General Aspects of Late Postoperative Care

Recipient lifestyle and care

In general, liver allograft recipients enjoy a near normal lifestyle following transplantation. Medical care is relatively simple for the majority of these recipients using the prescribed follow-up routine. The reason for this relative simplicity can be traced from two important facts.

First, most of these patients have relatively few other premorbid medical or surgical problems that are unrelated to liver disease. Second, these patients receive relatively small amounts of the immunosuppressive medications, Cyclosporine and Prednisone. Consequently, the problems of sepsis and other dose related drug side effects (i.e. headaches, tremors, system hypertension, and hyperglycemia) are minimized. Relatively low doses of immunosuppressants  are allowed in liver allograft recipients because of the low risk of chronic rejection. This is in contrast to renal transplantation in which a steady loss of allograft function occurs in essentially all cadaver donor renal allografts. The reason for this curious but fortuitous phenomenon is unknown and is a current subject of investigation in our animal research laboratory.

In general, there are no physical, social, dietary or sexual activity limitations impressed on these patients. However, with this freedom comes the risk of ad lib drug compliance. We insist on a rigorous follow-up schedule and religious adherence to the medication regime, especially cyclosporine and prednisone. An important cause of late mortality and/or loss of the liver allograft is acute or chronic rejection due to noncompliance with these medications. The groups of recipients particularly prone to this problem are the adolescent and young adult groups (ages 13 to 22). Five patients in this age group lost their graft in this manner.  Special supervision is urged for these individuals, including strong family support, close outpatient medical follow-up, and in some cases social work and psychological follow-up.

Patient diary

To aid these recipients in their self monitoring of any complications of liver transplantation or side of effects of medications (esp. cyclosporine and prednisone), we ask most of our patients to keep a diary of such important data as body weight, blood pressure, and episodes of diarrhea or vomiting, and when appropriate blood glucose values by glucometer.  This diary is helpful during outpatient clinic visits.

Late postoperative follow-up schedule

Liver allograft recipients usually spend two to four weeks as an inpatient following a liver transplantation procedure. Of this time, the first two to five days are typically spent in the intensive care unit. The stay may be as short as two weeks, but may extend to as long as six months. This length of time is determined largely by the clinical status of the patient prior to transplantation which tends to influence the extent and number of metabolic and infectious complications following the procedure. The general protocol for outpatient and inpatient follow-up following liver transplantation includes:

1. From discharge through the third month following the date of liver transplantation:
Weekly outpatient visits (for physical exam, history for specific complaints (see "Specific Problems"), and laboratory blood tests including: CBC, SMA-18 [(including serum Magnesium, a 12 hour trough whole blood level of cyclosporine by high pressure liquid chromatography (HPLC)].

2. Three months following transplantation:
Admission as an inpatient for a careful history and physical exam, blood laboratory tests, liver allograft biopsy, and 24 hour urine collection for creatinine and protein. The "t-tube" is usually removed following a cholangiogram.

3. Between three and six months following transplantation:
Outpatient visits are diminished to every two weeks for physical exam, history for specific complaints, and laboratory blood tests (CBC, SMA-18, 12 hour trough whole blood for cyclosporine level by HPLC).

4. Six months following transplantation:
Admission as an inpatient for careful history, physical exam, blood laboratory tests, liver allograft biopsy, and 24 hour urine collection for creatinine and protein.
At this time the prednisone dosage is usually decreased from 20 to 15 mg PO q day.

5. Six months to 12 months following transplantation:
Outpatient visits are further diminished to monthly intervals for physical exam, history for specific complaints, and laboratory blood tests (CBC, SMA-18, 12 hour trough for whole blood for cyclosporine level by HPLC)

6. One year following transplantation and on the yearly anniversary of their liver transplant procedure:
Admission as an inpatient for careful history, physical exam, blood laboratory tests, liver allograft biopsy, and 24 hour urine collection for creatinine and protein.

At this time the prednisone is usually decreased from 15 to 10 mg PO q day.

7. One year following transplantation and annually thereafter:
Outpatient clinic visits are diminished to two month intervals for physical exam, history, and laboratory blood tests (CBC, SMA-18, and 12 hour trough for whole blood level for cyclosporine by HPLC).