Liver transplant complications: Difference between revisions
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==Background== | ==Background== | ||
*2nd most frequently transplanted solid organ | *2nd most frequently transplanted solid organ | ||
*May be from living or deceased donor | *May be from living or deceased donor | ||
*Most common causes of liver failure necessitating transplant include hepatitis C or B infection, alcoholic [[cirrhosis]], idiopathic/autoimmune liver disease, primary biliary cirrhosis, primary sclerosing cholangitis, and [[acute liver failure]] (e.g. drug/toxin induced, acute hepatitis, etc.) | *Most common causes of liver failure necessitating transplant include hepatitis C or B infection, alcoholic [[Special:MyLanguage/cirrhosis|cirrhosis]], idiopathic/autoimmune liver disease, primary biliary cirrhosis, primary sclerosing cholangitis, and [[Special:MyLanguage/acute liver failure|acute liver failure]] (e.g. drug/toxin induced, acute hepatitis, etc.) | ||
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{{Immunosuppressant medication complications}} | {{Immunosuppressant medication complications}} | ||
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==Clinical Features== | ==Clinical Features== | ||
*Signs/symptoms of infection | *Signs/symptoms of infection | ||
**[[Fever]] and localizing symptoms may be blunted due to immunosupression | **[[Special:MyLanguage/Fever|Fever]] and localizing symptoms may be blunted due to immunosupression | ||
*[[GI bleed]] | *[[Special:MyLanguage/GI bleed|GI bleed]] | ||
*[[RUQ pain]], especially with biliary complications | *[[Special:MyLanguage/RUQ pain|RUQ pain]], especially with biliary complications | ||
*Neurologic findings | *Neurologic findings | ||
**[[focal neuro deficits]] or [[altered mental status]] due to bleed, infarct, thrombosis, osmotic demyelination, abscess, etc. | **[[Special:MyLanguage/focal neuro deficits|focal neuro deficits]] or [[Special:MyLanguage/altered mental status|altered mental status]] due to bleed, infarct, thrombosis, osmotic demyelination, abscess, etc. | ||
*[[Jaundice]] | *[[Special:MyLanguage/Jaundice|Jaundice]] | ||
**may indicate rejection or biliary leak/stricture | **may indicate rejection or biliary leak/stricture | ||
*[[Nausea/vomiting]] | *[[Special:MyLanguage/Nausea/vomiting|Nausea/vomiting]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Most common problems in liver transplant patients involve: | Most common problems in liver transplant patients involve: | ||
*Acute graft rejection | *Acute graft rejection | ||
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*Malignancy (squamous cell carcinoma, lymphomas, post transplant lymphoproliferative disorder) | *Malignancy (squamous cell carcinoma, lymphomas, post transplant lymphoproliferative disorder) | ||
*Adverse effects of immunosuppressant drugs<ref> Liver Transplants: Practice Essentials, Orthotopic Liver Transplantation, Immunosuppression Agents. Emedicinemedscapecom. 2016. Available at: http://emedicine.medscape.com/article/776313-overview#a1. Accessed September 23, 2016.</ref> | *Adverse effects of immunosuppressant drugs<ref> Liver Transplants: Practice Essentials, Orthotopic Liver Transplantation, Immunosuppression Agents. Emedicinemedscapecom. 2016. Available at: http://emedicine.medscape.com/article/776313-overview#a1. Accessed September 23, 2016.</ref> | ||
===Infections<ref>Long B, Koyfman A. The emergency medicine approach to transplant complications. Am J Emerg Med. 2016;34(11):2200-2208.</ref>=== | ===Infections<ref>Long B, Koyfman A. The emergency medicine approach to transplant complications. Am J Emerg Med. 2016;34(11):2200-2208.</ref>=== | ||
Time from transplantation affects the risk and type of infection. | Time from transplantation affects the risk and type of infection. | ||
*Early (within the first month) | *Early (within the first month) | ||
**Donor-derived - bacterial, fungal, parasitic | **Donor-derived - bacterial, fungal, parasitic | ||
**Nosocomial & surgical-site - [[C. diff]], [[aspiration Pneumonia]], [[UTI]], surgical-site, superinfection of graft tissue | **Nosocomial & surgical-site - [[Special:MyLanguage/C. diff|C. diff]], [[Special:MyLanguage/aspiration Pneumonia|aspiration Pneumonia]], [[Special:MyLanguage/UTI|UTI]], surgical-site, superinfection of graft tissue | ||
*Intermediate (1-6 months after) | *Intermediate (1-6 months after) | ||
