The liver transplant recipient: What you need to know for long-term care

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Applied Evidence

The liver transplant recipient: What you need to know for long-term care

J Fam Pract. 2006 February;55(2):136-144

By

Josh Levitsky, MD

Stanley Martin Cohen, MD

Anticipate known complications and your response in concert with the transplant center.

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References

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Practice recommendations

In general, long-term treatment of hypertension, diabetes, and obesity after liver transplantation is similar to that for the general population ( C ).
Measure bone density within the first year after transplantation. Treat osteoporosis with standard agents. Joint replacement surgery appears safe in this group of patients ( B ).
Resume standard screening for malignancy 2 to 3 years after transplantation, and repeat at intervals similar to that used with the general population. Given the high risk of skin cancer, transplant recipients should wear sunblock (SPF > 40) and have routine dermatologic examinations ( B ).
Patients should wait at least 2 years before considering pregnancy and use barrier-type methods in this period ( C ).
Vaccinate patients against hepatitis A and B, influenza, and pneumococcus. Avoid live vaccines ( C ).

Orthotopic liver transplantation (OLT) is the replacement of a whole diseased liver with a healthy donor liver. The number of persons receiving OLT is increasing. Though it is unlikely you will be involved in the care of a patient immediately after OLT, you ’ ll need to know about the complications that occur in this period as they may impact the long-term care of the patient.

Long-term issues — such as cardiovascular disease, bone disease, malignancy, anemia, psychiatric disorders, and financial stressors — put these patients at higher risk for problems more than the average patient. Perhaps the most important task is for you to keep in contact with the transplant center when questions or concerns arise. Over time, you will once again become the primary physician and advocate for these patients.

Complications after transplant (less than 1 year)

Within 1 month post-OLT, the most frequent complications are acute graft rejection, vascular thrombosis, biliary leak or stricture, and infection. Between 1 and 3 months, acute and chronic graft rejection can occur, but medication toxicity and opportunistic infections become more common (TABLE 1). ¹

A broad range of infections may develop, including cytomegalovirus, Epstein-Barr virus, herpes simplex virus, varicella zoster virus, adenovirus, tuberculosis, Pneumocystis , toxoplasmosis, Listeria spp, Candida spp, Aspergillus spp, and Cryptococcus spp. During this time, doses of immunosuppressive agents are lowered and corticosteroids are discontinued in many patients.

Once patients are considered stable after OLT, they will likely come under your supervision again. While opportunistic infections, surgical issues, and acute rejection become less common between 3 and 12 months, other complications related to OLT may occur.

Graft reinfection with hepatitis C virus (HCV) is universal, and 50% to 80% patients will develop biopsy-proven hepatitis. ² Many will require treatment for recurrent HCV to avoid progression to cirrhosis.

Recurrent hepatitis B infection is much less common due to prophylactic therapy with hepatitis B immunoglobulin and antiviral medications, although 10% of transplant recipients will develop hepatitis despite prophylaxis.

Other causes of recurrent liver disease post-OLT include liver injury due to recurrent drug or alcohol abuse, non-alcoholic steatohepatitis, cholestatic and autoimmune liver disease, and liver cancer.

Toxicity due to immunosuppressive medications is also common in this time frame (TABLE 2). ³ Be alert to the potential for hepatotoxicity and drug interactions with any new pharmacologic agent. Other drugs (eg, lipid-lowering agents, antibiotics, antifungals) may cause liver injury on their own and need to be closely monitored.

Lastly, even though patients are at increased risk for such common infections as influenza, pneumonia, and urinary tract infections, opportunistic infections are uncommon in this period. Keep in mind that patients usually develop infections that are community-acquired and not opportunistic, particularly as time goes on.

TABLE 1
Common complications immediately after liver transplantation

COMPLICATION	SIGNS/SYMPTOMS	LABORATORY TESTS	INITIAL MANAGEMENT
Acute rejection	Usually nonspecific or asymptomatic; low-grade fever, malaise, RUQ pain	Early: high AP, GGT; mild AST/ALT	1) Doppler U/S: exclude HAT, biliary obstruction
Acute rejection		Severe: high AST/ALT (usually < 1000) and TB	2) Liver biopsy
Biliary obstruction or leak	Nonspecific to cholangitis (high fever, jaundice, sepsis); often no abdominal pain	High TB, AP, GGT	1) Doppler U/S: exclude HAT, evaluate bile duct dilation
		Less common: elevations in AST/ALT	2) T-tube cholangiogram
		Less common: elevations in AST/ALT	3) ERCP or PTC; surgical revision if failure
Hepatic artery thrombosis (HAT)	High fever, RUQ pain, jaundice; may progress to liver failure rapidly	High AST/ALT, TB Prolonged INR	1) Doppler U/S: evaluate artery flow, bile ducts, liver abscess, infarction; if HAT, urgent revascularization
Hepatic artery thrombosis (HAT)		High AST/ALT, TB Prolonged INR	2) Equivocal presentation: arteriography
Hepatic vein or inferior vena cava obstruction	Hepatomegaly, ascites, lower extremity edema	Nonspecific liver test abnormalities	1) Doppler U/S
Hepatic vein or inferior vena cava obstruction	Hepatomegaly, ascites, lower extremity edema	Nonspecific liver test abnormalities	2) If positive or negative+high suspicion, contrast venogram; dilation/stent procedure if stenosis or thrombosis
Portal vein thrombosis	Hematemesis (variceal bleed), abdominal pain ± ascites	Nonspecific liver test abnormalities; rarely high liver enzymes	1) Doppler U/S
Portal vein thrombosis	Hematemesis (variceal bleed), abdominal pain ± ascites		2) If positive or negative+high suspicion: arteriography with portal venous phase; treat with shunt or retransplantation
Calcineurin-inhibitor toxicity	Tremor, headache, seizure, gastrointestinal	Elevated creatinine	1) Drug level and hold if high
		Hyperkalemia	2) Replete electrolytes/fluids
		Hypomagnesemia	3) Review other medications for interactions ( TABLE 2 )
		Anemia
ALT, alanine aminotransferase; AP, alkaline phosphatase; AST, aspartate aminotransferase; ERCP, endoscopic retrograde cholangiopancreatography; GGT, gamma glutamyl-transferase; HAT, hepatic artery thrombosis; INR, international normalized ratio; PTC, percutaneous transhepatic cholangiography, RUQ, right upper quadrant; TB, total bilirubin; U/S, ultrasound