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

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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 See Page 1 for disclaimer
Guidebook for the Solid Organ Transplant Programme Chapter 4 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. Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 26 See Page 1 for disclaimer
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