Liver transplant complications: Difference between revisions
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*Vascular thrombosis | *Vascular thrombosis | ||
*Biliary leak or stricture | *Biliary leak or stricture | ||
*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>=== | |||
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 | |||
==Evaluation== | ==Evaluation== | ||
| Line 33: | Line 42: | ||
**Elevated in biliary, vascular, and rejection complications | **Elevated in biliary, vascular, and rejection complications | ||
*BMP | *BMP | ||
**Hyperglycemia, sodium, and potassium | **[[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]] | ||
*Abdominal CT or [[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 [[steroids]] for rejection | ||
*See [[immunocompromised antibiotics]] | *See [[immunocompromised antibiotics]] | ||
*See [[upper GI bleed]] | *See [[upper GI bleed]] | ||
| Line 54: | Line 63: | ||
==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
- 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.