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Liver Transplant Complications
Sara M. O'Hara, MD, FAAP; Michael R. Aquino, MD, MHSc
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KEY FACTS

  • Terminology

    • Clinical Issues

      TERMINOLOGY

      • Synonyms

        • Segmental liver transplant = partial liver transplant, split liver transplant, reduced-size liver transplant, living donor liver transplant
      • Definitions

        • Segmental liver transplant
          • In children, left hepatic lobe or lateral segment of left lobe is usually transplanted
            • Technique was developed to ↑ supply of liver transplants for children
          • Usually adult donor, cadaveric or living
          • Combined with small bowel or kidney transplant in select cases
        • Vascular complications
          • Hepatic artery (HA): Vasospasm (immediate postoperative timeframe), HA thrombosis (HAT) or stenosis, pseudoaneurysm
          • Portal vein stenosis (PVS) & thrombosis
          • Hepatic vein stenosis (HVS)
          • Anastomotic bleeding
        • Biliary complications
          • Anastomotic: Biliary stenosis or leak
          • Nonanastomotic: Intrahepatic biliary stenosis → dilation, biloma, intraductal sludge or stone
        • Other complications
          • Extrahepatic collections: Hematoma, seroma, abscess
          • Posttransplant lymphoproliferative disorder (PTLD)
          • Infection: Abscess (hematologic spread), cholangitis (ascending route)
          • Organ rejection
          • Acute kidney injury
            • Most often mild, associated with higher INR suggesting relationship to severity of liver synthesis compromise
          • Diaphragmatic hernia post transplant

