Liver transplantation complications: Difference between revisions
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{{Liver transplantation}} | {{Liver transplantation}} | ||
==Overview== | ==Overview== | ||
Complications of liver transplantation include [[vascular]], [[biliary]], and [[Immunosuppressive therapy|immunosuppression drugs]] complications. [[Hepatic artery]] complications include [[thrombosis]], [[stenosis]], and [[pseudoaneurysm]]. [[Inferior vena cava|IVC]] complications include [[thrombosis]] and [[stenosis]], usually at the site of [[surgical anastomosis]]. [[Bile duct|Biliary]] complications include [[stenosis]], [[fistula]], [[obstruction]], [[Cholelithiasis|stone]] formation, dysfunction of the [[Sphincter of Oddi dysfunction|Oddi sphincter]], and recurrent biliary disease. Complications of [[immunosupression]] include [[Infection|infections]], [[metabolic syndrome]], [[hypertension]], [[diabetes mellitus]], [[obesity]], [[dyslipidemia]], [[coronary heart disease]], acute and [[Chronic renal failure|chronic renal disease]], metabolic bone disease, and [[malignancy]]. | |||
== Post-surgical complications == | == Post-surgical complications == | ||
| Line 51: | Line 52: | ||
==== Obstruction and Stenosis ==== | ==== Obstruction and Stenosis ==== | ||
* [[Obstruction]] is the most common biliary complication both in adults and in pediatric patients and is frequently caused by stenosis at the anastomotic site.<ref name="pmid10352596">{{cite journal| author=Fulcher AS, Turner MA| title=Orthotopic liver transplantation: evaluation with MR cholangiography. | journal=Radiology | year= 1999 | volume= 211 | issue= 3 | pages= 715-22 | pmid=10352596 | doi=10.1148/radiology.211.3.r99jn17715 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10352596 }}</ref> | * [[Obstruction]] is the most common biliary complication both in adults and in pediatric patients and is frequently caused by stenosis at the anastomotic site.<ref name="pmid10352596">{{cite journal| author=Fulcher AS, Turner MA| title=Orthotopic liver transplantation: evaluation with MR cholangiography. | journal=Radiology | year= 1999 | volume= 211 | issue= 3 | pages= 715-22 | pmid=10352596 | doi=10.1148/radiology.211.3.r99jn17715 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10352596 }}</ref> | ||
* Anastomotic strictures usually result from fibrotic proliferation with narrowing of the biliary lumen less frequently, they are due to ischemia caused by hepatic artery thrombosis or stenosis. | * Anastomotic [[strictures]] usually result from fibrotic proliferation with narrowing of the biliary lumen less frequently, they are due to [[ischemia]] caused by [[hepatic artery]] [[thrombosis]] or [[Stenosis|stenosis.]] | ||
* The possible causes of nonanastomotic strictures include pretransplantation biliary diseases such as primary sclerosing cholangitis, biliary ischemia, and infection | * The possible causes of nonanastomotic strictures include pretransplantation biliary diseases such as [[primary sclerosing cholangitis]], biliary [[ischemia]], and [[infection]]. | ||
* Some patients with clinical and [[Biochemical|biochemical evidence]] of [[biliary obstruction]] may have dilatation of both the donor and the recipient bile ducts. | |||
* Some patients with clinical and biochemical evidence of biliary obstruction may have dilatation of both the donor and the recipient bile ducts. Diffuse ductal dilatation may result from papillary dyskinesia due to devascularization or denervation of the papilla of Vater during transplantation. | * Diffuse ductal dilatation may result from papillary [[dyskinesia]] due to devascularization or denervation of the papilla of Vater during transplantation. | ||
==== Bile Leak ==== | ==== Bile Leak ==== | ||
| Line 75: | Line 76: | ||
* [[CT-scans|CT]] and [[Magnetic resonance imaging|MR]] imaging are more useful for differentiating [[Hematoma|hematomas]] from [[Seroma|seromas]] because [[blood]] has higher attenuation at [[Computed tomography|CT]] than do other fluids. | * [[CT-scans|CT]] and [[Magnetic resonance imaging|MR]] imaging are more useful for differentiating [[Hematoma|hematomas]] from [[Seroma|seromas]] because [[blood]] has higher attenuation at [[Computed tomography|CT]] than do other fluids. | ||
