Receiving a liver transplant both prolongs life and changes
it. Taking antirejection medicines as prescribed, following
diet recommendations, adhering to doctor's orders, and
keeping follow-up medical appointments are ways liver
transplant recipients can make the most of their new liver.
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:
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
- 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;
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
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 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
- increased appetite and weight gain
- salt and water retention (Ankles may become swollen.
Salt and fluid intake may need to be restricted.)
- 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 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.)
- decreased white blood cell count and/or platelets
- increased risk of certain infections
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.
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
- 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.
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:
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
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
For women with vaginal yeast infections, Monistat vaginal
suppositories are prescribed.
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
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.