Guidelines for the follow-up of children post
liver transplant.
Introduction
Intially weekly review alternating between specialist unit and DGH, increasing
the interval between visits with time. Parents to seek our opinion about any
immediate problems and then these problems could be discussed with the
Liver Unit Registrar on call (0121 333 9999 throughout 24 hours) or Ward 8 at
Birmingham Children’s Hospital (0121 3339065 or 0121 3339066) prior to any
change in management.
Information and suggestions for outpatient monitoring as detailed below.
Background Information
The Liver
Children receiving liver transplants will either have had a whole liver, a
reduced graft or a split liver all of which we anticipate will function and grow
with the child. They will be on immunosuppressive treatment lifelong, but we
anticipate that they will return to a near normal lifestyle within 12 months.
Children can travel on public transport following initial discharge from BCH.
They may return to school by 6 weeks if over 7 years of age. Younger children
should wait until steroids are stopped at 3 months.
Possible Complications
Please feel free to discuss the possible development of any complications
with a member of the Liver Unit at any time.
Thrombosis of anastomosed vessles
There are several major anastomoses (heptic artery, portal vein, hepatic vein,
inferior vena cava) required for liver transplantation. The risk of vascular
thrombosis is particularly high in the first month – portal vein thrombosis may
occur later. Children are given low dose Aspirin and Dipyridamole as
prophylaxis for 3 months.
Cholangitis and/or biliary obstruction
This is a common problem because of the Roux-en-y anastomosis and is
usually due to gram negative infection, and high-risk children will be on
antibiotic prophylaxis. The child may present with malaise, vomiting and fever
before jaundice is clinically apparent.
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Management:
Blood culture, full blood count and differential, liver profile and trough
Cyclosporin level before starting appropriate antibiotic(s).
Cefuroxime 20mg/kg/dose tds (max 750mgs tds) for 48 hours
Amoxyl 25mg/kg/dose tds for 48 hours (max 500mgs tds)
Metronidazole 8mg/kg/dose tds over 1 hour for 48 hours
(Note: aminoglycosides should be avoided as their nephrotoxicity is
addictive to Cyclosporin).
Please let BCH know if cholangitis occurs as operative or radiological
intervention may be required
Rejection
Needs prompt referral to Birmingham Children’s Hospital for liver biopsy and
treatment.
Acute Rejection
Presents as recurrent of jaundice and fever with elevation of transaminases,
alkaline phosphatase and gamma glutaryl transpeptidase and may be
associated with low cyclosporin/tacrolimus levels (e.g. secondary to
diarrhoea).
Chronic Rejection
Presents with mild cholestasis and moderately elevated enymes possibly
associated with low Cyclosporin/Tacrolimus levels. It does not respond well to
an increase in immunosuppression and may require treatment with
Tacrolimus and/or transplantation.
Intercurrent Infection
Gastroenteritis
Loose frequent stools, which might be due to gastro-enteritis, may result in
low Cyclosporin levels and precipitate acute or possibly chronic rejection. See
above.
If child develops watery diarrhoea, more than 4 motions per day, we suggest:
LFT, FBC, Stool culture and virology, Cyclosporin/Tacrolimus level
If diarrhoea is severe or persists more than 3-5 days with low
immunosuppressant levels, we suggest discussion with the Liver Unit and
admission for IV Cyclosporin (2mg/kg/day given over 12 hours bd) or IV
Tacrolimus0.15mg/kg/dose bd)
Chickenpox
 On significant contact:
o Direct face to face coversation
o 15 minutes in same room
 Get VZ antibody level estimated within 3 days
 If naturally immune – no action
 If vaccinated with demonstrable immunity – no action (Ab titre positive)
 If vaccinated with demonstrable immunity immediately or shortly after,
but no demonstrable immunity at time of contact, no VZIG needed but
start oral acyclovir
o Under 5 years
200mg/dose 5x a day for 3 weeks
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o Over 5 years
400mg/dose 5x a day for 3 weeks
If vaccinated with no immunity demonstrated at any time/or no natural
immunity give VZIG injection as soon as possible but no later than 10
days after exposure
o 0 – 5 years 250mg (1 vial)
o 6 - 10 years 500mg
o 11 – 14 years 750mg
o over 15 years 1000mg
Should 2nd exposure occur after 3 weeks, the above actions need to be
repeated
Development of chicken pox requires hospitalisation and administration
of IV Acyclovir 500mg/m2/dose 8 hourly until symptoms clear
Tuberculosis Contact
Please discuss with Birmingham Children’s Hospital., if there is direct contact
with newly diagnosed relative.