      IMAGING

      • Ultrasonographic Findings

        • CT Findings

          • MR Findings

            • Angiographic Findings

              • Nonvascular Interventions

                • Imaging Recommendations

                  PATHOLOGY

                  • General Features

                    CLINICAL ISSUES

                    • Presentation

                      • Demographics

                        • Treatment

                          Selected References

                          1. Franke D et al: Contrast-enhanced ultrasound of transplant organs - liver and kidney - in children. Pediatr Radiol. ePub, 2021
                          2. Lee AY et al: Non-operative management of biliary complications after liver transplantation in pediatric patients: a 30-year experience. Pediatr Transplant. e14028, 2021
                          3. Lim CJ et al: Clinical usefulness of T1-weighted MR cholangiography with Gd-EOB-DTPA for the evaluation of biliary complication after liver transplantation. Ann Hepatobiliary Pancreat Surg. 25(1):39-45, 2021
                          4. Namgoong JM et al: Outflow vein venoplasty of left lateral section graft for living donor liver transplantation in infant recipients. Pediatr Transplant. e13970, 2021
                          5. Uchida H et al: Impact of prolonged clamping of the portal vein during liver transplantation in infants with biliary atresia: renewed interest in a long-standing issue. Surg Today. 51(8):1292-9, 2021
                          6. Channaoui A et al: Management and outcome of hepatic artery thrombosis after pediatric liver transplantation. Pediatr Transplant. e13938, 2020
                          7. Elisofon SA et al: Society of pediatric liver transplantation: current registry status 2011-2018. Pediatr Transplant. 24(1):e13605, 2020
                          8. Gautier S et al: Time is of the essence: a single-center experience of hepatic arterial supply impairment management in pediatric liver transplant recipients. Pediatr Transplant. e13934, 2020
                          9. Karmazyn B et al: Initial experience with contrast-enhanced ultrasound in the first week after liver transplantation in children: a useful adjunct to Doppler ultrasound. Pediatr Radiol. 51(2):248-56, 2020
                          10. Kilic M et al: Bilioenteric reconstruction techniques in pediatric living donor liver transplantation. Liver Transpl. 27(2):257-63, 2020
                          11. Lin AN et al: Management of biliary stricture in pediatric living donor liver transplantation recipients. Transplant Proc. 52(6):1844-8, 2020
                          12. Na L et al: Clinical study of argatroban for preventing vascular thrombosis in the early period after pediatric living-related donor liver transplantation. Pediatr Transplant. 24(2):e13654, 2020
                          13. Phichaphop C et al: High prevalence of multidrug-resistant gram-negative bacterial infection following pediatric liver transplantation. Medicine (Baltimore). 99(45):e23169, 2020
                          14. Silver LJ et al: Acute kidney injury following pediatric liver transplant. J Intensive Care Med. 885066620978729, 2020
                          15. Taylor SA et al: Improved outcomes for liver transplantation in patients with biliary atresia since pediatric end-stage liver disease implementation: analysis of the Society of Pediatric Liver Transplantation Registry. J Pediatr. 219:89-97, 2020
                          16. Waldron LS et al: Diaphragmatic hernia following pediatric liver transplantation: an underappreciated complication prone to recur. Eur J Pediatr Surg. 31(5):396-406, 2020
                          17. Werner MJM et al: Routine postoperative antithrombotic therapy in pediatric liver transplantation: impact on bleeding and thrombotic complications. Thromb Haemost. 120(4):627-37, 2020
                          18. Yin C et al: Risk factors for portal vein stenosis in pediatric liver transplantation. Clin Transplant. 34(8):e13992, 2020
                          19. Ahmad T et al: Doppler parameters of the hepatic artery as predictors of graft status in pediatric liver transplantation. AJR Am J Roentgenol. 209(3):671-5, 2017
                          20. De Luca M et al: Invasive candidiasis in liver transplant patients: incidence and risk factors in a pediatric cohort. Pediatr Transplant. 20(2):235-40, 2016
                          21. Foster BJ et al: High risk of liver allograft failure during late adolescence and young adulthood. Transplantation. 100(3):577-84, 2016
                          22. Kerkar N et al: Pediatric liver transplantation: a North American perspective. Expert Rev Gastroenterol Hepatol. 1-11, 2016
                          23. Lee KW et al: Outcome of partial reconstruction of multiple hepatic arteries in pediatric living donor liver transplantation using left liver grafts. Transpl Int. 29(8):890-6, 2016
                          24. Neto JS et al: Alternatives for vascular reconstruction in pediatric living donor liver transplantation. Pediatr Transplant. 20(5):717-22, 2016
                          25. Ranawaka R et al: Combined liver and kidney transplantation in children: analysis of renal graft outcome. Pediatr Nephrol. 31(9):1539-43, 2016
                          26. Sang AX et al: EBV-associated lymphoepithelial carcinoma after pediatric liver transplant. Liver Transpl. 22(6):849-53, 2016
                          27. Seda-Neto J et al: Twenty years of experience in pediatric living donor liver transplantation: focus on hepatic artery reconstruction, complications, and outcomes. Transplantation. 100(5):1066-72, 2016
                          28. Stanescu AL et al: Pediatric abdominal organ transplantation: current indications, techniques, and imaging findings. Radiol Clin North Am. 54(2):281-302, 2016
                          29. Stine JG et al: Pre-transplant portal vein thrombosis is an independent risk factor for graft loss due to hepatic artery thrombosis in liver transplant recipients. HPB (Oxford). 18(3):279-86, 2016
                          30. Choi JW et al: Long-term outcome of endovascular intervention in hepatic venous outflow obstruction following pediatric liver transplantation. Liver Transpl. 21(9):1219-26, 2015
                          31. Crowley JJ et al: Retained surgical stents as a cause of biliary obstruction in pediatric liver transplants. Pediatr Radiol. 45(3):430-4, 2015
                          32. Feier FH et al: Biliary complications after pediatric liver transplantation: risk factors, diagnosis and management. World J Hepatol. 7(18):2162-70, 2015
                          33. Kamran Hejazi Kenari S et al: Current state of the art in management of vascular complications after pediatric liver transplantation. Pediatr Transplant. 19(1):18-26, 2015
                          34. Laurence JM et al: Biliary complications in pediatric liver transplantation: incidence and management over a decade. Liver Transpl. 21(8):1082-90, 2015
                          35. Tannuri U et al: Technique advance to avoid hepatic venous outflow obstruction in pediatric living-donor liver transplantation. Pediatr Transplant. 19(3):261-6, 2015
                          36. Teplisky D et al: Ultrasonography, laboratory, and cholangiography correlation of biliary complications in pediatric liver transplantation. Pediatr Transplant. 19(2):170-4, 2015
                          37. Jamieson LH et al: Doppler ultrasound velocities and resistive indexes immediately after pediatric liver transplantation: normal ranges and predictors of failure. AJR Am J Roentgenol. 203(1):W110-6, 2014
                          38. Lüthold SC et al: Risk factors for early and late biliary complications in pediatric liver transplantation. Pediatr Transplant. 18(8):822-30, 2014
                          39. Shaheen MF et al: Outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in below 15-kg pediatric liver transplant recipients. Pediatr Transplant. 18(8):831-8, 2014
                          40. Tannuri AC et al: A new simplified technique of arterial reconstruction in pediatric living-donor liver transplantation: a comparison with the classical technique. J Pediatr Surg. 49(10):1518-21, 2014
                          41. Yabuta M et al: Long-term outcome of percutaneous transhepatic balloon angioplasty for portal vein stenosis after pediatric living donor liver transplantation: a single institute's experience. J Vasc Interv Radiol. 25(9):1406-12, 2014
                          42. Moon SB et al: Graft rotation and late portal vein complications in pediatric living donor liver transplantation using left-sided grafts: Long-term computed tomography observations. Liver Transpl. 17(6):717-22, 2011
                          43. Babyn PS: Imaging of the transplant liver. Pediatr Radiol. 40(4):442-6, 2010
                          Related Anatomy
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                          Related Differential Diagnoses
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                          References
                          Tables

