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SURGICAL
Liver Resection Cholecystectomy
Liver Transplantation
 
 
History of Liver Transplantation Candidates of Liver Transplant
Pre Liver Transplant tests

Liver Transplantation – a Team   work

Types of Liver Transplantation   Surgeries Liver Transplantation Surgery
Medications prescribed after   Liver Transplant Complications that can arise after  Liver Transplantation
 Diet and Nutrition post Liver   Transplant  
 

History of Liver Transplantation

The history of liver transplantation began almost forty years ago. In the late 1950s, Welch and others explored heterotopic (other site) and orthotopic (same site) liver transplantation in animals. A few years later in 1963 the first successful orthotopic liver transplantation (OLT) in a human being was performed by Thomas Starzl. The initial enthusiasm generated by this new technique was dampened considerably as investigators encountered a multitude of intractable postoperative complications, most notably graft rejection; after seven consecutive patient deaths at three centers, all work on liver transplantation was temporarily suspended. However, time and effort brought important improvements and the number of OLTs increased significantly after the introduction of the potent antirejection drug cyclosporin-A in 1979.

Liver Transplantation

The liver is the second most commonly transplanted major organ, after the kidney, so it is clear that liver disease is a common and serious problem. Liver transplant is surgery to replace a diseased liver with a healthy liver from a donor.

It is important for liver transplant candidates and their families to understand the basic process involved with liver transplants, to appreciate some of the challenges and complications that face liver transplant recipients (people who receive livers), and to recognize symptoms that should alert recipients to seek medical help.
A healthy liver is usually obtained from a donor who has recently died, but has not suffered liver injury. Many donors are victims of some sort of trauma and have been declared brain dead. A donor with the right blood type and similar body weight is sought to help reduce the risk of rejection.

The donor liver is transported in a cooled saline solution that preserves the organ for up to 8 hours, thus permitting the necessary tests for donor-recipient matching.

The diseased liver is removed through an incision in the upper abdomen. The donor liver is put in place and attached to the patient's blood vessels and bile ducts. The operation may take up to 12 hours and requires a large amount of transfused blood.

In some cases, a living donor may donate a section of liver for transplant to someone else, often a family member or friend. This poses some risk to the donor because of the nature of the operation, but since the liver can regenerate itself to some extent, both parties usually end up with fully functioning livers after a successful transplant.
Need of Liver Transplant

The body needs a healthy liver. The liver is an organ located in the right side of the abdomen below the ribs. The liver has many vital functions.

It is a powerhouse that produces varied substances in the body, including

  • glucose, a basic sugar and energy source

  • proteins, the building blocks for growth

  • blood-clotting factors, substances that aid in healing wounds

  • bile, a fluid stored in the gallbladder and necessary for the absorption of fats and vitamins.

As the largest solid organ in the body, the liver is ideal for storing  important substances like vitamins and minerals. It also acts as a  filter, removing impurities from the blood. Finally, the liver metabolizes  and detoxifies substances ingested by the body. Liver disease occurs  when these essential functions are disrupted. Liver transplants are  needed when damage to the liver severely impairs a person's health  and quality of life.

Hence, Liver transplants are considered only when there is a high risk of death from liver disease. Being told that a liver transplant might be needed doesn't automatically mean that life is in danger of dying right away. It usually takes a long time to find a liver that is right for the recipient.

Liver disease severe enough to require a liver transplant can come from many causes. Doctors have developed various systems to determine the need for the surgery. Two commonly used methods are by specific disease process or a combination of laboratory abnormalities and clinical conditions that arise from the liver disease.
In adults, chronic active hepatitis and cirrhosis (from alcoholism, unknown cause, or biliary) are the most common diseases requiring transplantation.

In children, and in adolescents younger than 18 years, the most common reason for liver transplantation is biliary atresia, which is an incomplete development of the bile duct.

To summarize and make it brief, Liver transplant is indicated for many types of liver diseases. These diseases fall into four categories.

