Liver Transplant Complications: ICU Care to Follow-Up

The most important complications after a liver transplant are infection and rejection. In a living donor transplant, bile leaks and bile duct obstruction affect 10 to 26% of recipients, and clots in the hepatic artery or portal vein can threaten the graft. Most complications arise in the first few months, mostly in the first month, and long-term survival depends on disciplined follow-up once the patient returns home.

Dr. Sandeep Jha, Consultant, Liver Transplantation, Shalby Sanar International Hospital, Gurugram, India, devoted part of his masterclass, and much of the discussion with referring doctors, to what happens after the graft is in place. His central point was uncomfortable but practical: the operation is only the beginning, and many of the poor outcomes that doctors see in returning patients trace back to a break in continuity of care rather than to the living donor liver transplant itself.

The first days: intensive care after a liver transplant

Post-operative intensive care is demanding. Dr. Jha listed the issues his team manages from the moment the recipient leaves theatre: haemodynamics and how much fluid to give, the function of the new liver graft, and respiratory and cardiovascular problems.

A recipient arriving in the intensive care unit typically carries:

• an endotracheal tube for ventilation;
• an arterial line for continuous blood pressure monitoring;
• a central venous line, or a line for wedge pressure measurement;
• ECG and oxygen saturation (SpO2) monitoring and a temperature probe;
• a nasogastric tube and a urinary (Foley) catheter;
• two or three abdominal drains.

Every day, blood tests confirm that the graft is functioning and detect problems early. Dr. Jha's team keeps recipients in hospital for at least around 18 days.

Infection and rejection: the two principal threats

Many problems can arise after a transplant, but Dr. Jha singled out two as the most important: infection and rejection. They pull in opposite directions. The recipient's immune system recognises the new liver as foreign and will attack it, so immunity has to be suppressed for the graft to survive; that same suppression leaves the patient exposed to infection.

Bile leak and vascular complications after liver transplant

Two groups of technical complications stand out in his account.

• Biliary complications. Bile leaks and bile duct obstruction are especially common in living donor transplants. Dr. Jha put the rate at 10 to 26% of patients.
• Vascular thrombosis. Hepatic artery thrombosis and portal vein thrombosis, clots in the vessels that supply the graft, can occur. A clot in the hepatic artery is among the most serious early complications because the bile ducts depend on arterial blood supply.

Detecting problems of this kind early is the purpose of the Doppler ultrasound at the end of surgery and the daily tests that follow.

Immunosuppression after liver transplant: the three-drug regimen

Recipients need immunosuppression to keep the graft alive. The most commonly used regimen combines three drugs:

1. Tacrolimus, the mainstay, which blocks the activation of T cells, the immune cells that drive rejection.
2. Mycophenolate, which limits the multiplication of immune cells.
3. Corticosteroids.

All three have side effects, and Dr. Jha stressed that these have to be managed, both during the transplant admission and after the patient returns to the home country. Typical concerns are well recognised: tacrolimus can affect kidney function, blood pressure and blood sugar, and steroids raise blood sugar. Complications of immunosuppression, like any other complication, need to be managed early.

Infection after liver transplant: hit early, hit hard

A referring doctor in the discussion described a patient who had a successful transplant abroad, developed repeated serious infections, and died after returning home despite intensive care. Why, the doctor asked, are these infections so hard to control: is it the medication or the new liver?

Dr. Jha's answer was that it is the patient's immunity, deliberately suppressed so that the patient's own immune system does not destroy the new liver. The consequence is exposure to very severe infections. This does not happen to every patient, but in those it affects, recipients catch infections easily and even minor infections escalate very quickly.

His protocol for any suspected infection in a transplant recipient:

1. Investigate immediately: all blood investigations, including cultures and procalcitonin (a blood marker that rises in bacterial infection).
2. Find the source of infection as quickly as possible, and eliminate it.
3. Start very high-grade empirical antibiotics at once, without waiting for culture results. Antibiotic choices for transplant recipients differ from those for the general population; he advises going one or even two steps ahead of what a normal patient would receive.
4. Repeat cultures regularly.
5. Complete the course: at least 14 days of very high-grade antibiotics.

"Hit them early and hit them hard," was his summary. He was careful not to second-guess the individual case, noting that it is very difficult to say in hindsight why a particular patient did not do well, but he was clear that closer collaboration between the doctors in the home country and the transplant team in India would help in exactly this situation.

Disease recurrence after liver transplant

A transplant replaces the cirrhotic liver; it does not always remove the cause. Dr. Jha's team has seen each of the following after transplant:

• Hepatitis B can return.
• Hepatitis C can damage the new liver again if the patient has not been treated for it.
• Liver cancers can come back.
• Primary biliary cholangitis (formerly primary biliary cirrhosis), an autoimmune disease of the small bile ducts, can recur.
• Autoimmune hepatitis can recur.
• Alcohol: a patient who returns to drinking damages the new liver.

That is why, in Dr. Jha's view, every recipient must follow up with a doctor who understands these issues and can deal with them. Only then does the patient receive the complete benefit of the transplant.

Long-term outcomes: why some returning patients do worse

A doctor in the discussion challenged the outcomes, saying that the recipients he had seen often survived only three to five years and many were bedridden. Dr. Jha disagreed with the premise. Very large studies across the world, he said, show one-year survival close to 85 to 90% and five-year survival above 70%, with patients now followed for 20 years and longer.

The gap, in his account, is continuity of care. In Western countries, transplant teams follow their patients, prevent complications, and recipients live 15 to 20 years or more with a very good quality of life. When a patient travels for a transplant and goes home, the transplant team is often talking to the patient rather than to a treating doctor; patients do not always follow up or grasp the seriousness of what is happening, and they succumb to one complication or another. That, he said, explains the experience of survival limited to three to five years.

The recovery he sees when follow-up works is striking. Patients who have had a successful transplant and return at three months are, in his words, almost unrecognisable: stronger, with muscle mass restored and the distended abdomen gone.

What the referring doctor needs to do

Dr. Jha described the long-term follow-up and compliance of international patients as the weak point of the whole pathway. His team tries to follow these patients, but on immunosuppression, complications and recurrence of disease, its hands are tied once the patient is home. The practical responsibilities that fall to the doctor in the home country follow directly from his talk:

• Know the immunosuppressive regimen and watch for its side effects.
• Treat any suspected infection aggressively and early, with cultures, procalcitonin and high-grade antibiotics for at least 14 days.
• Watch for recurrence of the original disease, including hepatitis B, hepatitis C, cancer, autoimmune disease and alcohol relapse.
• Stay in contact with the transplant team, so that complications are discussed while they can still be prevented or treated.

The work-up that comes before all of this, for both recipient and donor, is described in liver transplant indications, contraindications and referral and living liver donor evaluation and right lobe surgery. The full exchanges with referring doctors, including the infection case, are in the Live Discussion. A broader view of long-term outcomes is in liver transplant survival rates and life after surgery.