**'''Highest risk for opportunistic infections''' - [[PCP]], [[TB]], fungal ([[cryptococcus]], [[histoplasma]]), viral (BK virus, [[hepatitis B]]/[[hepatitis C|C]], [[CMV]]) | **'''Highest risk for opportunistic infections''' - [[Special:MyLanguage/PCP|PCP]], [[Special:MyLanguage/TB|TB]], fungal ([[Special:MyLanguage/cryptococcus|cryptococcus]], [[Special:MyLanguage/histoplasma|histoplasma]]), viral (BK virus, [[Special:MyLanguage/hepatitis B|hepatitis B]]/[[Special:MyLanguage/hepatitis C|C]], [[Special:MyLanguage/CMV|CMV]]) | ||
**Dormant host infection reactivation - [[HSV]], [[VZV]], [[EBV]] | **Dormant host infection reactivation - [[Special:MyLanguage/HSV|HSV]], [[Special:MyLanguage/VZV|VZV]], [[Special:MyLanguage/EBV|EBV]] | ||
*Late (more than 6 months after) | *Late (more than 6 months after) | ||
**Community-acquired infection | **Community-acquired infection | ||
==Evaluation== | ==Evaluation== | ||
*CBC | *CBC | ||
**Infection may cause leukocytosis or leukopenia | **Infection may cause leukocytosis or leukopenia | ||
*[[LFTs]] | *[[Special:MyLanguage/LFTs|LFTs]] | ||
**Elevated in biliary, vascular, and rejection complications | **Elevated in biliary, vascular, and rejection complications | ||
*BMP | *BMP | ||
**[[Hyperglycemia]], sodium, and potassium derangements not uncommon | **[[Special:MyLanguage/Hyperglycemia|Hyperglycemia]], sodium, and potassium derangements not uncommon | ||
*Coags | *Coags | ||
*Tacrolimus/cyclosporine levels | *Tacrolimus/cyclosporine levels | ||
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**Blood and urine cultures | **Blood and urine cultures | ||
**+/- PCR and other studies for viral/fungal pathogens as indicated | **+/- PCR and other studies for viral/fungal pathogens as indicated | ||
**Diagnostic paracentesis if evidence of [[SBP]] | **Diagnostic paracentesis if evidence of [[Special:MyLanguage/SBP|SBP]] | ||
*Abdominal CT or [[Ultrasound: Abdomen|ultrasound]] with doppler, if concern for rejection, biliary obstruction, or thrombosis | *Abdominal CT or [[Ultrasound: Abdomen|ultrasound]] with doppler, if concern for rejection, biliary obstruction, or thrombosis | ||
*Biliary complications may need ERCP | *Biliary complications may need ERCP | ||
==Management== | ==Management== | ||
*Consult transplant team | *Consult transplant team | ||
*High-dose [[steroids]] for rejection | *High-dose [[Special:MyLanguage/steroids|steroids]] for rejection | ||
*See [[immunocompromised antibiotics]] | *See [[Special:MyLanguage/immunocompromised antibiotics|immunocompromised antibiotics]] | ||
*See [[upper GI bleed]] | *See [[Special:MyLanguage/upper GI bleed|upper GI bleed]] | ||
*See [[Spontaneous Bacterial Peritonitis]] | *See [[Special:MyLanguage/Spontaneous Bacterial Peritonitis|Spontaneous Bacterial Peritonitis]] | ||
*See [[Graft-vs-host disease]] | *See [[Special:MyLanguage/Graft-vs-host disease|Graft-vs-host disease]] | ||
==Disposition== | ==Disposition== | ||
*Admit in consultation with transplant team | *Admit in consultation with transplant team | ||
==See Also== | ==See Also== | ||
*[[Transplant complications]] | |||
*[[Neutropenic fever]] | *[[Special:MyLanguage/Transplant complications|Transplant complications]] | ||
*[[Immunocompromised antibiotics]] | *[[Special:MyLanguage/Neutropenic fever|Neutropenic fever]] | ||
*[[Special:MyLanguage/Immunocompromised antibiotics|Immunocompromised antibiotics]] | |||
==External Links== | ==External Links== | ||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:GI]] | [[Category:GI]] | ||
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Latest revision as of 23:18, 4 January 2026
Background
- 2nd most frequently transplanted solid organ
- May be from living or deceased donor
- Most common causes of liver failure necessitating transplant include hepatitis C or B infection, alcoholic cirrhosis, idiopathic/autoimmune liver disease, primary biliary cirrhosis, primary sclerosing cholangitis, and acute liver failure (e.g. drug/toxin induced, acute hepatitis, etc.)