Irreversible chronic liver disease can cause cirrhosis, which develops over a long period of time

Fulminant liver failure, which develops very quickly, can be caused by a virus or medication

Metabolic Diseases, including imbalances of iron, cholesterol,copper, or enzymes

Liver Cancer, only if the cancer is small and has not spread beyond the liver

Candidates of Liver Transplant

Ultimately, the transplantation team takes into account the type of liver disease, the person's blood test results, and the person's health problems in order to determine who is a suitable candidate for transplantation.

A person who needs a liver transplant may not qualify for one because of the following reasons:

Active alcohol or substance abuse: Persons with active alcohol or substance abuse problems may continue living the unhealthy lifestyle that contributed to their liver damage. Transplantation would only result in failure of the newly transplanted liver.

Cancer: Cancers in locations other than just the liver weigh against a transplant.

Advanced heart and lung disease: These conditions prevent a transplanted liver from surviving.

Severe infection: Such infections are a threat to a successful procedure.

Massive liver failure: This type of liver failure accompanied by associated brain injury from increased fluid in brain tissue rules against a liver transplant.

HIV infection

Pre Liver Transplant tests

Pretransplant tests, as well as giving a clear picture of the patient's overall health status, help in identifying potential problems before they occur. They also help in determining whether transplantation is truly the best option. This increases the likelihood of success.

The following procedures help in evaluating a patient's health status:

Chest x-ray - Determines the health of the patient's lungs and lower respiratory tract.

Electrocardiogram (EKG or ECG) - Determines how well the patient's heart is working and may reveal heart damage that was previously unsuspected.

Ultrasound with Doppler examination - Determines the openness of the bile ducts and major vessels. It is commonly done in all liver transplant recipients before and after transplantation.

CT (CAT) scan - This computerized image will show the size and shape of the patient's liver and major blood vessels.

MRI (magnetic resonance imaging) - May be used in place of CT scan or ultrasound to see inside the patient's body.

Total-body bone scan - If the patient has a liver tumor, ensures that it has not spread to his bones.

Blood tests - The patient's blood count, blood and tissue type, blood chemistries, and immune system function will all be checked. In addition, blood tests for certain infectious diseases will be performed.

Pulmonary function test - The patient will be asked to breathe into a tube attached to a measuring device, which will reveal how well his lungs are working and determine his blood's capacity to carry oxygen.

Hepatic angiograph - Dye injected into the patient's arteries will enable the transplant physician to see if there are any abnormalities or blockages in the patient's blood vessels.

Cholangiogram - Reveals any obstructions or growths in the patient's bile ducts.

Gallium, colloidal gold, or technetium scan - Gives the transplant physician a view of the patient's liver, gallbladder, and pancreas.

Peritoneoscopy - By inserting a flexible tube through a tiny incision in the patient's abdomen, the transplant physician will be able to see any structural changes in the liver.

Upper gastrointestinal (GI) series - This will show whether the patient's esophagus and stomach are disease free.

Lower GI series - Ensures that the patient is free of intestinal abnormalities.

Renal function studies - Urine may be collected from the patient for 24 hours in order to determine if the kidneys are working correctly. Blood tests such as serum creatinine are also performed to measure kidney function.


Liver Transplantation – a Team work

The Transplant Team consists of

Transplant Surgeon

Transplant Physician (Hepatologist)

Transplant Coordinator

Nurse Practitioner

Floor or Staff Nurse

Physical Therapist

Dietician

Psychologist / Psychiatrist

Social Worker

Pharmacist

Preparing the Patient for Surgery

The patient may receive an enema to clean out his intestines and prevent constipation after surgery. His chest and abdomen will be shaved clean to prevent infection, and an intravenous (IV) line will be inserted in his arm or just under his collarbone to give medication and keep him from getting dehydrated. The patient will also be given a sedative to help him relax and feel sleepy before going to the operating room.

Because transplantation is a major surgical procedure, the patient may need a transfusion. Today, all blood is screened very carefully; the likelihood of contracting a disease is very small. Any concerns that the patient has regarding the source of the blood should be relayed to the transplant team during the waiting period, before getting to the hospital. Most hospitals offer the option of "autotransfusion" - this is when the patient donates his own blood before surgery. His/her own blood is stored and then used during transplantation.

Types of Liver Transplantation Surgeries

Orthotopic liver transplantation(OLT) is the replacement of a whole diseased liver with a healthy donor liver.