* The other role of imaging is to guide interventional diagnostic or therapeutic procedures. | * The other role of imaging is to guide interventional diagnostic or therapeutic procedures. | ||
==== '''Complications of immunosupression''' ==== | |||
'''Infections''' | '''Infections''' | ||
* The leading cause of [[Mortality rate|mortality]] following liver transplantation is [[infection]].<ref name="pmid9455510">{{cite journal| author=Chang FY, Singh N, Gayowski T, Wagener MM, Marino IR| title=Fever in liver transplant recipients: changing spectrum of etiologic agents. | journal=Clin Infect Dis | year= 1998 | volume= 26 | issue= 1 | pages= 59-65 | pmid=9455510 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9455510 }}</ref> | * The leading cause of [[Mortality rate|mortality]] following liver transplantation is [[infection]].<ref name="pmid9455510">{{cite journal| author=Chang FY, Singh N, Gayowski T, Wagener MM, Marino IR| title=Fever in liver transplant recipients: changing spectrum of etiologic agents. | journal=Clin Infect Dis | year= 1998 | volume= 26 | issue= 1 | pages= 59-65 | pmid=9455510 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9455510 }}</ref> | ||
Latest revision as of 18:42, 6 January 2018
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
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Liver trasnsplantation Microchapters |
Overview
Complications of liver transplantation include vascular, biliary, and immunosuppression drugs complications. Hepatic artery complications include thrombosis, stenosis, and pseudoaneurysm. IVC complications include thrombosis and stenosis, usually at the site of surgical anastomosis. Biliary complications include stenosis, fistula, obstruction, stone formation, dysfunction of the Oddi sphincter, and recurrent biliary disease. Complications of immunosupression include infections, metabolic syndrome, hypertension, diabetes mellitus, obesity, dyslipidemia, coronary heart disease, acute and chronic renal disease, metabolic bone disease, and malignancy.
Post-surgical complications
Vascular Disorders
Hepatic Artery
- Hepatic artery complications include thrombosis, stenosis, and pseudoaneurysm.
- A normal hepatic artery waveform obtained at the porta hepatis does not exclude a hepatic artery obstruction.[1]
Thrombosis
- The incidence of hepatic artery thrombosis is 4%–12% in adults and 42% in children.[2]
- The mortality rates are 30% due to fulminant hepatic necrosis.[3]
- Arterial thrombosis may lead to biliary necrosis.
- Most cases require retransplantation.[4]
- Gadolinium-enhanced MR imaging is an accurate and noninvasive method for evaluating the hepatic vessels.
Stenosis
- Hepatic artery stenosis incidence rates are 5%–11% of liver transplant recipients.
- This complication usually occurs at the site of anastomosis within 3 months after transplantation.
- Causes of hepatic artery stenosis may include injury from a perfusion catheter, or disruption of the vasa vasorum with resultant ischemia of the arterial ends.[5]
- Doppler US is the method of choice for postoperative screening of liver transplant recipients because it is capable of depicting any focal increase in peak systolic velocity at the site of stenosis and any poststenotic turbulent flow.
- Both at contrast-enhanced CT and at MR angiography, this arterial lesion appears enhanced.
Portal Vein
- Portal vein thrombosis occurs in about 1%–2% of cases.[6]
- It most commonly results from technical problems (vessel misalignment, differences in the caliber of the anastomosed vessels, or stretching of the portal vein at the anastomotic site), previous portal vein surgery or previous thrombosis, increased downstream resistance due to a supra-hepatic stricture of the inferior vena cava (IVC), decreased portal inflow, and hypercoagulable states.
