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

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
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