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Common infections following liver transplantation include urinary tract, pulmonary, intra-abdominal, central venous catheter, and wound infections. Any fever or leukocytosis needs investigation for possible infection in these systems (Table 9.22).

If a T-tube is used, a T-tube cholangiogram is obtained at approximately the fifth postoperative day and in the absence of leak or obstruction, the T-tube is clamped. Clamping of the T-tube can result in a transient elevation in liver function tests. If the patient develops any abdominal pain following clamping of the T-tube, the house staff should be instructed to unclamp the T-tube and attach it to a drainage bag to gravity immediately. Following this, a repeat cholangiogram or HIDA scan should be obtained to rule out a biliary leak.

iii) Early Outpatient Care

As soon as the patients are tolerating a diet and able to ambulate, they can be discharged to the outpatient setting and followed closely in the outpatient clinic. Typically, blood work is obtained three times weekly and the patients are seen and examined on a weekly basis. A standard protocol for the frequency of laboratory investigations and clinic visits is established (Table 9.23). Clinic visits are used to evaluate the patient and to review their medications to avoid errors.

Any elevation in liver function tests or any lab work abnormality is investigated further. Standard algorithm for elevation in liver function tests includes an ultrasound doppler examination of the liver looking for patency of the hepatic artery, portal vein, and hepatic veins. Also, the ultrasound will detect any dilatation of the biliary tree and any abnormalities within the parenchyma such as liver abscess formation. If the ultrasound is unremarkable, the next step usually consists of a percutaneous liver biopsy to rule out rejection and infection. In the early postoperative period, especially in patients undergoing transplantation for diseases other than chronic viral hepatitis, elevation in liver numbers can be treated empirically with steroid boluses without a need for biopsy. When needed, biopsies can be performed as outpatients and rejection can also be treated in the outpatient setting. In the case of steroid-resistant rejection which must be documented by a liver biopsy, treatment consists of anti-lymphocyte preparations (OKT3, ATG) typically for two weeks. OKT3 can be administered via peripheral vein, but a cytokine release syndrome may be associated with injection of OKT3 and, therefore, the first two to three doses of OKT3 need to be given in the inpatient setting

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