Liver transplant complications


  • 2nd most frequently transplanted solid organ
  • May be from living or deceased donor
  • Most common causes of liver failure necessitating transplant include hepatitis C or B infection, alcoholic cirrhosis, idiopathic/autoimmune liver disease, primary biliary cirrhosis, primary sclerosing cholangitis, and acute liver failure (e.g. drug/toxin induced, acute hepatitis, etc.)

Immunosuppressant Medications

Clinical Features

Differential Diagnosis

Most common problems in liver transplant patients involve:

  • Acute graft rejection
    • 1 in 5 have rejection during first year, usually within <1 mo
  • Vascular thrombosis
  • Biliary leak or stricture
  • Malignancy (squamous cell carcinoma, lymphomas, post transplant lymphoproliferative disorder)
  • Adverse effects of immunosuppressant drugs[1]


Time from transplantation affects the risk and type of infection.

  • Early (within the first month)
    • Donor-derived - bacterial, fungal, parasitic
    • Nosocomial & surgical-site - C. diff, aspiration Pneumonia, UTI, surgical-site, superinfection of graft tissue
  • Intermediate (1-6 months after)
  • Late (more than 6 months after)
    • Community-acquired infection


  • CBC
    • Infection may cause leukocytosis or leukopenia
  • LFTs
    • Elevated in biliary, vascular, and rejection complications
  • BMP
  • Coags
  • Tacrolimus/cyclosporine levels

Additional work up will depend on presentation, but may include:

  • Infectious workup
    • Blood and urine cultures
    • +/- PCR and other studies for viral/fungal pathogens as indicated
    • Diagnostic paracentesis if evidence of SBP
  • Abdominal CT or ultrasound with doppler, if concern for rejection, biliary obstruction, or thrombosis
  • Biliary complications may need ERCP



  • Admit in consultation with transplant team

See Also

External Links


  1. Liver Transplants: Practice Essentials, Orthotopic Liver Transplantation, Immunosuppression Agents. Emedicinemedscapecom. 2016. Available at: Accessed September 23, 2016.
  2. Long B, Koyfman A. The emergency medicine approach to transplant complications. Am J Emerg Med. 2016;34(11):2200-2208.