Life after a liver transplant

After the liver transplantation the patient is usually allowed to recover in the intensive care unit as it is a major operation. Some patients may need a ventilator for assisted breathing. Intravenous fluids, antibiotics and nutritional support is needed for most patients.

Patients may leave the ICU in a few days and remain in the hospital ward for another two to three weeks before being allowed to go home.

Recovery at home is usually a longer and much slower process. It may take three to six months before the person may return to normal work and activities. 1-6

Graft rejection

After the liver from the donor is transplanted into the recipient, the body perceives it as a foreign tissue and mounts an immune reaction against it. This may severely damage the new liver and is called graft rejection reaction.

To prevent this, there are medications called immunosuppressants. These suppress the immunity and prevent it from attacking the new liver. The risk of rejection is highest in the first three months after a transplant.

High doses of immunosuppressants are prescribed initially. The dose is gradually reduced but is still high enough to suppress the immunity and lead to unpleasant side effects.

Immunosuppressants

There are two main types of medications or immunosuppresants. The most common are corticosteroids and others are calcineurin inhibitors.

Corticosteroids work by preventing the genes of the cells to release chemicals that may attack a foreign tissue or infection.

A widely used corticosteroid in liver transplant patients is prednisolone. It is given orally and has a wide range of side effects when used over a long time. These include:

• longer healing time

• mouth ulcers

• mood swings

• muscle weakness

• worsening diabetes

• high blood pressure

• retention of fluids

• weight gain

• muscle weakness

• skin marks

• osteoporosis

• cataracts etc.

The calcineurin inhibitors work by blocking the effects of a protein called calcineurin. Calcineurin normally works by activating a type of white blood cell known as T cells to fight foreign invaders like infections.

Commonly used drugs of this class are ciclosporin and tacrolimus. These are given as pills. Ciclosporin leads to side effects like:

• tingling numbness

• nausea

• vomiting

• loss of appetite

• hypertension or high blood pressure

• dizziness

• headaches

• tremors

• muscle cramps and pains

• increased hair growth on skin etc.

Tacrolimus may lead to:

• insomnia

• high blood pressure

• tremors

• diarrhea

• confusion

• anxiety

• seizures

• hair loss

• skin rash and itchiness etc.

In addition these drugs interact with other medications and herbs, and care must be taken. Despite side effects, the dose of the drugs should not be reduced or they should not be stopped without medical advice.

All immunosuppressants reduce the capability to fight infections and the person may be at risk of developing life threatening or serious infections.

Regular check-ups and precautions

After transplant there is an increased risk of cardiovascular disease and coronary heart disease. These need to be anticipated and managed early. After the operation regular blood tests are needed to see if the new liver is functioning adequately.

Transplant recipients may be at greater risk for bone fractures due to poor nutrition before transplant, chronic liver disease, or long-term use of steroids. To check this a bone density test may be prescribed.

Diet

Patients are advised to eat a healthy diet, avoid alcohol and smoking after the operation. Nutrition is important for wound healing and rapid return to normal functions. Weight gain, high blood sugar or cholesterol should be avoided and corrected as early as possible as these may be detrimental to the new liver. A diet consultant’s help may be sought to devise a nutrition plan.

Safe food handling is vital for everyone especially for liver transplant patients. These patients are at higher risk of food borne infections. All food should be thoroughly washed and cooked before consumption. Patients are advised to avoid raw or undercooked meat, fish (sushi, oysters), poultry, or eggs.

Canned or tinned foods should be used within “sell by” dates. All milk, cheese, and fruit juices consumed should be pasteurized. Foods should be stored as per requirements of temperature and condition and hands washed before each meal and before and after preparing food and particularly after touching raw meat, fish, or poultry.

Exercise

Regular exercise helps return to normal activities sooner after a major operation. Exercise initially however, should be supervised and as prescribed to prevent complications of delayed healing suture breakage etc. Exercise may be begun with the help of a physical therapist.

Return to normal activities

Most people may return to work, school or normal activities within 2 to 3 months after the operation. It is often helpful to return on a part-time basis and increase the hours slowly as the energy levels rise. Most patients can resume driving within 4-6 weeks after transplant but this depends on the general health of the patient.

Most people can have a normal sex life after a liver transplant. A usual wait of 6-8 weeks before resuming sexual activity is recommended because there may be stress on the abdominal muscles. These patients are at a higher risk of Sexually Transmitted Diseases and are advised a monogamous relationship, use of latex condoms and other precautions.

It is recommended that women avoid pregnancy the first year after a transplant. Birth control barrier methods using latex condoms with spermicidal jelly or cream are recommended. Birth control pills or other hormonal methods of contraception need to be discussed with the physician as these may damage the liver.

Travelling should be undertaken at least 6-12 months after the operation especially if it is somewhere remote. Vaccinations, medications etc. are important before considering a vacation.

Many centers recommend that patients wear a Medic-Alert necklace or bracelet so that they may be identified as a transplant recipient in case of an accident and/or if emergency care is needed.