Liver Transplantation

Immunosuppression and Rejection

Your immune system is important in protecting your body from infection and cancer. T-cells from your immune system are always circulating in the blood and identifying foreign tissue, such as a newly transplanted organ. Human Lymphocyte Antigens (HLA) are molecules that provide a unique signature on all your cells, telling the T-cells that the cells in your body are your own. When you receive an organ transplant, the T-cells of the immune system in your body will notice that the transplanted organ does not have the same HLA antigens as the rest of your body. The T-cells and other cells of your immune system will then try to destroy the transplanted organ

What is Rejection?

Your body's immune system is designed to seek and destroy any foreign object that it finds in your body, such as a cold or flu virus, or a transplanted organ. The process of destroying the transplanted organ, is called rejection. Rejection occurs as your body's immune system responds to the presence of the transplanted liver. However, in transplant recipients, this immune response needs to be suppressed to protect the transplanted liver from rejection.

There are several types of liver rejection. These types are described by the kind of cells causing the rejection, when the rejection occurs, and by the severity of the rejection.

• Acute Cellular Rejection: This the most common form of rejection. In this type of rejection, the body's blood cells identify the liver as foreign and begin mounting an army of cells to attack the liver. Although acute rejection can happen at any time, it is more common within the first three months after transplant. Acute rejection can be treated. Having acute rejection does not mean that you will lose your transplanted liver, but it is extremely important that rejection is diagnosed and treated as soon as possible. To help detect rejection, you should have your blood tests completed routinely as requested by your transplant center, have routine follow-up visits with your doctor, and report any symptoms you are having to your transplant center.
• Chronic Rejection: This form occurs if the rejection process does not completely resolve, or if it continues slowly over time. Chronic rejection is more difficult to treat because of more permanent changes in the liver tissue and eventually will lose all function.

How Do I Know I am Rejecting My Liver?

Measuring the liver function tests regularly and watching the pattern of the results can help your doctor decide what is happening to your liver. If your blood test results are out of the normal range, your transplant physician or transplant coordinator will discuss the results with you. Some abnormal lab values may be acceptable as you recover from transplant or a related complication and should improve over time.

What are the Symptoms of Rejection?

After you leave the hospital, your blood tests will be monitored less frequently. If rejection occurs, you may experience some mild symptoms, although some patients may continue to feel fine for a while. The most common early symptoms include a fever greater than 100° F or 38° C, increased liver function tests, yellowing of the eyes or skin, and fatigue.

Additionally, your doctor may want you to have a liver biopsy to confirm that your symptoms are caused by rejection.

What is a Liver Biopsy?

Although your symptoms and liver-function test results help diagnose rejection, a liver biopsy confirms the liver is being rejected. A small piece of liver tissue is examined under a microscope for signs of rejection. The biopsy procedure is usually done as an outpatient or short-stay hospital procedure.

To prepare for the biopsy, the area where your liver was placed will be cleaned with an antiseptic solution. You will be given an injection of a local anesthetic into the area where the biopsy will be done. An ultrasound is usually done to determine the best place to insert the biopsy needle. After the area is numb, the doctor will advance a special needle into the liver to take out a small piece of tissue. It may look like a short piece of string. The actual biopsy only takes a few seconds. The tissue is placed into a special solution and taken to the pathology lab to be processed and viewed under the microscope.

Following a liver biopsy, you will be required to rest in bed for 2 to 4 hours. Your nurse will monitor you for complications related to the biopsy through your vital signs, physical assessment, blood tests, and/or any physical complaints. Most patients feel fine after a liver biopsy.

To decrease the risk of rejection and to monitor symptoms of rejection, patients should:

• Know and understand the signs and symptoms of liver rejection.
• Take all medications as prescribed.
• Make sure to always have a supply of your medications.
• Stay in regular contact with the transplant coordinator or transplant team for any changes in immunosuppression.
• Have blood testing done as instructed.
• Follow up on blood test results with the transplant coordinator.
• Call the transplant coordinator or physician if you think you are experiencing any symptoms of rejection.
• Avoid excessive alcohol, recreational/illegal drugs, and any herbal remedies or supplements.