When an orthotopic transplantation is performed, a segment of the inferior vena cava attached to the liver is taken from the donor as well. The same parts are removed from the recipient and replaced by connecting the inferior vena cava, the hepatic artery, the portal vein and the bile ducts.

The operation itself can be divided in two stages: recipient hepatectomy and implantation of the graft.

The recipient's abdomen is opened through a transverse incision which can be extended vertically in the midline to the xiphoid process for better exposure ("Mercedes" incision). The diseased liver is mobilised using diathermy. This stage of the operation may be difficult due to the presence of dense vascular adhesions and portal hypertension particularly after previous surgery.

The porta hepatis is dissected to ligate and divide the common bile duct and the common hepatic artery. The portal vein is skeletonised and the vena cava is identified and isolated.

When veno-venous bypass is required, both the femoral and the axillary veins are dissected and cannulated.

Finally, vascular clamps are placed on the portal vein and inferior vena cava above and below the liver, veno-venous bypass is started and the diseased liver is then excised. The donor liver is then implanted by suturing the supra-hepatic and then the infra-hepatic vena cava. Any residual UW solution is then flushed from the graft. The portal vein is anastomosed and the liver is reperfused. After haemostasis, the gallbladder is removed. The donor hepatic artery is then anastomosed to the recipient common hepatic artery. If the native artery does not provide an adequate arterial inflow, an infrarenal donor iliac artery conduit may be used to rearterialise the graft. Biliary drainage is established either by primary end-to-end anastomosis of the bile duct or by using a Roux-en-Y hepatico-jejunostomy. Complete haemostasis is secured before abdominal closure.


Heterotopic transplantation is the addition of a donor liver at another site, while the diseased liver is left intact.

When there is a possibility that the afflicted liver may recover, a heterotopic tranplantation is performed. The donor liver is placed in a different site, but it still has to have the same connections. It is usually attached very near the original liver, and if the original liver recovers, the donor shrivels away. If the original liver does not recover, it will shrivel, leaving the donor in place.

Reduced-size liver transplantation is the replacement of a whole diseased liver with a portion of a healthy donor liver. Reduced-size liver transplants are most often performed on children.

Reduced-size liver transplantation tranplants part of a donor liver into a patient. It is possible to divide the liver into eight pieces, each supplied by a different set of blood vessels. Two of these pieces have been enough to save a patient in liver failure, especially if the patient is a child. It is therefore possible to transplant one liver into at least two patients and to transplant part of a liver from a living donor and have both donor and recipient survive. Liver tissue grows to accommodate its job so long as there is initially enough of the organ to use. Patients have survived with only 15-20% of their original liver, provided that 15-20% was healthy.

Split Liver Transplantation is the technique of splitting a whole liver into two grafts, the left lateral segment for a child and the residual right lobe for an adult became established in the mid-1990's overcoming early problems of patient selection and technical complications.


Liver Transplantation Surgery

Liver transplants usually take from six hours to 12 hours. During the operation, surgeons will remove the liver and will replace it with the donor liver. Because a transplant operation is a major procedure, surgeons will need to place several tubes in the patient’s body. These tubes are necessary to help the patient’s body carry out certain functions during the operation and for a few days afterward.

During the operation, a tube will be placed through the patient’s mouth into his/her windpipe (trachea) to help him/her breathe during the operation and for the first day or two following the operation. The tube is attached to a ventilator that will expand the patient’s lungs mechanically. A nasogastric tube will be inserted through the patient’s nose into his/her stomach. The N/G tube will drain secretions from the patient’s stomach, and it will remain in place for a few days until his/her bowel function returns to normal. A tube called a catheter will be placed in the patient’s bladder to drain urine. This will be removed a few days after the operation. Three tubes will be placed in the patient’s abdomen to drain blood and fluid from around the liver. These will remain in place for about one week.

In most cases, the surgeon will place a special tube, called a T-tube, in the patient’s bile duct. The T-tube will drain bile into a small pouch outside of his/her body so it can be measured several times daily. Only certain transplant patients receive a T-tube, which remains in place for five months. The tube causes no discomfort and does not interfere with daily activities.

