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

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Guidebook for the Solid Organ Transplant Programme Chapter 4 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 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 20 mg/kg IV or IM * 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 Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 23 See Page 1 for disclaimer
4.4.4 LATE COMPLICATIONS Guidebook for the Solid Organ Transplant Programme Chapter 4 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. Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 24 See Page 1 for disclaimer
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