- Portal vein stenosis has a reported incidence of 1% after liver transplantation.
- The treatment in symptomatic cases is thrombolysis or surgery (thrombectomy, venous graft)
- CT and MR angiography provide excellent depiction of filling defects and focal narrowing of the portal vein.
- Transhepatic or transjugular portography may be necessary to achieve a definitive diagnosis.[7]
Inferior Vena Cava (IVC)
- IVC complications include thrombosis and stenosis, usually at the site of surgical anastomosis.[8]
- The anastomosis gained wide acceptance internationally and is the preferred technique for orthotopic liver transplantation at many institutions.
- However, it is especially vulnerable to two types of complications:
- Hemorrhage due to hepatic injury during surgery
- Budd-Chiari syndrome due to inadequate venous drainage[9]
- An obstruction of hepatic venous outflow may be treated with placement of a balloon-expandable stent.
- Cross-sectional modalities such as CT and MR imaging are commonly used to confirm suspicions aroused by doppler US findings.
Biliary Disorders
- Biliary complications include stenosis, fistula, obstruction, stone formation, dysfunction of the Oddi sphincter, and recurrent biliary disease.[10]
- MR cholangiography is the best noninvasive technique for evaluation of the biliary tree. It does not provide a means of therapeutic intervention, it can be used for percutaneous, endoscopic, and surgical treatments.
- Endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography provide high-quality images of the biliary tree and allow therapeutic intervention.
Obstruction and Stenosis
- Obstruction is the most common biliary complication both in adults and in pediatric patients and is frequently caused by stenosis at the anastomotic site.[11]
- Anastomotic strictures usually result from fibrotic proliferation with narrowing of the biliary lumen less frequently, they are due to ischemia caused by hepatic artery thrombosis or stenosis.
- The possible causes of nonanastomotic strictures include pretransplantation biliary diseases such as primary sclerosing cholangitis, biliary ischemia, and infection.
- Some patients with clinical and biochemical evidence of biliary obstruction may have dilatation of both the donor and the recipient bile ducts.
- Diffuse ductal dilatation may result from papillary dyskinesia due to devascularization or denervation of the papilla of Vater during transplantation.
Bile Leak
- The incidence of bile leaks in liver transplant recipients is 5%.
- Bile leaks usually occur in more than 70% occur within the 1st postoperative month.
- Leaks occur most often at the T-tube site.
- Bile may leak freely into the peritoneal cavity or may form a perihepatic collection.
- Treatment includes stent placement and drainage of collections.
Ductal Ischemia
- Bile duct ischemia is usually a consequence of stenosis or thrombosis of the hepatic artery; the bile ducts are entirely dependent on the hepatic artery for their blood supply.[12]
- This leads to necrosis, bile leak, fibrosis, and bile collection.
- A ductal stenosis may be treated with balloon dilation, which frequently is used in drainage procedures.
- However, in most cases, retransplantation ultimately is necessary.
Fluid Collections
- Seromas and hematomas are commonly observed near areas of vascular anastomosis and biliary anastomosis.
- Pleural fluid also is a common finding.
- US is highly sensitive for the detection of fluid collections, it is not specific.
- CT and MR imaging are more useful for differentiating hematomas from seromas because blood has higher attenuation at CT than do other fluids.
- The other role of imaging is to guide interventional diagnostic or therapeutic procedures.
Complications of immunosupression
Infections
- The leading cause of mortality following liver transplantation is infection.[13]
- Serious infections occur most frequently within the first three months post-transplantation.
Metabolic syndrome
- The metabolic syndrome is common among patients who have undergone liver transplantation.
- It is defined by a combination of hypertension, insulin resistance, dyslipidemia, and obesity.[14]
- Liver transplant recipients may meet criteria for the metabolic syndrome prior to transplantation, in which case immunosuppressive medications can exacerbate the problem.
