ 

Name of Recipient: ________________________Organ transplanted:______________ 

A copy of the Exceptional Distribution is attached. 

PLEASE INFORM THE RECIPIENT'S MEDICAL PHYSICIAN IMMEDIATELY. 

If further information is required, please do not hesitate to contact our 

department. 

_____________________________________________________________________________________________________ 

Notice of Confidentiality 

This communication is intended for the individual or institution to which it is addressed. It may not be distributed, forwarded, or disclosed to 

other unauthorized persons. It may contain confidential or personal information subject to the Freedom of Information and Protection of 

Privacy Act and the Personal Information Protection and Electronic Documents Act. If you receive this communication in error, please notify 

the sender immediately and destroy the communication, thank you. 




Appendix S (con’t) 

Recommended Follow-up Testing for Recipients Transplanted under Risk for Viral 

Mediated Disease Transmission 

NOTICE TO TRANSPLANT RECIPIENT MEDICAL TEAM: 

The following protocol has been approved by the BC Transplant Medical Advisory Committee 

(MAC) as a course of action for follow-up of recipients transplanted at risk for HIV and/or Hepatitis: 

IT IS RECOMMENDED THAT RECIPIENTS ARE RETESTED FOR HIV, HEPATITIS B AND 

HEPATITIS C at: 

• 4 weeks 

• 8 weeks 

• 6 months 

• 1 year 

Recommended Test Methods**: 

HIV - Conventional antibody testing 

HBV - HBsAg and HBcIgM 

HCV - Conventional antibody testing 

**NOTE: If there is clinical or epidemiological evidence to suggest a patient may have become 

infected with any of these viruses and antibody tests are negative, then PCR testing should be 

discussed with the medical team.

4. Clinical Guidelines for Liver Transplantation (PDF) - British ...

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