What are the complications of a liver transplant?

Overview

Liver transplantation has become an effective therapy for patients with acute or chronic end-stage liver disease. Initially, transplantation was considered the last therapeutic option for patients who were in a very serious clinical condition at the time of surgery, and therefore premature mortality was very high. Currently, although survival rates have improved over years, new problems have arisen that affect transplant recipients with long-term follow-up. In fact, despite considerable medical, surgical and technological advances, liver transplantation remains a complex procedure that is accompanied by significant morbidity-mortality.

What does the liver do?

The liver, considered to be the largest internal organ in your body, performs a lot of vital functions. The liver is essential for survival and there is no way to compensate for absence of liver. Vital liver functions include:

• Production of bile, a mixture of chemicals, which help in digestion.
• Helping in breaking down food to turn it into energy.
• Liver also acts as a filter and removes harmful substances from your blood.
• Liver makes chemicals that help in fighting infection.
• Liver makes chemicals that are important for blood clotting.
• Liver stores iron, vitamins and other essential substances.

What Is Liver Transplantation?

Liver transplantation is surgery performed to remove a diseased liver to replace it with a healthy one. Such surgeries have been done for over 38 years. Many people who have undergone liver transplants go on to lead perfectly normal lives.

Who needs a liver transplant?

A liver transplant becomes necessary when the patient’s liver fails to perform its functions and its functions cannot be recovered with medical treatment. Many diseases can cause liver failure. The most common indication for a liver transplant is liver cirrhosis (scarring of the liver). Common causes of liver cirrhosis are

• Chronic Hepatitis B
• Chronic Hepatitis C
• Alcoholic liver disease
• Fatty liver disease
• Genetic diseases
• Autoimmune liver diseases

Liver transplants are also done for treatment of liver cancer, acute liver failure and certain bile duct diseases in both children and adults.

What Complications are associated with Liver Transplantation?

The complications occur both immediately post-transplantation and in the long-term. This article describes the most frequent complications post liver transplantation divided into two groups, Immediate Complications and Long-Term Complications.

Immediate complications

The major immediate or short-term complications include:

1. Technical complications: Arterial complications, particularly the thrombosis (blood clotting) of the hepatic artery (the blood vessel that supplies blood to the liver) are the most frequent ones.
2. Medical complications: When the transplant is successful, the patient is awake, stable, with spontaneous respiration, preserved kidney function and with the gradual improvement of the liver activity. When complications develop, the stay in the ICU is prolonged and the risk of mortality increases. The most frequent medical complications that can be expected during the early post-transplant period are hemodynamic alterations, and neurological respiratory and kidney complications.
3. Liver graft dysfunction: The early dysfunction of the graft can be due to:

• Problems of the graft itself (rejection of the new liver, dysfunction/malfunction, nonspecific cholestatic syndrome)
• Complications of the surgical technique (vascular – arterial, poor drainage of the suprahepatic veins, portal thrombosis – or biliary)
• Other causes such as drug-related liver toxicity or infections

4. Infections: Infections are the major short-term complications. Anti-rejection drugs (immunosuppression) increase the risk for infections. Anti-rejection drugs suppress the immune system that rejects the transplanted liver. This problem reduces with time. Most infections can be successfully treated as and when they occur.
5. Rejection: In the absence of anti-rejection drugs, a transplanted organ invariably experiences rejection from the immune system as the immune system cannot distinguish between the transplanted liver and unwanted bacteria and viruses. Anti-rejection drugs are given to ward off the rejection episode.

Long-term complications

In earlier times, liver transplantation was considered an experimental procedure and the last therapeutic option for patients who were in a very critical condition. In these circumstances, the long-term complications were never considered as a great concern. Today, with improved survival in most transplant centers, increasing attention is being given to long-term complications, which are highly related to the immunosuppressive treatment. The most frequent complications are chronic renal failure, systemic arterial hypertension, diabetes mellitus, dyslipidemia, obesity, bone or neurological complications etc.

1. Chronic rejection: Chronic rejection is usually not evident until at least 6 months after transplant. The pathogenesis (the manner in which the disease is developed) is still unclear.

2. Renal failure: Post-transplantation chronic renal failure is closely related to the use of calcineurin inhibitors. The prevalence is variable, depending on the criterion used to define it and to the method used to assess renal function.
3. Arterial hypertension: This is a frequent complication in liver transplant recipients. Its prevalence varies between 50-70% in the first post-transplantation months but decreases thereafter probably due to the reduction of the immunosuppressive doses.
4. Diabetes mellitus: A few may develop diabetes mellitus following transplantation. The occurrence depends on the time elapsed since transplantation and particularly on the immunosuppressive drugs.
5. Bone complications: Osteopenia (when bones become weaker than normal) is a frequent finding in patients with advanced, chronic liver disease. Globally, 20-40% of liver transplant recipients suffer from atraumatic bone fractures (fractures not resulting from injury or trauma). The most frequent fracture locations include the vertebrae and the ribs.
6. Obesity: Obesity is a quite frequent complication in transplantation patients with a prevalence that ranges between 15 and 40% one-year post-transplantation (the period when the highest weight gain is seen).