Problems that could happen after liver transplant
Many parents ask about pain medication. Pain medication is provided to the children to keep them as comfortable as possible. However, it is very important to assess neurologic function, so children are not given medication to make them sleep all of the time.
Biliary Leaks
Biliary leaks or obstructions account for 10 percent of complications in the pediatric transplant population. Children with reduced size liver grafts are at a greater risk for developing a biliary leak or stricture. The complication is related to inadequate blood supply to the biliary anastomosis (surgical connection) or a technical difficulty because of the small structures. Prompt treatment is required; the child will require reexploration in the operating room. Obstruction of the biliary tree is usually a late finding. It can occur as long as a year after surgery. Usually the child will have symptoms of cholangitis, such as a mild fever or deteriorating liver function. Obstructions are managed with transhepatic stenting. This procedure is performed in the interventional radiology suite (CVDL) and does not require a second surgical procedure.
Hepatic Artery Thrombosis
Hepatic artery thrombosis is a serious complication that occurs in 10 to 20 percent of pediatric liver transplant recipients. The hepatic artery, which is attached to the new liver’s artery, narrows or a blood clot forms. Usually the child will develop acute graft failure or formation of an intrahepatic abscess or sepsis. Correction requires surgical intervention, or in some cases. retransplantation. Routine studies to assess blood flow to the liver will be obtained in the immediate post-operative period to determine if blood flow to the liver is a problem. Additionally, cultures of the fluid from the abdominal drains will assist in early detection of infection.
Rejection
Rejection is the most common post-transplant complication: more than 90 percent of the children experience it at least once. Don’t panic if this happens to your child! The first episode of rejection usually occurs about seven to ten days after transplant. However, even after months at home, your child may experience rejection. How will you know your child is rejecting his liver? The classic signs include a fever (temperature greater than 38.5C or 101F, elevation of the AST and ALT liver enzymes, dark urine or clay colored stools, loss of appetite, jaundice and/or pain over the graft. Often changes in lab values are the only sign of a rejection episode. Usually a liver biopsy is performed by the pediatric gastroenterologist to confirm the diagnosis. If rejection is confirmed, most children receive large doses of steroids, one of the medications that provides immunosuppression. If the liver enzymes return to normal after the initial steroid doses, the doctors will prescribe a 10-day course of oral steroids. Occasionally children need a stronger medicine to help fight the rejection episode.
Infection
The same medications that prevent rejection also decrease the body’s ability to fight infection. As a result, care must be taken to limit your child’s exposure to infections such as colds or the flu. You must be alert to signs of infection in your child, including a fever (temperature greater than 101F), a sore throat, a cough that last longer than 24 hours, rashes and diarrhea.
Common viral infections include CMV (cytomegalovirus), herpes and fungal infections such as candida. Some of the common sites for CMV infection include the new liver, the gastrointestinal tract (GI) or the lungs. Typical symptoms include night sweats, low grade fever and diarrhea. A first time exposure occurs in many children who are CMV negative at the time of transplantation because they may receive a CMV positive donor organ. All children who are test negative for the CMV virus and receive a CMV positive organ, will receive Intravenous Immunoglobulin (IVIG) or Cytogam on an eight-week schedule to prevent CMV infection. Regardless, many children will develop CMV. Treatment involves administration of Ganciclovir IV for four weeks and adjustment in other immunosuppressant medications. Viral shedding may persist for several weeks to months after the initial infection occurs. Good hand washing will help prevent further spread of this virus.
The herpes virus is another common viral infection, which appears as an itchy, small blistery, red rash on the skin or in the mouth. Treatment involves the administration of Acyclovir by mouth or IV.
The most common fungal infection that occurs in an immunosuppressed child is candida or thrush. This fungus often grows in the mouths of children on antibiotics, such as Bactrim, because the antibiotics eliminate bacteria that is normally present in the body. The primary symptom of thrush is an outbreak of white spots on the tongue, gums and inside the lips and cheeks. Your child may also develop a fever, cough or digestive problems. Oral nystatin is prescribed to prevent or treat the thrush. If a fungal diaper rash occurs, mycostatin cream may be applied to the affected area.
After transplantation your child is at risk for a number of bacterial infections. Initially they will receive antibiotics such as Bactrim to prevent an infection and routine cultures will be taken several times a week in the immediate post-operative period. If an organism is identified, the appropriate antibiotic will be ordered to fight the infection.
Post-Transplant Lymphoproliferative Disorders (PTLD)
Lymphocytes are white blood cells that are part of your immune system and play a key role in attacking foreign invaders such as bacteria and viruses. The lymphocytes are divided into B cells and T cells. The immunosuppressant medications your child takes suppress the activity of the T cells and prevent rejection. The medications are not specific to the organ but in fact suppress the entire immune system. Normal regulation or control of B cell production and T lymphocytes is altered when a child takes immunosuppressant medications. As a result of this imbalance the B cells can multiply rapidly.
When a person has a virus, the normal immune response is to produce more B cells to fight the infection. The Epstein-Barr Virus (EBV) is a virus that directly attacks B cells and causes an overproduction of B cells. In a healthy person the EBV infection is called mononucleosis, and the patient recovers from the virus by controlling the B cells that are activated. In a transplant patient, the normal T cell control over the infected B cells is compromised by the immunosuppression, and these B cells may grow uninhibited. This is lymphoproliferative disorder.
When the donor and recipient are an EBV mismatch (in other words, the child is negative for the virus and the donor is positive), your child will be given an antiviral called Acyclovir to prevent this problem. However, if the EBV virus develops, the amount of immunosuppression medication is usually reduced to allow the immune system to recover and fight the overproduction of B cells. The usual signs and symptoms include fever, malaise, lymph node enlargement and liver and spleen enlargement.
