Postoperative Care

The aspects and specifics of postoperative care are best delineated according to the particular postoperative period. These periods include: i) the immediate postoperative, ii) early postoperative inpatient, iii) early outpatient, and iv) long-term outpatient periods.

i) Immediate Postoperative Inpatient Care

The bulk of the specifics of the immediate postoperative care are discussed above. The immediate postoperative period is defined by the postoperative intensive care unit stay. However, since immunosuppression is usually instituted in this period, a discussion of immunosuppression as it applies to liver transplantation follows.

Immunosuppression

Induction therapy, traditionally in the form of anti-lymphocyte preparations (MALG, ATG, OKT3), have for the most part, not been widely used in liver transplantation. More recently, a resurgence of interest in induction therapy has resulted from the introduction of humanized IL-2 receptor antibodies (Zenapax and Simulect). The role of these and other newer induction agents in liver transplantation remain to be elucidated.

Baseline immunosuppression is instituted in the immediate postoperative period and typically consists of a calcineurin inhibitor (either Neoral (cyclosporine) or Prograf (tacrolimus)) and steroids. There are very few indications for intravenous administration of calcineurin inhibitors. Steroids are administered initially as intravenous Solu-Medrol and, once the patient is tolerating oral intake with sips of fluids, prednisone is used. Some centers advocate the use of a third agent, historically Imuran (azathioprine). Cellcept (mycophenolate mofetil) which has largely replaced Imuran in kidney and kidney/pancreas transplantation is being used increasingly either as a third agent or in an attempt to obviate the use of steroids, and in some patients the use of calcineurin inhibitors. The role of Cellcept in baseline immunosuppression for liver transplantation remains to be better defined. Rapamycin is presently being evaluated as an additional agent for baseline immunosuppression.

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