Monitoring the grafted liver

Survival of the patient is dependent on normal function of the graft. Good clinical prognostic features include evidence of normal cerebral function, the production of bile from the T-tube, normal to high blood sugars, the need for intravenous potassium supplements, and a normalizing prothrombin time. Progressive organ system dysfunction in the absence of another cause indicates graft failure.

Biochemical liver function tests are useful for evaluating graft function. A small early rise in transaminases (serum alanine aminotransferase and aspartate aminotransferase) during the first 24 h post-transplant represents mild injury during organ procurement, storage, and reperfusion. Substantial increases which continue to rise indicate graft ischemic injury, which may be severe and should prompt ultrasound examination of vascular patency and maximization of cardiac output to ensure adequate splanchnic oxygen supply. Alkaline phosphatase and g-glutamyl transferase are indicators of cholestatic injury. Management is focused on avoiding further injury to the liver graft during the period of recovery by ensuring adequate hemoglobin, circulating volume, and perfusion pressures. A later rise in bilirubin is an indicator of graft rejection.

Duplex ultrasonography is a safe and routine investigation, but must be performed by an experienced radiologist. Absent flow in an otherwise stable patient who is progressing well suggests that there are problems with the investigation, not the patient. Angiography or biopsy may be required for cases that are difficult to interpret. Bile cultures should be performed routinely. Cholangiography should be performed to evaluate the common duct if bile flow is inadequate.

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