Liver Transplant and Hepatobiliary DiseasesThe Transplant ProcessAfter the Transplant Printer Friendly Page

Liver transplant recipients take medication for the rest of their lives to help prevent the body from rejecting the liver. It is important that they become familiar with the names and dosages of each medicine.

All medicines–whether over-the-counter or prescribed by other doctors–must be approved by the transplant team. If it is believed that the medicine may cause a harmful drug interaction, a different medicine will be suggested to the patient and his or her physician. If it is an emergency, have the physician contact either the transplant coordinator or transplant physician.

Some guidelines for taking medicines include:

• Attend classes while in the hospital to learn about the medicines.
• Take the prescribed doses each day on time and record them in a medication diary.
• Always wash hands before taking the medicine.
• Unless told otherwise, store medicine in a cabinet at room temperature outside of the bathroom to avoid moisture.

  * Keep the medicine out of reach of children

Anti-Rejection (Immunosuppressive) Medications

Neoral ® (cyclosporine)
This medication is given to prevent rejection of the transplanted liver. It must be taken every twelve (12) hours. The prescribed dosage maybe changed frequently to maintain an appropriate blood level.

There are some common side effects of cyclosporine. Most of these are not severe and are treatable. If side effects occur, patients should not stop taking the cyclosporine; instead, they should contact the transplant team to discuss the appropriate treatment.

Common side effects of cyclosporine are:

• high blood pressure (May require medication)
• hand tremors
• headache
• tingling of hands and feet
• runny nose with nasal congestion
• decreased kidney function (Kidney function is monitored by blood tests and should be checked as directed by the transplant team)
• increased hair growth
• swollen gums
• night sweats
• increased sex drive
• depression or other mental symptoms

Prograf ® (tacrolimus; FK 506)

This drug acts in a similar fashion to cyclosporine. In addition, use of this medication can result in the need for lower dosages of Prednisone. It comes in 5 milligram (pink) and 1 milligram (white) capsules that are taken twice daily, 12 hours apart. Some patients will take either Prograf or cyclosporine, but never both.

The side effects of Prograf are similar to those found with cyclosporine. Once again, these side effects are treatable, so patients should not stop taking Prograf if one or more of these symptoms occur.

Prednisone

Prednisone is another medication used to prevent rejection. It is classified as a steroid and used in combination with Prograf ®or Neoral®. Patients are gradually tapered off of Prednisone after the transplant as the liver function improves. It is taken once daily and will be prescribed in 5 milligram tablets.

Common side effects of Prednisone are:

• increased blood sugar (Thirst, tiredness, and frequent urination may be signs of high blood sugar and should be reported to the transplant team.)
• stomach ulcers (Anti-ulcer drugs, such as Pepcid®, Axid®, or Zantac®, are helpful while taking Prednisone)
• increased appetite and weight gain
• salt and water retention (Ankles may become swollen. Salt and fluid intake may need to be restricted.)
• acne
• increased hair growth
• "moon face" (One way to prevent this is to avoid weight gain from overeating.)
• mood changes
• night sweats, nightmares, insomnia
• increased sun sensitivity, heat intolerance
• bone and joint changes
• cataracts, glaucoma, blurry vision (Patients should not obtain new glasses until the dosage is stabilized)

Solu-Medrol ® (methylprednisolone)

Solu-Medrol, another steroid, is the IV form of Prednisone and carries the same side effects. Solu-Medrol may be given in large doses if rejection occurs. Prednisone and Solu-Medrol are not taken concurrently. The dosage will be tapered as the rejection improves and then Prednisone is started once again.

CellCept ®(mycophenolate mofetil; MMF)

CellCept is another anti-rejection medication that may be used with Prograf or cyclosporine and Prednisone. It comes in a capsule form and is taken twice daily, 12 hours apart.

Common side effects of CellCept are:

• abdominal pain, cramping (Try to take with food if this occurs.)
• diarrhea
• headache
• decreased white blood cell count and/or platelets
• increased risk of certain infections

OKT3

OKT3 is an IV medication given only for severe rejection. It is an antibody that kills specific white blood cells that are involved in the rejection process. This is only given to patients having rejection that is not responding to Prednisone. It is given once daily for 7 to 14 days.

There are some serious side effects of OKT3, such as wheezing (as with asthma) and shortness of breath. This is why it is only given under close supervision. Some patients may not have any side effects at all. The most common side effects occur with the first two or three doses, are flu-like in nature and include: fever, chills, nausea, vomiting, diarrhea, and headaches. Tylenol, Benadryl and Solu-Medrol may be given prior to each dose to decrease the incidence of these side effects.

Daily Living

After liver recipients are discharged from the hospital, they have the responsibility for monitoring their health and avoiding rejection. The following guidelines should become a natural way of life for them:

• Always wear a medical bracelet or necklace. It is imperative for emergency health care personnel to know that a person has had a transplant.
• Avoid anyone who has a cold, flu, or does not feel well until that person is free of symptoms.
• Avoid crowds and crowded rooms.
• Stay away from areas under construction or areas where animals live or have lived.
• Make certain any pets are carefully screened by a veterinarian. It is not advisable to have birds as pets, as their waste contains a high level of germs. Do not handle any type of pet waste.
• Keep clean by showering or bathing daily and washing hands with antibacterial soap before meals and after using the bathroom.
• Wash all fresh fruits and vegetables. Molds and fungi may be present on their skins.
• Immediately wash minor cuts and scrapes with soap and water. If they do not heal well, contact the transplant coordinator.
• Report any blisters, sores, suspicious lumps, or growths in the armpits, groin, or elsewhere in the body to the transplant coordinator.
• Check with a member of the transplant team before receiving any type of vaccination.
• Do not smoke!
• Stay away from day care centers, where there may be exposure to childhood infections.
• Discuss any travel plans with the transplant team. Travel in underdeveloped countries is not advised.

