Liver transplant complications: Difference between revisions

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==Background==
==Background==
{{Transplant emergency types}}
*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 medication complications}}
{{Immunosuppressant medication complications}}


==Clinical Features==
==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==
==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<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>===
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]]/[[hepatitis C|C]], [[CMV]])
**Dormant host infection reactivation - [[HSV]], [[VZV]], [[EBV]]
*Late (more than 6 months after)
**Community-acquired infection


==Diagnosis==
==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: Abdomen|ultrasound]] with doppler, if concern for rejection, biliary obstruction, or thrombosis
*Biliary complications may need ERCP


==Management==
==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==
==Disposition==
*Admit in consultation with transplant team


==See Also==
==See Also==
*[[Transplant complications]]
*[[Transplant complications]]
*[[Neutropenic fever]]
*[[Immunocompromised antibiotics]]


==External Links==
==External Links==

Latest revision as of 19:57, 8 March 2021

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

Clinical Features

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)
  • 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
  • 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

Disposition

  • Admit in consultation with transplant team

See Also

External Links

References

  1. ↑ 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.
  2. ↑ Long B, Koyfman A. The emergency medicine approach to transplant complications. Am J Emerg Med. 2016;34(11):2200-2208.
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