CMV
There is a close association between CMV infection and rejection. It may
present with malaise, fever and raised transaminases. It may be secondary to
blood transfusion/donor liver or reactivation. However, if there are suggestive
symptoms we advise testing IgG/IgM serology and culturing from a very fresh
urine. Severe infection requires admission to reduce immunosuppression and
treat with Gancylovir 5mg/kg every 12 hours for 14 – 21 days. Please consult
with BCH for discussion.
Herpes simplex
If in contact with oral herpes simplex, treat with oral Acyclovir for 1 week
Under 5 years 200mg/dose 5x a day
Over 5 years 400mg/dose 5x a day
Measles
If non-immune child is in contact with measles they require immediate single
dose of IM hyperimmune globulin (1gm/m2)
Other Viruses
Mild intercurrent viral illnesses are inevitable and not usually serious.
Candidiasis
While on high doses of immunosuppressants, oral Nystatin and Amphotericin
are used as prophylaxis.
Immunisations
If immunisations are incomplete prior to transplantation, the course should be
completed using killed vaccines only.
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MEDICATIONS:
Immunosuppression:
Cyclosporin M.E. (Neoral)
Regular monitoring on trough levels:
Weekly initially until 6 weeks
Fortnightly until 3 months
Monthly until1 year
3 monthly in 2nd year if stable
6 monthly in 3rd year if stable
The following levels are acceptable using the Abbot Axsyn Assay:
In 1st 3 months
3 month-1year
2nd year
3rd year
On twice daily dose
180-230mcg/l
100-160mcg/l
70-110mcg/l
60-90mcg/l
advice will be given in discharge or out-patients letters if levels are to be set
differently for specific patients
Tacrolimus trough levels
First 2 weeks
3rd/4th week
2nd/3rd month
thereafter
10-15ng/ml
8-12ng/ml
5-8ng/ml
3-5ng/ml
Cyclosporin/Tacrolimus specimens will be monitored at BCH, packs will be
provided with the parents
Prednisolone po
Dosage is
Day 14-20
Day 21-28
Month 2-3
Month 3 onwards
0.75mg/kg/day 1 dose
0.5mg/kg/day 1 dose
0.25mg/kg/day 1 dose
5mg alternate days
Azathioprine
Dosage
1.5 – 2mg/kg/day as a single dose
A special formulation of 10mg tablets are available from Wellcome. This is
usually stopped one year post transplant
Anti-hypertensive
Nifedipine
Atenolol
5-10 mg/kg/dose prn
25-100mg daily
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Anti-thrombotic
Aspirin
Dipyridamole
3mg/kg po daily
(max 75mg)
25mg/kg tds (under 10kg)
50mg/kg tds (over 10kg)
stopped at 3 months
Prophylaxis – against candidiasis
Nystatin
Amphotericin
100,000 units qds
1ml once daily
Stopped at 6 months
Prophylaxis – against pneumocystitis carinii
Cotrimoxazole
240mg 3x per week under 5
480mg 3x per week over 5
stopped at 6 months
Sections in the original BCH protocol, held in Dr Smiths office on:
Outpatient monitoring
Advice on overseas travel
Side effects and interaction of medication
FJT
Updated ALS (from BCH guidelines) Jan 2004, reviewed 2008
Next review 2011
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