Dental care is very important after transplantation and includes brushing teeth after every meal, daily flossing, and gum stimulation. Regular check-ups should be scheduled once a year or as the patient’s dentist recommends. Often, preventive antibiotics are prescribed before dental visits to avoid infection. An antibiotic (amoxicillin, or clindamycin for amoxicillin/penicillin allergic patients) is given 1-2 hours before the dental procedure to ensure that there is an adequate level of antibiotic in the blood. The second dose is given 6 hours after the initial dose.

Sexual relations may resume 4-6 weeks after surgery, or as the transplant doctor recommends. Because ovulation in women of child-bearing age may occur before their menstrual cycles regulate, these transplant recipients should use birth control. The barrier methods are the best types of birth control in transplant patients. These include condoms, diaphragms, and sponges, all with spermicides. Intrauterine devices (IUDs) carry a risk of infection, and therefore are not recommended. Oral contraceptives ("the pill") should not be used, as they may affect liver function.

Some men may be interested in taking Viagra (sildenafil). Viagra is not known to interfere with any of the medications commonly taken by transplant patients. However, men taking nitrates for angina or chest pains should not take Viagra–the combination may cause blood pressure to drop to dangerous levels and also arrhythmias (abnormal heart rhythms). Male liver transplant patients should consult a urologist or private physician if they feel that they may need Viagra.

Rejection of the Transplanted Liver

Approximately 60-70% of patients develop rejection at some time after a liver transplant. In the past decade, major improvements have occurred in the ability to control rejection. It is uncommon for patients to lose the new liver to rejection, provided they take their antirejection medications as prescribed.

Some of the signs of rejection are:

• fever above 100 degrees
• swelling or tenderness over the new liver
• flu-like feelings
• clay-colored stools
• dark, tea-colored urine
• jaundice (yellow skin or eyes - late sign)

Rejection may occur at any time after the transplant, sometimes without any symptoms of illness. That is why it is extremely important for liver transplant recipients to not miss having their liver function blood tests. If the patient’s liver tests become abnormal, he or she may need a liver biopsy, in which a small sample of the liver is obtained by a small needle. The elevation in the liver tests may be due to rejection or various infections, such as hepatitis.

Liver transplant recipients should call their transplant coordinator or go to their hospital immediately for treatment if they are experiencing rejection symptoms. The quicker treatment is received, the more successful it is likely to be.

Infection

As describe earlier, recipients receive several different medications to prevent them from developing infections. Opportunistic infections would not usually be harmful to most people, but can be to transplant recipients. Such infections include the following:

Bacterial Infections

Pneumonia (lung infection) may occur. To help prevent pneumonia, recipients should faithfully follow the exercise program given to them by their physical therapist. Any phlegm or blood brought up from the lungs should be immediately reported to the patient’s nurse, transplant coordinator, or local physician. A specific type of pneumonia, Pneumocystis carinii, can be very dangerous and may occur in people with suppressed immune systems, such as patients after transplant. Bactrim or Septra (trimethoprim-sulfamethoxazole) may be prescribed to prevent this infection.

Urinary tract infections are another common problem, and patients should notify their nurse or transplant coordinator if they experience burning or pain while urinating or a frequent need to urinate.

Any time the incision becomes red, swollen, or is draining pus or fluid, patients should notify their nurse or transplant coordinator.

Fungal Infections

Fungal infections may occur in the mouth, throat, or throughout the body in the blood; the greatest risk is in the first 3 months after transplant. Nystatin liquid, a liquid that can be swished around in the mouth and then swallowed, is commonly prescribed for some fungal infections.

For women with vaginal yeast infections, Monistat vaginal suppositories are prescribed.

Viral Infections

Viral infections, such as herpes, may occur after a liver transplant. This virus causes inflammation of the skin with collections of small blisters. One type of herpes infection is herpes simplex or a "cold sore". This infection may occur in the mouth or the vagina. Another type is herpes zoster or "shingles". This is the same virus that causes chicken pox, and it appears along the distribution of a nerve, often in the face, chest, or abdomen. Liver transplant recipients are prescribed acyclovir (Zovirax) after transplant to prevent herpes infections.

Another serious viral infection is caused by cytomegalovirus (CMV). CMV infections can occur in the liver, lungs (pneumonitis), eyes (retinitis), and rarely, the brain (encephalitis). During the transplant evaluation, the recipient’s blood is tested for antibodies for CMV to see if he or she has been previously exposed to the virus. The liver donor has also been tested. Based on both of these tests, the recipient is categorized as being at 1) high risk, 2) moderate risk, or 3) low risk for CMV infection. Based upon the identified level of risk, medication dosage and duration will vary.

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