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

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Guidebook for the Solid Organ Transplant Programme Chapter 4 4.3.2 EARLY COMPLICATIONS CONT. 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. Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 15 See Page 1 for disclaimer
Guidebook for the Solid Organ Transplant Programme Chapter 4 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) Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 16 See Page 1 for disclaimer
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