Post-Transplant Complications: Biliary, Vascular, Infectious, Renal, Neurologic, and Malignancy
Timing narrows the differential
Complications follow a clock. Early (<1 month):** technical and surgical - primary nonfunction, hepatic artery thrombosis, portal vein thrombosis, biliary leak, hemorrhage, and bacterial or Candida infection. **Intermediate (1-6 months):** opportunistic infection (CMV, PCP, aspergillus), acute cellular rejection, and drug toxicity. **Late (>6 months): community-acquired infection, chronic rejection, biliary strictures, recurrence of primary disease, and de novo malignancy.
Biliary complications occur in 10-25%: anastomotic strictures (most common) and leaks, treated with ERCP dilation and stenting; nonanastomotic strictures should prompt evaluation for hepatic artery problems.
Vascular: hepatic artery thrombosis (2-9%) is the most feared early event and can present as biliary leak, sepsis, or fulminant graft failure. Portal vein stenosis and hepatic vein outflow obstruction are less common.
Infection: CMV highest risk in D+/R− serostatus; valganciclovir prophylaxis for 3-6 months. EBV-driven PTLD usually appears in the first year and is managed by reducing immunosuppression plus rituximab.
Renal: calcineurin-inhibitor nephrotoxicity is the leading cause of late CKD; consider switching to mycophenolate-based therapy.
Neurologic: tremor, seizures, and posterior reversible encephalopathy syndrome from calcineurin-inhibitor toxicity.
Malignancy: skin cancer, PTLD, and de novo solid tumors; sun protection and age-appropriate screening.
Rule of thumb: fever in the first month is a surgical complication until imaging says otherwise; new cholestasis after month 1 is a biliary or vascular problem until proven otherwise.