Possible Complications

Rejection is a signal that your immune system has identified your new liver as foreign tissue and is trying to get rid of it. Preventing rejection with immune-suppressive medications is the first priority. Only about 30 percent of patients may experience some signs of rejection during the first six months after the transplant operation. The most common presentations of rejection are:

• Elevated liver function tests, as determined by frequent measurements of your liver blood tests
• Fever
• Tenderness over the liver

If it appears that you are having a rejection episode, you will need a liver biopsy. During the evaluation of the elevated liver blood tests, we will also need to do an ultrasound to be sure there is no blockage in the arteries and veins that carry blood to and from the liver. An endoscopic test (through the mouth) may be necessary if doctors suspect a problem with the bile ducts in the liver.

If tests verify that your body is rejecting the transplanted liver, we will increase your amount of anti-rejection medication or prescribe a different combination of anti-rejection medications. These types of rejection episodes are nearly always reversible and rarely lead to loss of the liver so long as you continue to take your anti-rejection medications.

The anti-rejection medications that you take to prevent and treat rejection tell your immune system to accept your new liver in your body. In doing so, they also can be telling your immune system to accept other things that it ordinarily would fight. In other words, the anti-rejection medications put you at greater risk for developing an infection. A variety of infectious complications can occur following liver transplantation. The most common infections are of the lungs, the surgical incision, and the bladder or urinary tract.

To check for infection, your caregivers may take sputum (the substance coughed up from your lungs), blood and urine samples, and, if you have a catheter or open wound, samples from your catheter, wound and drain sites. Symptoms of infection may include fever, exhaustion, diarrhea or vomiting, redness or drainage around your incision, or a cough and sore throat.

To help prevent infections after your transplant, you will take antibacterial, antiviral and antifungal medications. If an infection develops after you leave the hospital, we can usually treat it with outpatient antibiotics. However, sometimes people need to be readmitted for treatment with intravenous (IV) medications.

As your new transplanted liver starts to work, the efficiency with which it metabolizes and eliminates certain medications is unpredictable. So medication side effects and toxicity (how poisonous the drugs are in your system) can be a serious problem after liver transplantation. Because the drugs you are taking are so strong, the transplant team keeps a watchful eye on the type of medication you need, the dose and drug levels within your system. We review your medication list daily and make adjustments as necessary. And we continue to carefully monitor your medication list after discharge. Before you go home, we will teach you and your family about the medicines you are taking, their doses and their potential side effects. Because of the possibility of medication interactions, where one medication may interfere with the metabolism of another, you MUST NOT take any medication or over-the-counter medication without discussing this with your transplant team.

Bleeding after your surgery, or postoperative hemorrhage, may occur after liver transplantation. You may need a blood transfusion or another operation to stop the bleeding.

A very small percentage of patients may experience a blood clot in either the new liver's hepatic artery (supplies blood to the liver) or portal vein (ferries blood from the intestines and stomach to the liver). A variety of tests can confirm this diagnosis including ultrasound, angiography (a special type of X-ray) and CT scanning. Physicians treat this condition with thrombolytic (or clot-dissolving) medications, surgery to remove the clot and enlarge the vessel, or by inserting a vascular stent (a tiny wire mesh or plastic tube) to hold the blood vessel open. Additional surgery may be needed if there is an obstruction in the new liver's inferior vena cava, the large vein that returns blood to the heart from the abdominal organs (including the liver) and the lower limbs.

The bile ducts the surgeon connected to your new liver may not heal properly and may leak bile or become blocked after the transplant operation. An ultrasound may detect the problem. A leak may be treated by placing tubes or drains through the skin and into the liver to drain bile from the liver into a bag worn outside the body for a period of time. This procedure often can be done without having surgery. A gastroenterologist may also treat a bile leak by inserting a stent (a tiny wire mesh or plastic tube) in the bile duct to keep it open and allow bile to flow appropriately and stop the leak. They can insert the stent through an endoscope, a tube that is placed through the mouth and into the stomach.

Bile duct strictures (narrowing of the large ducts that drain the liver) can also occur after liver transplantation. If this happens, some of them can be fixed without surgery by dilating the narrowing with a balloon and placing a stent in the narrowed area using an endoscopic procedure (through the mouth) or percutaneous procedure (through the skin). The stent widens the narrowed area and keeps it open.

There is always a small chance that your donated liver will not function after surgery. This condition is called primary graft non-function and occurs very rarely. In this case, we will work with a team of specialists in the Transplant and Liver Centers to treat symptoms of end-stage liver failure until another liver becomes available for you.

Even if you have never had diabetes, the anti-rejection medications you take to suppress your immune system may cause diabetes. If you had diabetes before your liver transplant, controlling your blood sugar may be more difficult.

The anti-rejection medications you take may also increase your risk for certain types of cancer - sun-related skin cancer and a rare form of lymph node cancer.