The liver transplant recipient: What you need to know for long-term care
Anticipate known complications and your response in concert with the transplant center.
Anemia
The prevalence of anemia after OLT reportedly is between 4.3% and 28.2%, depending on the population studied and time after transplantation. 24 , 25 Blood loss, sepsis, medications, renal dysfunction, or hypersplenism can contribute to immediate postoperative anemia. Beyond the immediate postoperative period, anemia may be related to different causes (TABLE 3). 26 Medication-induced anemia is usually related to bone marrow suppression, although calcineurin inhibitors may cause microangiopathic hemolysis, hemolyticuremic syndrome, or pure redcell aplasia.
Viral infections often cause anemia in the first 12 weeks after transplantation. Aplastic anemia may be related to parvovirus B19 infection, although it is more commonly seen in patients who undergo liver transplantation for acute liver failure.24,27 Posttransplant lymphoproliferative disorder ranges from polyclonal B-cell hyperplasia (related to Epstein-Barr virus) that responds to reduction in immunosuppression to aggressive lymphoma treated with high dose chemotherapy.
Graft-versus-host disease is a rare but important cause of pancytopenia after OLT and is diagnosed by establishing chimerism, donor and recipient lymphocytes, in the blood and bone marrow; mortality is high.28
Lastly, renal failure and iron deficiency are other common causes of anemia after OLT that warrant investigation. Despite complete evaluation, half of adult patients do not have an identifiable cause of anemia and may respond to a therapeutic trial of erythropoietin (SOR: C).26
TABLE 3
Evaluation of anemia after liver transplantation
| CAUSE | TIME AFTER TRANSPLANT* | EVALUATION |
|---|---|---|
| Medications | ||
| Common : mycophenylate mofetil, azathioprine, sirolimus, tacrolimus, cyclosporine, interferon, ganciclovir | > 2 weeks | Alter immunosuppression, discontinue drug |
| Infrequent : dapsone, furosemide, trimethoprim/sulfamethoxazole | Discontinue drug | |
| Viral Infection | ||
| Parvovivurs B19 | 2 – 6 weeks | IgM titer, B19 DNA |
| Cytomegalovirus | 4 – 12 weeks | Rapid antigen, DNA |
| Epstein-Barr virus | 4 – 12 weeks | IgM titer, DNA |
| Aplastic anemia | 2 – 6 weeks | Bone marrow biopsy |
| Post-transplant lymphoproliferative disorder | > 6 weeks | Hemolysis indices (indirect bilirubin, haptoglobin, Coomb ’ s test), bone marrow biopsy |
| Graft-versus-host disease | 2 – 6 weeks | Demonstrate chimerism |
| Renal insufficiency | ||
| Common : tacrolimus, cyclosporine, diabetes, hypertension | > 2 weeks | Alter immunosuppression, treat diabetes/hypertension |
| Infrequent : HBV/HCV-related glomerulonephritis or cryoglobulinemia | Urinalysis, HBV DNA, HCV RNA, renal ultrasound/biopsy | |
| Iron-deficiency | > 6 weeks | Iron studies, evaluate for chronic blood loss (GI, GU) |
| Unknown cause | > 6 weeks | EPO trial |
| * These values represent the typical interval after transplantation | ||
| EPO, erythropoietin; GI, gastrointestinal; GU, genitourinary; HBV, hepatitis B virus; HCV, hepatitis C virus; IgM, immunoglobulin M. | ||
Psychosocial and socioeconomic concerns
Liver transplantation is a tremendously stressful and life-altering procedure affecting patients and their families. In the initial postoperative period, the stress of the operation and other factors (immunosuppression, infection, prolonged hospital stay) can lead to a variety of psychiatric disorders, such as delirium, anxiety, depression, mania, and psychosis. A multidisciplinary approach, including psychiatry, social work, and nursing care, is required to help the patients and families through this period, as expectations for full recovery may be delayed by psychiatric conditions.
Psychiatric problems
Many transplant recipients have long-term psychiatric problems. Depression and anxiety diminish quality of life, particularly for patients whose transplant was for hepatitis C and those with post-transplant viral recurrence.29,30 Most patients will respond to antidepressants and ongoing psychiatric care. The side-effect profile should be individualized for each patient, keeping in mind the potential interactions with the current medications.
Mania and hypomania, while less common than depression, are often related to higher doses of immunosuppression (eg, corticosteroids). Cyclosporine may increase lithium levels, leading to toxicity.31 Treatment with anticonvulsant medications, such as carbamazepine, may decrease calcineurin-inhibitor levels and should be monitored in coordination with the transplant team. Finally, some patients with encephalopathy prior to OLT have persistent cognitive deficits long after OLT.32
Drug and alcohol recidivism are common post-OLT and typically occurs in about 20% of patients. It is important that active steps are taken to avoid recidivism immediately after OLT. Long-term psychiatric care and continued attendance at support groups help maintain sobriety. The important contributions you can make are maintaining a heightened awareness for recidivism, communicating with patients regularly about drug and alcohol abuse, and providing support and referral services.
Socioeconomic problems
While most transplant recipients maintain a good quality of life, some have long-term socioeconomic problems. One study showed that only one third of OLT recipients returned successfully to work, just slightly higher than the percentage working before OLT.33 The economic situation improved in 11.9% of the recipients, worsened in 33.9%, and stayed the same in 54.2%. Concurrent illness, prolonged inactivity, psychiatric disorders, and the level of physical requirements at work are the main contributing factors to unemployment.
