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

Guidebook for the Solid Organ Transplant Programme Chapter 4
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)
Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 25
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