Perioperative and Long-Term Post-Transplant Management
Perioperative care
Graft types include whole, reduced, split, and living-donor left lateral segment. Early graft function is assessed by lactate clearance, glucose, acid-base status, bile output, and INR trend. Doppler ultrasound is essential for hepatic artery thrombosis, portal vein stenosis, and hepatic vein outflow obstruction. Biliary complications include leak and stricture; presentation may be fever, rising bilirubin, or cholangitis. Primary nonfunction is suggested by persistently high transaminases, poor INR, lactic acidosis, and encephalopathy.
Long-term management
Long-term care addresses immunosuppression, infection prophylaxis, growth, nutrition, renal function, hypertension, bone health, and adherence. EBV and CMV are key infections; PTLD risk rises with EBV and intensified immunosuppression. Recurrence of disease is possible with autoimmune hepatitis, fatty liver disease, and HCC. Transition to adult care should begin in adolescence.
Traps
Fever with abnormal liver tests after transplant is not automatically rejection; consider biliary obstruction, infection, vascular thrombosis, and drug toxicity. Tacrolimus levels fluctuate with interacting drugs. A normal ultrasound does not fully exclude biliary disease.
Worked example
On postoperative day 2, a child has ALT 900 U/L, INR 2.2, lactate 5 mmol/L, and low urine output. Obtain urgent Doppler, check tacrolimus level, cultures, and surgical review. This pattern suggests vascular compromise or primary graft dysfunction, not isolated rejection; biopsy is rarely the first step in the unstable early postoperative patient.
Rule of thumb: in the first week, think vascular and biliary before rejection.