Like most other organ transplants, a liver transplant will be rejected by the recipient unless immunosuppressive drugs are used. Liver transplantation is unique in that the risk of chronic rejection decreases over time, although recipients need to take immunosuppressive medication for the rest of their lives. It is possible to be slowly taken off an anti-rejection medication but only in certain cases.
The first 3 months after transplantation is when the patient requires the most medication. After that time, some medicines can be stopped or their dosages decreased. Some of the medication is dosed according to the patient's weight. It is important for the patient to be familiar with the medications. It is also important to note their side effects and to understand that the side effects may not occur with everyone. The side effects may lessen or disappear as the doses of medicine are lowered over time. Not every patient having a liver transplant takes the same medications. Some commonly used medications are as follows:
Cyclosporine (Neoral/Sandimmune) helps prevent rejection. It comes in pill and liquid form. If the liquid is given, it is important to mix the liquid in apple juice, orange juice, white milk or chocolate milk. The patient can "shoot" it directly into the mouth and then follow it with any liquid. Cyclosporine should not be mixed in a paper or Styrofoam cup because they absorb the drug. It should only be mixed in a glass container directly before taking the drug.
Tacrolimus (Prograf) helps prevent and treat rejection and works in a similar way to cyclosporine. Certain medications and substances, including alcohol, antibiotics, antifungal medicines, and calcium channel blockers (high blood pressure medications), may elevate levels of tacrolimus and cyclosporine. Other medications, including anti-seizure medicines (phenytoin and barbiturates) and other antibiotics, may decrease tacrolimus and cyclosporine levels.
Prednisone (Deltasone, Meticorten), a steroid, acts as an immunosuppressant to decrease the inflammatory response. Initially, just prior to surgery, prednisone is given intravenously. Later, prednisone is given in pill form. Note: Patients must never stop or reduce the prednisone without medical advice. The body normally produces small amounts of a chemical similar to prednisone. When a person takes in extra amounts of this substance, the body senses this and may reduce or stop its natural production of this chemical. Therefore, if a person suddenly stops taking the medication form of prednisone, the body may not have enough natural prednisone-like chemical available. Serious side effects may result.
Prednisone may cause the following side effects:
_Increased susceptibility to infection Weakened bones (osteoporosis) Muscle weakness Salt and water retention Potassium loss Easy bruising Stretch marks Nausea Vomiting Gastric (stomach) ulcers
_Increased cholesterol and triglyceride levels Increased hunger Blurred vision Rounded face ("chipmunk cheeks") Enlarged abdomen Inability to sleep Mood swings Hand tremors (shaking) Acne Steroid dependency
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Azathioprine (Imuran) is an immunosuppressant that acts on the bone marrow by decreasing the amount of cells that would attack the new liver. The dose is based on the person's weight and white blood cell count.
Muromonab-CD3 (Orthoclone OKT3) is an immunosuppressant used for people who are rejecting the transplant, for those in whom prednisone is not working well enough, and for those who cannot take tacrolimus or cyclosporine.
Mycophenolate Mofetil (CellCept) is an antibiotic that acts as an immunosuppressant and is used for acute rejection.
Sirolimus (Rapamune) is an antibiotic used as an immunosuppressant.
Sulfamethoxazole-trimethoprim (Bactrim, Septra, SMZ/TMP), an antibiotic, acts to prevent Pneumocystis carinii pneumonia, which occurs more often in people who are immunosuppressed.
The 1-year survival rate after liver transplantation is about 90% for patients living at home and about 60% for those who are critically ill at the time of the surgery. At 5 years, the survival rate is about 80%. Survival rates are improving with the use of better immunosuppressive medications and more experience with the procedure. The patient's willingness to stick to the recommended post transplantation plan is essential to a good outcome.
Generally, anyone who develops a fever within a year of receiving a liver transplant is admitted to the hospital. Patients who cannot take their immunosuppressive medicines because they are vomiting should also be admitted. Patients who develop a fever more than a year after receiving a liver transplant and who are no longer on high levels of immunosuppression may be considered for management as an outpatient on an individual basis.