A Recovery Guide After a Liver Transplant

As a transplant recipient recovering from both liver transplantation and liver cancer, you are embarking on a long road of recovery. Following discharge, you will require frequent follow-ups to monitor your recovery. These follow-ups typically include:

• Blood tests: To monitor liver function and medication levels
• Wound care: To care for the surgical incision to prevent infection
• Blood pressure and pulse checks: To detect early signs of complications
• Monitoring for complications: To help patients recognize signs of infection or organ rejection or side effects from immunosuppression regimens.

This article will guide you through the common complications, essential post-transplant care and the lifestyle adjustments necessary to ensure the best possible outcomes.

Liver cancer patients may experience various complications at different stages after a liver transplant.

Liver rejection

Despite immunosuppressive therapy, liver rejection may still occur, especially in the early months after transplantation. Most of the acute liver rejection occurs in the first few months post-transplant, with a declining risk further out from transplant. Rejection is often detected through elevated liver enzymes in blood tests and confirmed with a liver biopsy. Acute rejection is often managed by adjusting the immunosuppressant dosage. Though rare, chronic rejection is more difficult to treat and usually starts late, ranging from months to years after transplantation.

Infections

While preventing organ rejection, immunosuppressants also weaken the immune system, making transplant recipients more vulnerable to infections. Even mild infections can pose a serious threat to individuals with weakened immunity. The risk of infection is highest during the first six months after transplantation.

Infections may occur for several reasons, including:

• Disease transmission from the donor, despite the routine screening of transplant donors and the use of antimicrobials.
• Surgical factors, such as contamination during or after the operation.
• Reactivation of pre-existing viral infections, such as hepatitis B and C.
• Opportunistic infections that take advantage of the weakened immune system.

Cancer development

A weakened immune system leads to a reduced ability to detect and eliminate cancer cells. Immunosuppressive therapy increases the risk of certain cancers, particularly skin cancer and lymphoma. Additionally, patients who are immunosuppressed may have elevated risk of developing other cancers related to their preexisting risk factors. For example, those who smoke are at higher risk of lung cancer, and patients with inflammatory bowel disease are more prone to colorectal cancer. In the context of liver cancer, about 20% of liver transplant patients may develop a second liver cancer, most commonly within the first three years after the transplant.

Other long-term complications

Post-transplant patients may develop the following conditions:

• Hypertension: High blood pressure is common due to the side effects of medication.
• High blood sugar and diabetes: Immunosuppressants may increase the risk of developing diabetes mellitus (type 2 diabetes).
• Kidney disease: Kidney function can deteriorate, particularly if pre-existing liver-related kidney issues were present before the transplant.

Liver transplant patients, particularly those with a history of liver cancer, must adhere to strict post-transplant management to avoid complications:

• Adopt a healthy diet and engage in regular exercise to reduce complications such as high blood pressure or diabetes. Doctors may advise special diets such as smaller meals with low sugar.
• Strictly adhere to the medication regimen prescribed by the doctor. Take the correct dosage of immunosuppressants and other medications exactly as prescribed. Never skip doses. Even minor lapses can increase the risk of organ rejection.
• Follow vaccination schedules closely and take extra precautions to avoid exposure to infections.
• Monitor the following signs for liver rejection and infections. Report any of the following to your care team:
  • A fever* over 100°F (38°C)
  • Yellowing of the eyes or skin (jaundice)
  • Swelling (in the legs, ankles or abdomen)
  • Diarrhoea or vomiting
  • Unexplained fatigue

*An aggressive evaluation is necessary to determine the cause of fever. Depending on the results, the dosage of immunosuppressants may be adjusted or temporarily stopped.

Most liver transplant recipients can resume work within one to two months and gradually return to all normal activities within six to 12 months. The National Comprehensive Cancer Network (NCCN) Guidelines recommends the following surveillance tests for liver cancer patients after transplantation:

• Imaging tests (either one of the following):
  • Contrast-enhanced computed tomography (CT) scan or
  • Magnetic resonance imaging (MRI)
• Alpha-fetoprotein (AFP) tumor marker test

The recommended surveillance schedule is:

• Every three to six months in the first two years
• Every six months in the following five years

Depending on the technique used, the surgical scar may look like a hockey stick, a Mercedes-Benz logo or a V shape. Some scars fade over time, while others remain more visible.

The number of follow-up tests and potential complications after a liver transplant can be overwhelming, especially for liver cancer patients. While it’s natural to have concerns, focusing on your health and following post-transplant guidelines can help you navigate your survivorship journey with optimism. And remember, your medical team will always be there to support and guide you each step of the way.