- In addition, many patients will develop the metabolic syndrome de novo.[15]
- Fifty-two percent had metabolic syndrome following transplantation, compared with only 5 percent prior to transplantation.
- The rate of obesity increased from 24 percent four months after transplantation to 41 percent three years after transplantation.
Immunosuppressant use is associated with all aspects of the metabolic syndrome:
- Hypertension: Glucocorticoids, cyclosporine, tacrolimus
- Diabetes mellitus: Glucocorticoids, tacrolimus, cyclosporine
- Obesity: Glucocorticoids, cyclosporine
- Dyslipidemia: Glucocorticoids, cyclosporine. tacrolimus, sirolimus
Hypertension
- Approximately 65 to 70 percent of liver transplant recipients develop hypertension following transplantation.[16]
- Patient's blood pressure be assessed at home with self-monitoring every week for six months after the surgery.
- The cause of hypertension is multifactorial but is mostly related to the use of calcineurin inhibitors and glucocorticoids.[17][18]
Diabetes mellitus
- Glucocorticoids, cyclosporine, tacrolimus, and weight gain predispose to the development of diabetes following liver transplantation.
- The risk also appears to be increased in patients transplanted for hepatitis C virus.[19]
- Fasting plasma glucose levels or hemoglobin A1C are sceened every six months and annual eye examinations to look for cataracts or diabetic changes.
Obesity
- Over one-third of patients after liver transplantation are obese.[20]
- Approximately one-third of patients who are normal weight at the time of transplantation will become obese following transplantation.[21]
- Body weight tends to increase during the first two years after transplantation and then stabilizes.[22]
Dyslipidemia
- Dyslipidemia is common after liver transplantation.
- Hypertriglyceridemia usually develops within the first month post-transplantation and then remains stable throughout the first year.
- Serum cholesterol increases gradually and plateaus at six months.[23]
- Patients should have a fasting lipid profile obtained annually.[24]
Cardiovascular risk
- Coronary heart disease is common after liver transplantation.
- Ten-year risk of cardiovascular events was 14 percent and was particularly high among those with the metabolic syndrome.[25]
- Factors that have been associated with cardiovascular events include older age at transplantation, male sex, post-transplantation diabetes, post-transplantation hypertension, history of coronary artery disease, and use of mycophenolate mofetil.[26]
Acute and chronic renal disease (CNI)
- Acute and chronic kidney injuries are common in liver transplantation.[27]
- Important contributing factors are preexisting chronic kidney disease, renal failure prior to liver transplantation, acute tubular necrosis around the time of transplantation, hypertension, and diabetes mellitus.
- CNI-related acute renal failure is due to renal vasoconstriction and improves with dose reduction.
- Chronic renal disease can also be induced by these drugs, warranting continued monitoring of the plasma creatinine concentration and urinalysis.
- Nephrotoxicity in liver transplant recipients is more common with cyclosporine or tacrolimus.
Metabolic bone disease
- Bone mineral density is assessed prior to transplantation and every other year after transplantation to assess for osteoporosis.
- The majority of osteopenia and fractures occur within the first six months following transplantation, and fractures often involve the spine.[28]
- Patients transplanted for cholestatic liver disease are particularly vulnerable to the development of osteoprosis before liver transplantation.[29]
Malignancy
- The incidence of malignancy is increased in liver transplant recipients.
- Intensive screening than is done in the general population.
References
- ↑ Tamsel S, Demirpolat G, Killi R, Aydin U, Kilic M, Zeytunlu M; et al. (2007). "Vascular complications after liver transplantation: evaluation with Doppler US". Abdom Imaging. 32 (3): 339–47. doi:10.1007/s00261-006-9041-z. PMID 16967253.
- ↑ Väli T, Tein A, Tiganik V, Ulst K (2013). "Vascular complications after orthotopic liver transplantation in Estonia". Transplant Proc. 45 (3): 1201–3. doi:10.1016/j.transproceed.2012.10.011. PMID 23622659.