Recovery from Liver transplantation

Initially in the intensive care unit there is very careful monitoring of all body functions including the liver. Once the patient is transferred to the ward, the frequency of blood testing, etc. is decreased, eating is allowed and physiotherapy is used to regain muscle strength. The drug or drugs to prevent rejection are initially given by vein, but later by mouth. During the transplantation, frequent tests are done to monitor liver function and detect any evidence of rejection.

Tips !

  • Care for the T-tube. Make sure that it is draining and does not look infected. Swab the insertion site with betadine at least daily.

  • Patient should evaluate himself daily for signs of rejection and/or infection.

  • Take post-transplant medications exactly as ordered. Do not skip a dose, crush your pills or double your dosage.

  • Make sure that the transplant coordinator's phone number is known to the patient and his /her family as well.

  • Avoid salt and alcohol, as ordered by the doctor. Salt encourages fluid retention in the body, and alcohol is harmful to your liver, especially in combination with certain liver-transplant drugs.

  • Patient should move legs around when lying in bed, to help prevent blood clots from forming.

  • Take pain relievers as seldom as possible. An analgesic would be needed for the first four to seven days, but after that, pain would not be experienced to an extent where a great deal of pain medication is required.

  • Avoid vigorous exercise for the first six weeks. Patient can resume to daily activities as soon as they feel up to it. But use common sense - don't lift heavy objects, don't strain your incision, don't dive off the high dive.


Warnings !

Call the doctor if signs of rejection, infection, swelling, fluid retention or vomiting are experienced.

Avoid handling soil and animal waste. Do not clean cages, fish tanks or cat litter boxes.

Care post Liver Transplantation

Medical care of the liver transplant patient is exactly that: monitoring and maintaining health of organ recipients and donors, pre, during and post-operatively.

Transplant recipients directly contribute to the success of their transplant. Failure to comply with the immunosuppression medical regimen is the number one cause of organ failure. Close follow-up with your transplant team and primary-care physician can help ensure a good outcome. Careful attention to medication schedules, lifestyle changes, infection-avoidance techniques are all important ways to prolong one's life after transplantation.

In sum, the longest known liver transplant survivor is living a normal life over 30 years after the operation. If all goes well, a liver transplant can last as long as the patient.

Post-transplant care is typically categorized into four general time periods. The following table outlines possible complications and common infections in each time period.

Time Period Complication Common Infections
0-1 months Regimen-related toxicityGraft failureDrug reactions Most bacteriaCandida, AspergillusHerpes simplex
     
1-3 months Acute GVHD Acute GVHD Graft-Versus-Host Disease Candida, other fungiPneumocystis cariniiCytomegalovirus
     
3-12 months Chronic GVHDRelapse
P.cariniiVaricella-Zoster virusesCytomegalovirus
Encapsulated bacteria
     
12 months Chronic GVHDRelapse P.cariniiVaricella-Zoster virusesCytomegalovirus
Encapsulated bacteria
     

Medications prescribed after Liver Transplant

Cyclosporine

Therapeutic action: This medication is given to prevent rejection of the transplanted liver.
Dosage:

The initial oral dose of Cyclosporine can be given 4-12 hours prior to transplantation as a single dose of 15 mg/kg.

It must be taken every 12 hours. The prescribed dosage maybe changed frequently to maintain an appropriate blood level.

The initial single daily dose can be continued postoperatively for 1-2 weeks and then tapered by 5% per week to a maintenance dose of 5-10 mg/kg/day. Some centers have successfully tapered the maintenance dose to as low as 3 mg/kg/day in selected renal transplant patients without an apparent rise in rejection rate.

Cyclosporine is dosed according to blood levels and renal function. The dose is highly individualized because of variable absorption, elimination, and effect on renal function. The drug is initiated at 1-2 mg/kg/d in 2 divided doses and advanced as tolerated, but maintenance dose ranges widely from 1-10 mg/kg/d.

   
Adverse / side effects:
  • high blood pressure (May require medication)

  • hand tremors

  • headache

  • tingling of hands and feet· runny nose with nasal congestion· decreased kidney function (Kidney function is monitored by blood tests and should be checked as directed by the transplant team)

  • increased hair growth· swollen gums

  • night sweats
  • increased sex drive

  • depression or other mental symptoms
   
Remark: The principal toxic effect of cyclosporine is nephrotoxicity, manifested acutely by elevations in BUN and creatinine. This effect usually is reversible with reductions in dosage. However, an irreversible form is associated with histologic changes in the kidney. Other toxic effects include hyperkalemia and hepatotoxicity.
   