                          Tables

                          KEY FACTS

                          • Terminology

                            • Clinical Issues

                              TERMINOLOGY

                              • Synonyms

                                • Segmental liver transplant = partial liver transplant, split liver transplant, reduced-size liver transplant, living donor liver transplant
                              • Definitions

                                • Segmental liver transplant
                                  • In children, left hepatic lobe or lateral segment of left lobe is usually transplanted
                                    • Technique was developed to ↑ supply of liver transplants for children
                                  • Usually adult donor, cadaveric or living
                                  • Combined with small bowel or kidney transplant in select cases
                                • Vascular complications
                                  • Hepatic artery (HA): Vasospasm (immediate postoperative timeframe), HA thrombosis (HAT) or stenosis, pseudoaneurysm
                                  • Portal vein stenosis (PVS) & thrombosis
                                  • Hepatic vein stenosis (HVS)
                                  • Anastomotic bleeding
                                • Biliary complications
                                  • Anastomotic: Biliary stenosis or leak
                                  • Nonanastomotic: Intrahepatic biliary stenosis → dilation, biloma, intraductal sludge or stone
                                • Other complications
                                  • Extrahepatic collections: Hematoma, seroma, abscess
                                  • Posttransplant lymphoproliferative disorder (PTLD)
                                  • Infection: Abscess (hematologic spread), cholangitis (ascending route)
                                  • Organ rejection
                                  • Acute kidney injury
                                    • Most often mild, associated with higher INR suggesting relationship to severity of liver synthesis compromise
                                  • Diaphragmatic hernia post transplant

