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not typically used in the immediate postoperative period given its potential
impact on wound healing. There are case reports of serious complications with
sirolimus as a primary agent in liver (e.g., HAT) and lung (e.g., bronchial
anastomotic breakdown) transplant recipients. Sirolimus is effective for long-term
maintenance and adjunct therapy because it spares the renal system. It is useful as
an antiproliferative agent and may arrest the progression of post heart transplant
graft coronary artery disease. Some studies have suggested a role of sirolimus for
the treatment of de novo autoimmune hepatitis in the transplanted allograft.
Common adverse effects include mouth ulcers, hyperlipidemia, abdominal pain,
marrow suppression, and hypercholesterolemia.

OTHER EMERGENCIES
CLINICAL PEARLS AND PITFALLS
Biliary complications occur in approximately 10% of pediatric liver
transplant recipients and include biliary leaks (early) and biliary
strictures (late).
Recurrence of primary disease can occur in liver or renal transplant
recipients.

BILIARY COMPLICATIONS
Early biliary complications occur in roughly 10% of transplant recipients. The
type of allograft and biliary anastomosis and the status of the hepatic artery
determine the spectrum of complications. Biliary leaks are an early complication
and are more common in recipients of split livers and reduced allografts with
multiple bile duct anastomoses. Later complications typically include biliary
stricture that can lead to biliary sludge formation and recurrent cholangitis.
Biliary strictures can occur in isolation or multiple. Isolated biliary strictures
usually occur at the biliary anastomosis and are more commonly seen with a ductto-duct anastomosis (choledochocholedochostomy). Graft ischemia can lead to
ischemic biliary strictures that may affect all areas of the biliary tree.
Biliary strictures may present with jaundice and pruritus. Early laboratory
findings include elevated bilirubin, GGT, or alkaline phosphatase, often in the

setting of normal or mildly elevated transaminases. Suspicion for biliary
complications should prompt imaging via ultrasound with Doppler to assess for
biliary leaks and hepatic vascular flow. Additional imaging with CT or MRI may


be indicated. Management of biliary strictures may require cholangiography for
placement of a stent to decompress the biliary tree.

RECURRENCE OF PRIMARY DISEASE
The risk of recurrent primary disease is prominent in liver and renal transplant
recipients. Most notable liver diseases with risk of recurrence include
autoimmune hepatitis and bile salt excretory pump (BSEP) disease. For patients
transplanted for autoimmune hepatitis, elevation of transaminases should also
prompt screening for autoimmune hepatitis antibodies including anti-smooth
muscle antibody, anti–liver-kidney microsomal antibody, and antinuclear
antibody. Following transplantation for BSEP, recurrent cholestasis associated
with immunoglobulin G antibodies can develop. Management with rituximab, a
monoclonal anti-CD20 antibody, in combination with intravenous
immunoglobulin and plasmapheresis has been used, but retransplantation may be
indicated in some cases.
The risk of recurrence of primary disease in renal transplant patients depends
on the primary disease. Diseases that commonly recur are membranoproliferative
glomerulonephritis, IgA nephropathy, and focal segmental glomerulosclerosis.
Graft loss due to recurrent glomerulonephritis is the third most common cause of
graft failure, yet the impact of recurrence greatly varies according to the primary
disease.

ACKNOWLEDGMENT
The authors of this chapter acknowledge Anne Bernis, RPh, for her contributions
to Table 125.1 , interactions between transplant immunosuppressents and other

commonly used medications.
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