Tacrolimus

Therapeutic action:
The mainstay of immunosuppressive drug for you after liver transplantation. Tacrolimus lowers the activity of the immune system and in turn keeps the body from rejecting the new liver
Dosage:

Patient Population

 

Recommended Initial Oral Dose*

 

Typical Whole Blood Trough Concentrations

 

Adult liver transplant patients 0.10-0.15 mg/kg/day month 1-12 : 5-20 ng/mL
Pediatric liver transplant patients 0.15-0.20 mg/kg/day month 1-12 : 5-20 ng/mL
   
*Note: two divided doses, q12h
Adverse / side effects:
  • Nausea, vomiting, diarrhea, constipation
  • Tremor, headaches
  • Alopecia
  • Hypertension
  • Nephrotoxicity
  • Increased blood sugar levels
   
Remark:
  • Tacrolimus is best given on an empty stomach, so it is ideal to give it before meals or 2-3 hours after meals.
  • Tacrolimus needs to be given approximately 12 hours apart so that a constant level is in the blood stream to prevent organ rejection. Before breakfast and after dinner are ideal times.

  • The dosage of Tacrolimus is different for each individual patient. Only the doctor can adjust the dosage in accordance with the blood FK506 level.

  • Post-liver transplantation patients must have regular follow-ups and blood-taking after discharge
 

Mycophenolic Acid

Therapeutic action:
It is indicated for the prophylaxis against acute rejection.
Dosage:

If necessary, the dose should be increased gradually (over a few days) to improve tolerability and avoid GI problems. Thrice daily dosing may be more effective than twice daily dosing.

Children: 600 mg /m2 per dose given po twice a day (q12h) or 400 mg /m2 per dose given po three times daily (q8h).

Adults: Increase gradually from 500 mg bid to 750 mg tid (maximum = 3 g per day) Reduce dose in the presence of severe renal impairment (CLcr<20 mL/min).

Reduce dose or discontinue therapy in the presence of diarrhea or neutropenia

The drug should be taken on empty stomach. Avoid antacids and cholestyramine.

   
Adverse / side effects:
  • Diarrhea

  • Lower the white cell count and increase the risk of bacterial or viral infection
Remark:
  • Contraindication to known hypersensitivity to mycophenolate sodium, mycophenolic acid and MMF.

  • Precaution in pregnancy and breast-feeding women.

  • Mycophenolic acid tablets should not be crushed and should be swallowed whole

Mycophenolate Mofetil (Mmf)

Therapeutic action:
Mycophenolate mofetil is used for the prevention of rejection. It could be used in conjunction with other immunosuppressants.
Dosage:

250 mg per capsule and 500 mg per capsule is available.

The dosage needs to be adjusted in accordance with your white cell count.

Take this medication as directed usually twice daily on an empty stomach one hour before or two hours after meals. Swallow this medication whole. Do not crush, chew or open it.

   
Adverse / side effects:
  • Nausea, vomiting, diarrhea

  • Lower the white cell count and increase the risk of bacterial

  • or viral infection
Remark: Contraindication are known hypersensitivity to MMF and breast-feeding women.

Prednisolone

Therapeutic action:

Prednisolone is in a class of drugs called steroids. Prednisolone reduces swelling and decreases the body's immune response.

Prednisolone is given with other drugs to prevent acute rejection. Prednisolone is a corticosteroid that can be used for life long immunosuppression to prevent organ rejection, or in higher doses, for the treatment of rejection. Corticosteroids are manufactured naturally in the body in a 24-hour rhythm. You should take your corticosteroid medication first thing in the morning so that you can copy your body's natural rhythm.

 
Dosage:

5 mg per tablet. This drug will be withdrawn gradually during the first post-transplantation year.

