Care after liver transplant in children

Introduction

Liver diseases are common in children and liver transplant is a major operation in which the child’s diseased liver is replaced with the healthy liver of the donor. It is usually done for

• Acute liver failure (i.e sudden failure of liver which was previously normal),
• Advanced liver disease / cirrhosis (child who has a long standing liver disease)
• Metabolic and/or genetic diseases
• Liver tumors

Children have an excellent outcome after liver transplantation and they lead a life like any other normal child. This is made possible with a combined effort from both the transplant team and parents. There are some specific matters which should be looked into a child who has undergone a liver transplant and who is going to live the rest of his life with a new liver inside his tummy.

1)How does the child behave in the immediate post-transplant period ?

In the immediate post-transplant period, the child need to stay in ICU for a few days and will be monitored for any problems. Child will be started on specific medicines called immune suppressants immediately after surgery and this is to prevent rejection from happening (explained below). The child gradualy gains consciousness and feeding is started on 3^rd to 5^th post-operative day. Shifting to ward is done once the child is stable, usually on 4^th to 5^th post-operative day. Blood tests and ultrasound scanning will be done frequently in the initial few days to know about the functioning of the liver and also to check the adequacy of immunosupression drugs (i.e medicines which prevents the body from rejecting the new liver).

2)What are the complications expected in the immediate post-operative period ?

This can be divided into medical and surgical complications. Among the medical complications, infections and rejections are the commonest. Infection can be caused by bacteria, viruses or funguses. They are treated with antibiotics, antivirals and antifungal agents respectively and intravenous route is usually required. Rejection is a normal immunological response of the body to react against a forgein organ and it can damage the new liver. It is proven after doing a liver biopsy. It can be efficiently treated with medications like steroids. Surgical complications depends on the technical expertise of the team and it includes bile leak, hepatic artery thrombosis, portal vein thrombosis etc.

3)How to prepare for getting discharged ?

– Awareness of medicines : The parents should be knowing the dosage and timing of giving medicines to the child, particularly the immunosuppressants. Some medicine Immunosuppressants are “oxygen” to the transplanted liver and cannot be skipped by a reason. These are medicines which needs tom be continued lifelong for the child.

– The child along with the parents need to stay for 4 – 6 weeks in the post-operative period at a place near the transplant centre from where they can approach the center easily in case of an emergency. It is always better to find a place which is less crouded, clean air & water and with lesser number of family attendees. This will reduce the chance of infection as the child is more prone for getting a severe infection in the immediate post-transplant period due to a relatively higher immunosuppression. It is always better to fumigate the apartment before the child starts his/her stay there.

– the diet which is being followed during ward stay needs to be continue and gradual introduction of other foods can be done as per a systematic diet chart. Raw fruits or vegetables, grapes or introduction of exotic foods/formulae should be avoided. Things like raw honey, foods which care kept open/ uncovered, indigenous herbal materials (which are sometimes added to the diet )also needs to be avoided.

4)What are the common symptoms to be looked into the child in the immediate post-operative period, which can indicate a major problem ?

The following symptoms are to be taken seriously : Fever, yellow eyes/skin, dark urine, sudden distension of the abdomen, pain abdomen interrupting sleep, loose stools, breathing difficulty, refusal to feed, letharginess, non-consolable cry or irritability. They should immediately consult the transplant in case of above mentioned symptoms and may require admission. It needs a special mention that fever is the most misinterpreted symptom and it needs to be measured with a thermometer ( roughly taken as more than 100 F) and not just by warmth of the child.

5)What are the general precautions taken in the post-transplant period ?

It is advisable the child wears a face mask when he is going out of the staying place. It should be ensured that the mask is covering both nose and mouth. As explained earlier, visitors should not be entertained atleast for initial 3-6 months and if any of the care takers have symptoms of infection like fever, sore throat, loose stools or cough, they need to stay away from the child and self-isolate. Strict food hygiene needs to be maintained. Children are dynamic from second to second and this can make them prone for trauma. The child should be lying either on a cot with side railings or on the floor with a low-rise bed to prevent falling down and hurting themselves. Routine activities can be restored from 6 months post-transplant period and he/she can go to school after 1 year of transplant, but strict and complete adherence to medications need to be continued.

6) How frequently the child has to have OPD review and should undergo blood tests ?

As explained previously, immediate post-transplant period warrants a twice a month OPD review with blood tests and Tacrolimus trough levels and once a month ultrasound scan of the abdomen. This will be for the next three months and the interval between each visits care increased with time as the liver functions are normal and immunosupression levels are stabilized and acceptable. Two viruses we screen are CMV and EBV and the testing is done over interval of 3-6 months depending on the results of the previous tests. Once the child goes back to the native place, we usually call them once after 6 months and later they can review once a year if things are going well.

7) How many medicines the child will be taking on long term basis ?

Initially child will be on multiple medicines and after 6 months, the two medicines the child needs to take include a) Tacrolimus & b) Prednisolone (low dose).

8) How to go about vaccines in the post-transplant period ?

The child should not be vaccinated in the initial 6 months post liver transplant as the immune response won’t be adequate because of relatively higher immune suppression. After that, only killed vaccines can be given to the child. Liver vaccines should never be given to the child (eg : MMR, OPV). Exposure to chickenpox and Herpes Zoster contact should be managed depending on the duration since exposure and varicella antibody levels. Hospitalization and administration of IV Acyclovir will be required if the child develops Chickenpox.

9) What are the late complications seen in liver transplant recepients ?

These includes chronic rejection (occurs when the medicines are not taken adequately), post-transplant lymphoproliferative disorder (usually caused by EBV and hence the importance of monitoring its levels), late onset surgical complication (relatively rare) including biliary strictures, portla vein thrombosis etc.

10 ) What to do if the child develops any features of infection ?

The child can be consulted immediately with the pediatrician in their locality and management can be commenced immediately like other pedaitric patients. But a few things need to be kept in mind.

• Fever :Focus of fever need to be identified and any fever without focus needs to be taken seriously. The child should be started on intravenous antibiotics. The I V antibiotics can be adjusted as per the blood culture reports.
• Tacrolimus blood levels : This can be altered by other medications and this needs to be this is to be addressed each time a new medicine is started for the child . The treating physician or the parent can discuss with the transplant team through the helpline number, on this aspect.
• Paracetamol could be given at standard dose and avoid ibuprofen and other NSAIDs as it can cause gastritis and bleeding
• Diarrhea and Gastroenteritis: Child may require hospitalization for rehydration to prevent graft thrombosis (graft getting blocked due to clots secondary to dehydration) . Tacrolimus levels also need to be checked additionally during these episodes.
• The transplant team needs to be communicated and updated about the management the child is undergoing at their local place
• In can of major issues, especially related to liver (eg symptoms like new onset/persistent jaundice, pale stools, abdominal distension), the child needs to come for consultation in the transplant center for evaluation and management (after initial stabilization at their local place)