The body's immune system is its’ natural defense against diseases. The immune system recognizes and tries to destroy all foreign substances to protect the body. Foreign substances include viruses, bacteria, fungi and foreign tissues (such as a transplanted liver). Therefore, the immune system treats your child's new liver as it would any other foreign substance - it tries to destroy it. This attack on the new liver is called rejection.
We try to prevent these "attacks" by giving your child immunosuppressive medications. However, there is still a strong possibility that your child will experience one or more episodes of rejection even if he or she takes these medications as directed.
The first rejection episode usually occurs between one and two weeks after the transplant. As time goes on, the chance of rejection decreases, but it can occur at any time following transplantation.
Signs & Symptoms of Rejection
- Elevation of liver enzymes
- Fever greater than 100.4 degrees F (38 degrees C)
- Clay-colored stools
- Yellow eyes
- Tea-colored urine
- Feeling ill
If any of the above symptoms occur, you should notify your transplant team immediately.
Potential Causes of Decreased Prograf or Cyclosporine Absorption
- Missing doses of immunosuppression
- Switching to generic immunosuppression
- Taking a medication that interacts with the immunosuppression
- Taking too little immunosuppression
With infection or rejection early detection and treatment is key. This is why it is vital to monitor labs frequently and ensure your child is receiving the right dose of immunosuppression and their liver enzymes are stable.
Work Up for Rejection
If your child's liver function tests are elevated, further testing will be done to confirm a rejection diagnosis. These tests include an abdominal ultrasound to ensure there is not a problem with the bile ducts and/or blood flow to the liver, blood tests to check for viruses and a liver biopsy.
Liver Biopsy and Treatment
The liver biopsy is the only way to diagnose rejection. Your child will likely be admitted to the hospital the night before to prep them for the biopsy. They will not be able to eat anything by mouth after midnight and will receive IV fluids for hydration. They will go to either the Operating- Minor Procedure Room or the Interventional Radiology Suite where they will be under anesthesia and a small needle will penetrate the skin over their liver in order to take a biopsy from the liver. After the biopsy they will recover, and be asked to lay on their right side to place pressure at the site. Labs will be drawn four hours after the biopsy to check for bleeding. Most patients will have little or no pain and a band aid will cover the site. A pathologist will examine the biopsy under a microscope and make a diagnosis of rejection depending on the amount of inflammation and damage present. This will direct the transplant provider to what treatment, if any, should be given.
The most common treatment for a rejection is high doses of intravenous steroids, which may be administered for one to two weeks in the hospital. Your child’s liver enzymes will be drawn daily to ensure the treatment is effective and their blood glucose and blood pressure will also be monitored closely.
If the liver enzymes are not improving it may be necessary to repeat a liver biopsy. Should intravenous steroids be ineffective there, are stronger medications available.