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Transplant Q&AQuestion: Our 14-year-old daughter received her new liver earlier this year. She hasn’t had any rejection episodes yet, but I know it is common and I worry constantly about it. What exactly are the signs and symptoms of rejection?Answer: Here is a list of signs and symptoms that may indicate liver graft rejection: Fever greater than 100° None of these symptoms are specific for rejection; but they are important enough that when they occur, they should prompt a call to your transplant center. Most centers have transplant nurse specialists who take such calls and decide whether the situation warrants further investigation or should be observed for the time being. It is very important to realize that rejection of transplanted organs is quite variable. Some patients will feel perfectly well, only to discover that their graft is being attacked by their immune system. In fact, it is more likely than not that there will be minimal or no symptoms of rejection. Since rejection may have no symptoms at all, the standard strategy for post-transplant care is to regularly run blood tests that may be early indicators of liver graft rejection. In the beginning, these tests are run daily. For the first month or so after a liver transplant the tests are run at least weekly. Gradually the interval between measurement is increased as the months and years pass. The common blood tests include bilirubin, AST (also called SGOT), ALT (also called SGPT), GGT, alkaline phosphatase, and LDH. These lab tests are often grouped together and called "liver function tests" or "LFT’s." In truth, LFT’s are not measures of liver function per se, but are indicators of liver "well being." The tests are not perfect, however. LFT’s can be extremely abnormal despite the fact that the liver is perfectly fine. They can also read normal even though the liver is barely working! Interpretation of these tests, therefore, requires some expertise in liver transplantation as well as detailed knowledge of the patient’s previous laboratory studies and medical history. When rejection is suspected it can be confirmed by a liver biopsy. In some instances a biopsy is not needed because rejection is strongly suspected. In other situations, a biopsy is critical. The chief problem that must be differentiated from rejection is infection. Since the treatment of rejection (increased immunosuppression) can make an infection worse, it may be important to confirm the diagnosis of rejection with a biopsy prior to proceeding with treatment. Another important thing to know is that most rejection happens in the first year after a transplant. This is particularly true in the case of liver transplant rejection. In fact, most liver graft rejection happens in the first three months after the transplant. As long as the immunosuppression drugs are continued and taken properly, the risk of rejection of the liver is very low after the first year. Dr. Punch is a transplant surgeon at the University of Michigan and member of the C.L.A.S.S. Scientific Advisory Committee.
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Children’s Liver Association for Support Services
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