- ↑ García-Criado A, Gilabert R, Bargalló X, Brú C (2002). "Radiology in liver transplantation". Semin Ultrasound CT MR. 23 (1): 114–29. PMID 11866218.
- ↑ Glockner JF (2001). "Three-dimensional gadolinium-enhanced MR angiography: applications for abdominal imaging". Radiographics. 21 (2): 357–70. doi:10.1148/radiographics.21.2.g01mr14357. PMID 11259700.
- ↑ Dodd GD, Memel DS, Zajko AB, Baron RL, Santaguida LA (1994). "Hepatic artery stenosis and thrombosis in transplant recipients: Doppler diagnosis with resistive index and systolic acceleration time". Radiology. 192 (3): 657–61. doi:10.1148/radiology.192.3.8058930. PMID 8058930.
- ↑ Quiroga S, Sebastià MC, Margarit C, Castells L, Boyé R, Alvarez-Castells A (2001). "Complications of orthotopic liver transplantation: spectrum of findings with helical CT". Radiographics. 21 (5): 1085–102. doi:10.1148/radiographics.21.5.g01se061085. PMID 11553818.
- ↑ Pieters PC, Miller WJ, DeMeo JH (1997). "Evaluation of the portal venous system: complementary roles of invasive and noninvasive imaging strategies". Radiographics. 17 (4): 879–95. doi:10.1148/radiographics.17.4.9225389. PMID 9225389.
- ↑ Navarro F, Le Moine MC, Fabre JM, Belghiti J, Cherqui D, Adam R; et al. (1999). "Specific vascular complications of orthotopic liver transplantation with preservation of the retrohepatic vena cava: review of 1361 cases". Transplantation. 68 (5): 646–50. PMID 10507483.
- ↑ Wang SL, Sze DY, Busque S, Razavi MK, Kee ST, Frisoli JK; et al. (2005). "Treatment of hepatic venous outflow obstruction after piggyback liver transplantation". Radiology. 236 (1): 352–9. doi:10.1148/radiol.2361040327. PMID 15955856.
- ↑ Ward J, Sheridan MB, Guthrie JA, Davies MH, Millson CE, Lodge JP; et al. (2004). "Bile duct strictures after hepatobiliary surgery: assessment with MR cholangiography". Radiology. 231 (1): 101–8. doi:10.1148/radiol.2311030017. PMID 14990819.
- ↑ Fulcher AS, Turner MA (1999). "Orthotopic liver transplantation: evaluation with MR cholangiography". Radiology. 211 (3): 715–22. doi:10.1148/radiology.211.3.r99jn17715. PMID 10352596.
- ↑ Orons PD, Sheng R, Zajko AB (1995). "Hepatic artery stenosis in liver transplant recipients: prevalence and cholangiographic appearance of associated biliary complications". AJR Am J Roentgenol. 165 (5): 1145–9. doi:10.2214/ajr.165.5.7572493. PMID 7572493.
- ↑ Chang FY, Singh N, Gayowski T, Wagener MM, Marino IR (1998). "Fever in liver transplant recipients: changing spectrum of etiologic agents". Clin Infect Dis. 26 (1): 59–65. PMID 9455510.
- ↑ Fussner LA, Heimbach JK, Fan C, Dierkhising R, Coss E, Leise MD; et al. (2015). "Cardiovascular disease after liver transplantation: When, What, and Who Is at Risk". Liver Transpl. 21 (7): 889–96. doi:10.1002/lt.24137. PMID 25880971.
- ↑ Laish I, Braun M, Mor E, Sulkes J, Harif Y, Ben Ari Z (2011). "Metabolic syndrome in liver transplant recipients: prevalence, risk factors, and association with cardiovascular events". Liver Transpl. 17 (1): 15–22. doi:10.1002/lt.22198. PMID 21254340.
