11. Management of the Complications of Liver Transplantation

Summary

Early complications after liver transplantation include bleeding, bile leaks, anastomotic and non-anastomotic biliary strictures, and hepatic artery or portal vein thrombosis. Acute cellular rejection occurs in 20% of patients, typically in the first three postoperative months. Its diagnosis requires a liver biopsy and it usually responds to increased immunosuppression. Immunosuppression predisposes to infections, cytomegalovirus infection/disease being one of the most important ones, and to malignancies, in particular Epstein–Barr virus associated post-transplant lymphoproliferative disorder. The individual immunosuppressive agents used have their individual side effect profile. Calcineurin inhibitors (cyclosporine A, tacrolimus), which formthe backbone of maintenance immunosuppression, are, among others, associated with nephrotoxicity. Steroids and calcineurin inhibitors predispose to weight gain, hypertension, dyslipidemia, and insulin resistance/diabetes, which develop in 30–60% of patients. Thus, liver transplant recipients are at a threefold higher risk for fatal and non-fatal cardiovascular events than the normal population. Finally, some underlying liver disease may recur with varying frequency and may impact, such as hepatitis C recurrence, on survival outcome. The internist/family physician and transplant hepatologist share the long-term care for the liver transplant recipient, the former bringing his or her expertise with managing cardiovascular risk factors and many conditions common in the non-transplant population that may occur also in the liver transplant recipient, the latter his or her experience with managing immunosuppression and graft related issues.