Immunosuppressant Medications
- Balance between immune suppression, rejection and susceptibility to infection
- Typical regimen includes: calcineurin inhibitor + antimetabolite + steroid
- Calcineurin inhibitor
- Steroids
- +/- Antimetabolite
Clinical Features
- Signs/symptoms of infection
- Fever and localizing symptoms may be blunted due to immunosupression
- GI bleed
- RUQ pain, especially with biliary complications
- Neurologic findings
- focal neuro deficits or altered mental status due to bleed, infarct, thrombosis, osmotic demyelination, abscess, etc.
- Jaundice
- may indicate rejection or biliary leak/stricture
- Nausea/vomiting
Differential Diagnosis
Most common problems in liver transplant patients involve:
- Acute graft rejection
- 1 in 5 have rejection during first year, usually within <1 mo
- Vascular thrombosis
- Biliary leak or stricture
- Malignancy (squamous cell carcinoma, lymphomas, post transplant lymphoproliferative disorder)
- Adverse effects of immunosuppressant drugs[1]
Infections[2]
Time from transplantation affects the risk and type of infection.
- Early (within the first month)
- Donor-derived - bacterial, fungal, parasitic
- Nosocomial & surgical-site - C. diff, aspiration Pneumonia, UTI, surgical-site, superinfection of graft tissue
- Intermediate (1-6 months after)
- Highest risk for opportunistic infections - PCP, TB, fungal (cryptococcus, histoplasma), viral (BK virus, hepatitis B/C, CMV)
- Dormant host infection reactivation - HSV, VZV, EBV
- Late (more than 6 months after)
- Community-acquired infection
Evaluation
- CBC
- Infection may cause leukocytosis or leukopenia
- LFTs
- Elevated in biliary, vascular, and rejection complications
- BMP
- Hyperglycemia, sodium, and potassium derangements not uncommon
- Coags
- Tacrolimus/cyclosporine levels
Additional work up will depend on presentation, but may include:
- Infectious workup
- Blood and urine cultures
- +/- PCR and other studies for viral/fungal pathogens as indicated
- Diagnostic paracentesis if evidence of SBP
- Abdominal CT or ultrasound with doppler, if concern for rejection, biliary obstruction, or thrombosis
- Biliary complications may need ERCP
Management
- Consult transplant team
- High-dose steroids for rejection
- See immunocompromised antibiotics
- See upper GI bleed
- See Spontaneous Bacterial Peritonitis
- See Graft-vs-host disease
Disposition
- Admit in consultation with transplant team
See Also
External Links
References
- ↑ Liver Transplants: Practice Essentials, Orthotopic Liver Transplantation, Immunosuppression Agents. Emedicinemedscapecom. 2016. Available at: http://emedicine.medscape.com/article/776313-overview#a1. Accessed September 23, 2016.
- ↑ Long B, Koyfman A. The emergency medicine approach to transplant complications. Am J Emerg Med. 2016;34(11):2200-2208.