 
Adverse / side effects:
  • Fluid retention
  • High blood pressure· Gastric ulcer· Weight gain due to increased appetite
  • Night sweating
  • Moon face
  • Muscle weakness, joint pain, osteoporosis
  • High blood sugar level· Increased risk of infection
  • Bruising
  • Impaired vision
 
Remark: Prednisolone is best given with milk and food.Inform doctor if there are signs and symptoms of infection.Regular body weight check up.

Lamivudine

Therapeutic action:

Lamivudine inhibits the replication of hepatitis B virus.

 
Dosage:

100 mg per tablet

 
Adverse / side effects:
  • Nausea, vomiting, diarrhea, abdominal discomfort
  • Malaise, musculoskeletal pain
  • Lactic acidosis
   
Remark: Contraindicated in breast-feeding women.Lamivudine is used in patients with hepatitis B infection after liver transplantation. Close monitoring is necessary to check for recurrence of hepatitis B virus.

Ursodeoxycholic Acid

Therapeutic action:

Ursodeoxycholic acid increases the secretion of bile and decreases the risk of gallstone formation.

   
Dosage:

250 mg per capsule, 500 - 1250 mg daily

   
Adverse / side effects: Rare
   
Remark: Contraindicated in pregnant and breast-feeding women.

Nystatin

Therapeutic action:

An anti-fungal drug for prevention and treatment of candidiasis and oral infection

   
Dosage:

Oral suspension 5 ml each time and 4 times daily; it is effective by rinsing the mouth for a few minutes before swallowing. Do not eat and drink within 30 minutes after taking the drug.

   
Adverse / side effects: Nausea, vomiting, diarrhea
   
Remark: Contraindicated in pregnant and breast-feeding women.

Acyclovir

Therapeutic action:

An anti-viral drug for prevention and treatment of viral infection such as herpes.

 
Dosage:

400 mg per tablet and 3 times daily; duration of therapy is about 3 months.

 
Adverse / side effects: Nausea, vomiting, diarrhea, abdominal pain
 
Remark: Not suitable for patients with known Acyclovir hypersensitivity and impaired renal function.

Fluconazole

Therapeutic action:

An anti-fungal drug for prevention and treatment of candidal and cryptococcal infection

 
Dosage:

It has syrup and capsule preparation. 50 - 400 mg daily adjusted according to severity of infection; duration of therapy is about 3 months.
Dosage will be adjusted according to your condition.

 
Adverse / side effects:
  • Nausea, vomiting, diarrhea, abdominal pain

  • Headache

  • Skin rash

  • Hypokalemia
 
Remark: It is well absorbed by oral administration. Rinse mouth for a few minutes before swallowing. Do not eat and drink within 30 minutes after taking the drug.

Complications that can arise after Liver Transplantation

Common complications are:


Bleeding

There is a small risk of bleeding at the anastomosis, the place where the blood vessels from donor and recipient were sewn together. This is minimized by monitoring clotting factors in the blood after surgery and measuring output from the drains placed during the operation.


Hepatic Artery Thrombosis

If a clot forms in the hepatic artery it can cause the liver to malfunction. Abdominal ultrasound is performed the day after your surgery to look for this condition and will monitor the aptient throughout postoperative recovery. If found, medications or surgical repair can minimize permanent damage and avoid the need for re-transplantation.

Bile Duct Leaks

The ducts that drain from the new liver are attached to a bile duct or portion of intestine in the recipient. This connection can leak and bile can drain into the abdominal cavity, causing infection. If a bile leak occurs, a catheter may be inserted into the abdomen to allow external drainage. This is temporary and can usually be managed without surgery.

Rejection

Rejection is a normal reaction of the body to a foreign object. When a new liver is placed in a person's body, the body sees the transplanted organ as a threat and tries to attack it. The immune system makes antibodies to try to kill the new organ, not realizing that the transplanted liver is beneficial. To allow the organ to successfully live in a new body, medications must be given to trick the immune system into accepting the transplant and not thinking it is a foreign object. The first rejection commonly occurs within three months after the operation. Patients are monitored closely during this time so the warning signs of rejection can be spotted early and steps taken to control it.
A biopsy of the liver is usually necessary to diagnose the extent of the rejection taking place, and to rule out any other problems. Biopsy results will help determine which anti-rejection therapy would be best for you.