- ↑ Taler SJ, Textor SC, Canzanello VJ, Wilson DJ, Wiesner RH, Krom RA (1995). "Loss of nocturnal blood pressure fall after liver transplantation during immunosuppressive therapy". Am J Hypertens. 8 (6): 598–605. doi:10.1016/0895-7061(95)00077-3. PMID 7544983.
- ↑ Textor SC, Canzanello VJ, Taler SJ, Schwartz L, Augustine J (1995). "Hypertension after liver transplantation". Liver Transpl Surg. 1 (5 Suppl 1): 20–8. PMID 9346597.
- ↑ Mangray M, Vella JP (2011). "Hypertension after kidney transplant". Am J Kidney Dis. 57 (2): 331–41. doi:10.1053/j.ajkd.2010.10.048. PMID 21251543.
- ↑ Younossi Z, Stepanova M, Saab S, Trimble G, Mishra A, Henry L (2015). "The association of hepatitis C virus infection and post-liver transplant diabetes: data from 17 000 HCV-infected transplant recipients". Aliment Pharmacol Ther. 41 (2): 209–17. doi:10.1111/apt.13027. PMID 25413020.
- ↑ Bianchi G, Marchesini G, Marzocchi R, Pinna AD, Zoli M (2008). "Metabolic syndrome in liver transplantation: relation to etiology and immunosuppression". Liver Transpl. 14 (11): 1648–54. doi:10.1002/lt.21588. PMID 18975273.
- ↑ Canzanello VJ, Schwartz L, Taler SJ, Textor SC, Wiesner RH, Porayko MK; et al. (1997). "Evolution of cardiovascular risk after liver transplantation: a comparison of cyclosporine A and tacrolimus (FK506)". Liver Transpl Surg. 3 (1): 1–9. PMID 9377752.
- ↑ Everhart JE, Lombardero M, Lake JR, Wiesner RH, Zetterman RK, Hoofnagle JH (1998). "Weight change and obesity after liver transplantation: incidence and risk factors". Liver Transpl Surg. 4 (4): 285–96. PMID 9649642.
- ↑ Liu LU, Schiano TD (2007). "Long-term care of the liver transplant recipient". Clin Liver Dis. 11 (2): 397–416. doi:10.1016/j.cld.2007.04.003. PMID 17606214.
- ↑ Gisbert C, Prieto M, Berenguer M, Bretó M, Carrasco D, de Juan M; et al. (1997). "Hyperlipidemia in liver transplant recipients: prevalence and risk factors". Liver Transpl Surg. 3 (4): 416–22. PMID 9346772.
- ↑ Albeldawi M, Aggarwal A, Madhwal S, Cywinski J, Lopez R, Eghtesad B; et al. (2012). "Cumulative risk of cardiovascular events after orthotopic liver transplantation". Liver Transpl. 18 (3): 370–5. doi:10.1002/lt.22468. PMID 22140067.
- ↑ Johnston SD, Morris JK, Cramb R, Gunson BK, Neuberger J (2002). "Cardiovascular morbidity and mortality after orthotopic liver transplantation". Transplantation. 73 (6): 901–6. PMID 11923689.
- ↑ Ojo AO, Held PJ, Port FK, Wolfe RA, Leichtman AB, Young EW; et al. (2003). "Chronic renal failure after transplantation of a nonrenal organ". N Engl J Med. 349 (10): 931–40. doi:10.1056/NEJMoa021744. PMID 12954741.
- ↑ Haagsma EB, Thijn CJ, Post JG, Slooff MJ, Gips CH (1988). "Bone disease after orthotopic liver transplantation". J Hepatol. 6 (1): 94–100. PMID 3279109.
- ↑ U.S. Multicenter FK506 Liver Study Group (1994). "A comparison of tacrolimus (FK 506) and cyclosporine for immunosuppression in liver transplantation". N Engl J Med. 331 (17): 1110–5. doi:10.1056/NEJM199410273311702. PMID 7523946.