Possible Complications
Accelerated Acute Rejection
This is a very early, rapidly progressive and aggressive rejection reaction. It can occur within the first week of transplantation. The pathologic characteristics are massive infiltration of lymphocytes, macrophages, and plasma cells. There is injury to the renal tubules, damage of interstitial capillaries and vascular injury of larger vessels marked by endothelial swelling. The very aggressive and rapid nature of this rejection reaction makes it difficult to reverse. Immediate therapy with anti-T-cell antibodies, in addition to pulse corticosteroids, may reverse the process. Approximately 50% of the grafts can be salvaged. It would be expected that long-term function would be compromised.
Infection
All infections identified in the immunosuppressed transplant recipient should be treated expeditiously to limit sequelae. Patients with persistent low-grade fevers or acute spiking fevers (greater than 101 F) should be admitted to the hospital for stabilization and infectious work-up. The transplant center would like to be informed of any hospitalizations that a recipient requires. We would also appreciate a copy of the discharge summary from each admission.
Hypertension
Many liver transplant recipients develop systemic hypertension as an adverse effect when using cyclosporine or Prograf in addition to maintenance steroid therapy. Many patients respond to single antihypertensive therapy but a number of them require multiple agents for adequate control. Immunosuppression doses are also decreased, if possible, to improve renal artery perfusion, thus lowering rennin production. Certain calcium channel blockers (diltiazem, verapamil) increase cyclosporine levels- discuss with transplant center.
Bile Duct Problems
Complications can arise with the connection between the donor and recipient bile duct or between the donor bile duct and intestine. If it does not heal properly, bile may leak out. Scar tissue can also block the bile duct causing bile the inability to flow .
Problems with Blood Vessels
Complications can arise with blood vessel connections between the donor liver and the recipient's blood vessels. A more serious complication is a clot in an artery or vein attached to the liver. If a clot occurs, the liver may fail.
Major Bleeding
It is common for a liver transplant patient to experience bleeding after surgery. The new liver needs time to make blood-clotting proteins. Patients usually need blood transfusions, and an additional operation may be required within the first 24 to 48 hours after the transplant to resolve the problem.
Renal Dysfunction
Calcineurin inhibitors (cyclosporine, Prograf) are moderately potent nephrotoxins and frequently cause dose-related renal dysfunction. This is caused by vasoconstriction of the afferent renal arterioles, thereby decreasing the glomerular filtration rate. Patients should not be treated with drugs that increase the nephrotoxicity effect of their immunosuppression. These drugs include NSAIDS, indocin, erythromycin or medications that may increase calcineurin inhibitor levels (see Medications to Avoid table).
Hyperlipidemia
Hyperlipidemia can occur early post-transplant and affects 60-80% of liver transplant recipients due to the effects of cyclosporine and Prograf. HMG-CoA reductase inhibitors are used with care in these patients because of risk of myositis when used in conjunction with calcineurin inhibitors. Patients are placed on Pravachol immediately following transplant for lipid control and it’s beneficial effects on lowering the risk of coronary vasculopathy. Pravachol has been shown to have the lowest incidence of myositis in this population as it is not metabolized through the same pathway as calcineurin inhibitors.
Malignancy
Transplant recipients are at increased risk for developing malignancies due to immunosuppressants necessary to maintain allograft function. Skin cancers (basal cell and squamous cell carcinomas) are the most commonly encountered. The treatment of skin cancers can include cryotherapy, excision and reduction in immunosuppression, if possible.
