Liver transplant complications: Difference between revisions
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==Background== | ==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 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 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 | |||
*Vascular thrombosis | |||
*Biliary leak or stricture | |||
*Infection | |||
*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> | |||
==Evaluation== | ==Evaluation== | ||
*CBC | |||
**Infection may cause leukocytosis or leukopenia | |||
*LFTs | |||
**Elevated in biliary, vascular, and rejection complications | |||
*BMP | |||
**Hyperglycemia, sodium, and potassium derrangements 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 US 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 [[immunosupressed antibiotics]] | |||
*See [[upper GI bleed]] | |||
*See [[Spontaneous Bacterial Peritonitis]] | |||
*See [[Graft-vs-host disease]] | |||
==Disposition== | ==Disposition== | ||
Revision as of 14:25, 23 September 2016
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 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
- Vascular thrombosis
- Biliary leak or stricture
- Infection
- Malignancy (squamous cell carcinoma, lymphomas, post transplant lymphoproliferative disorder)
- Adverse effects of immunosuppressant drugs[1]
Evaluation
- CBC
- Infection may cause leukocytosis or leukopenia
- LFTs
- Elevated in biliary, vascular, and rejection complications
- BMP
- Hyperglycemia, sodium, and potassium derrangements 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 US 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 immunosupressed antibiotics
- See upper GI bleed
- See Spontaneous Bacterial Peritonitis
- See Graft-vs-host disease
Disposition
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.