Infection

Because the immune system is suppressed by medications after transplantation, you are at higher risk for developing certain infections. Doctors will prescribe other medications to prevent the more common post-transplant infections. Patients would need to routinely monitor their temperature at home, and make certain adjustments in their daily living to avoid contracting harmful infections.

Hepatitis Recurrence

If the patient is suffering from Hepatitis B or C prior to receiving the new liver, it is possible to experience a recurrence of the virus after transplantation. To help identify and control any recurrence, patient will be screened with blood tests and liver biopsies at regular intervals. If recurrence is detected, medications will be prescribed.


Graft-Versus-Host Disease

By definition, acute GVHD occurs before day 100 post-transplant and chronic GVHD occurs beyond day 100. Recent advances have reduced the incidence and severity of this post-transplant complication, but GVHD, directly or indirectly, still accounts for approximately 15% of deaths in BMT patients.

Acute GVHD should be treated by the BMT team at the transplant center where the patient was transplanted. Chronic GVHD can develop months or even years post-transplant, and so physicians assuming the care of transplant patients need to be aware of its symptoms. Table 2 outlines the major symptoms of chronic GVHD. This table explains Organ involvement indicators for chronic GVHD:

Organ/Tissue

Organ/Tissue Symptoms

 
Skin/Hair

Rash, scleroderma, lichenoid skin changes, dyspigmentation, alopecia

 
Eyes Dryness, abnormal Schirmer's Test, corneal erosions, conjunctivitis
 
Mouth Atrophic changes, lichenoid changes, mucositis, ulcers, xerostomia, dental caries
   
Lungs Bronchiolitis obliterans
   
GI tract Esophageal involvement, chronic nausea/vomiting, chronic diarrhea, malabsorption, fibrosis, abdominal pain/cramps
   
Liver Abnormal LFTs, biopsy abnormalities
   
Genitourinary Vaginitis, strictures, stenosis, cystitis
   
Musculoskeletal Arthritis, contractures, myositis, myasthenia, fascities
   
Hematologic Thrombocytopenia, eosinophilia, autoantibodies

Cyclosporine A and methotrexate are indicated for chronic GVHD, but these should only be administered by physicians familiar with using these drugs to treat chronic GVHD.

Patients must take many medications after a liver transplant: some to prevent rejection (immunosuppressants), some to fight infection, and others to treat the side effects of the immunosuppressants. Patients return home after transplantation having been started on approximately 7 to 10 different type of medicines. As the transplant patient heals and recovers health with the help of their new liver, the dosages and number of medications are reduced over time. By six months, it is common to be down to 1 or 2 medications. However, transplant patients will be on life-long immunosuppression in virtually all cases. It is vital that these medications are taken as prescribed, in the proper amounts and at the specified times. Missing medication doses or discontinuing them on one's own can lead to rejection and organ failure.

Diet and Nutrition post Liver Transplant

It is important that during the first three months after a transplant patient should avoid eating foods that may contain ‘listeria’. This is a bacteria that can cause problems whilst the patients are taking higher doses of anti rejection drugs.

Foods that may contain listeria include the following:

Unpasturised cheese

Live yoghurt / curds

Foods containing raw eggs eg. Mayonnaise

Regular diet should comprise of:

Fruits

Vegetables

Whole-grain cereals and breads

Low -fat milk and dairy products or other sources of calcium

Lean meats, fish, poultry, or other sources of protein

Caring for your bones

Liver disease decreases the ability to absorb vitamin D which plays a part in maintaining the strength of the bones. Research has shown that transplant patients are at higher risk of developing bone fracture as a result of ‘thin’ bones (known as osteoporosis)

To lower the fracture risk, patients should make sure that they are getting enough calcium and vitamin D in their diet. The following foods are a good dietary source of calcium.

Canned Sardines / salmon

Calcium fortified orange juice

Milk – including skimmed and low-fat

 Cheese from pasturised milk

Avoid:

Avoid sugary snacks such as cakes and biscuits between meals.

While on steroids, try to restrict your salt intake.

Do not eat cheese made from unpasteurised milk and avoid cheeses    with mould.

Alcoholic beverages are not recommended.

Stop smoking!


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