                              IMAGING

                              • Ultrasonographic Findings

                                • CT Findings

                                  • MR Findings

                                    • Angiographic Findings

                                      • Nonvascular Interventions

                                        • Imaging Recommendations

                                          PATHOLOGY

                                          • General Features

                                            CLINICAL ISSUES

                                            • Presentation

                                              • Demographics

                                                • Treatment

                                                  Selected References

                                                  1. Franke D et al: Contrast-enhanced ultrasound of transplant organs - liver and kidney - in children. Pediatr Radiol. ePub, 2021
                                                  2. Lee AY et al: Non-operative management of biliary complications after liver transplantation in pediatric patients: a 30-year experience. Pediatr Transplant. e14028, 2021
                                                  3. Lim CJ et al: Clinical usefulness of T1-weighted MR cholangiography with Gd-EOB-DTPA for the evaluation of biliary complication after liver transplantation. Ann Hepatobiliary Pancreat Surg. 25(1):39-45, 2021
                                                  4. Namgoong JM et al: Outflow vein venoplasty of left lateral section graft for living donor liver transplantation in infant recipients. Pediatr Transplant. e13970, 2021
                                                  5. Uchida H et al: Impact of prolonged clamping of the portal vein during liver transplantation in infants with biliary atresia: renewed interest in a long-standing issue. Surg Today. 51(8):1292-9, 2021
                                                  6. Channaoui A et al: Management and outcome of hepatic artery thrombosis after pediatric liver transplantation. Pediatr Transplant. e13938, 2020
                                                  7. Elisofon SA et al: Society of pediatric liver transplantation: current registry status 2011-2018. Pediatr Transplant. 24(1):e13605, 2020
                                                  8. Gautier S et al: Time is of the essence: a single-center experience of hepatic arterial supply impairment management in pediatric liver transplant recipients. Pediatr Transplant. e13934, 2020
                                                  9. Karmazyn B et al: Initial experience with contrast-enhanced ultrasound in the first week after liver transplantation in children: a useful adjunct to Doppler ultrasound. Pediatr Radiol. 51(2):248-56, 2020
                                                  10. Kilic M et al: Bilioenteric reconstruction techniques in pediatric living donor liver transplantation. Liver Transpl. 27(2):257-63, 2020
                                                  11. Lin AN et al: Management of biliary stricture in pediatric living donor liver transplantation recipients. Transplant Proc. 52(6):1844-8, 2020
                                                  12. Na L et al: Clinical study of argatroban for preventing vascular thrombosis in the early period after pediatric living-related donor liver transplantation. Pediatr Transplant. 24(2):e13654, 2020
                                                  13. Phichaphop C et al: High prevalence of multidrug-resistant gram-negative bacterial infection following pediatric liver transplantation. Medicine (Baltimore). 99(45):e23169, 2020
                                                  14. Silver LJ et al: Acute kidney injury following pediatric liver transplant. J Intensive Care Med. 885066620978729, 2020
                                                  15. Taylor SA et al: Improved outcomes for liver transplantation in patients with biliary atresia since pediatric end-stage liver disease implementation: analysis of the Society of Pediatric Liver Transplantation Registry. J Pediatr. 219:89-97, 2020
                                                  16. Waldron LS et al: Diaphragmatic hernia following pediatric liver transplantation: an underappreciated complication prone to recur. Eur J Pediatr Surg. 31(5):396-406, 2020
                                                  17. Werner MJM et al: Routine postoperative antithrombotic therapy in pediatric liver transplantation: impact on bleeding and thrombotic complications. Thromb Haemost. 120(4):627-37, 2020
                                                  18. Yin C et al: Risk factors for portal vein stenosis in pediatric liver transplantation. Clin Transplant. 34(8):e13992, 2020
                                                  19. Ahmad T et al: Doppler parameters of the hepatic artery as predictors of graft status in pediatric liver transplantation. AJR Am J Roentgenol. 209(3):671-5, 2017
                                                  20. De Luca M et al: Invasive candidiasis in liver transplant patients: incidence and risk factors in a pediatric cohort. Pediatr Transplant. 20(2):235-40, 2016
                                                  21. Foster BJ et al: High risk of liver allograft failure during late adolescence and young adulthood. Transplantation. 100(3):577-84, 2016
                                                  22. Kerkar N et al: Pediatric liver transplantation: a North American perspective. Expert Rev Gastroenterol Hepatol. 1-11, 2016
                                                  23. Lee KW et al: Outcome of partial reconstruction of multiple hepatic arteries in pediatric living donor liver transplantation using left liver grafts. Transpl Int. 29(8):890-6, 2016
                                                  24. Neto JS et al: Alternatives for vascular reconstruction in pediatric living donor liver transplantation. Pediatr Transplant. 20(5):717-22, 2016
                                                  25. Ranawaka R et al: Combined liver and kidney transplantation in children: analysis of renal graft outcome. Pediatr Nephrol. 31(9):1539-43, 2016
                                                  26. Sang AX et al: EBV-associated lymphoepithelial carcinoma after pediatric liver transplant. Liver Transpl. 22(6):849-53, 2016
                                                  27. Seda-Neto J et al: Twenty years of experience in pediatric living donor liver transplantation: focus on hepatic artery reconstruction, complications, and outcomes. Transplantation. 100(5):1066-72, 2016
                                                  28. Stanescu AL et al: Pediatric abdominal organ transplantation: current indications, techniques, and imaging findings. Radiol Clin North Am. 54(2):281-302, 2016
                                                  29. Stine JG et al: Pre-transplant portal vein thrombosis is an independent risk factor for graft loss due to hepatic artery thrombosis in liver transplant recipients. HPB (Oxford). 18(3):279-86, 2016
                                                  30. Choi JW et al: Long-term outcome of endovascular intervention in hepatic venous outflow obstruction following pediatric liver transplantation. Liver Transpl. 21(9):1219-26, 2015
                                                  31. Crowley JJ et al: Retained surgical stents as a cause of biliary obstruction in pediatric liver transplants. Pediatr Radiol. 45(3):430-4, 2015
                                                  32. Feier FH et al: Biliary complications after pediatric liver transplantation: risk factors, diagnosis and management. World J Hepatol. 7(18):2162-70, 2015
                                                  33. Kamran Hejazi Kenari S et al: Current state of the art in management of vascular complications after pediatric liver transplantation. Pediatr Transplant. 19(1):18-26, 2015
                                                  34. Laurence JM et al: Biliary complications in pediatric liver transplantation: incidence and management over a decade. Liver Transpl. 21(8):1082-90, 2015
                                                  35. Tannuri U et al: Technique advance to avoid hepatic venous outflow obstruction in pediatric living-donor liver transplantation. Pediatr Transplant. 19(3):261-6, 2015
                                                  36. Teplisky D et al: Ultrasonography, laboratory, and cholangiography correlation of biliary complications in pediatric liver transplantation. Pediatr Transplant. 19(2):170-4, 2015
                                                  37. Jamieson LH et al: Doppler ultrasound velocities and resistive indexes immediately after pediatric liver transplantation: normal ranges and predictors of failure. AJR Am J Roentgenol. 203(1):W110-6, 2014
                                                  38. Lüthold SC et al: Risk factors for early and late biliary complications in pediatric liver transplantation. Pediatr Transplant. 18(8):822-30, 2014
                                                  39. Shaheen MF et al: Outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in below 15-kg pediatric liver transplant recipients. Pediatr Transplant. 18(8):831-8, 2014
                                                  40. Tannuri AC et al: A new simplified technique of arterial reconstruction in pediatric living-donor liver transplantation: a comparison with the classical technique. J Pediatr Surg. 49(10):1518-21, 2014
                                                  41. Yabuta M et al: Long-term outcome of percutaneous transhepatic balloon angioplasty for portal vein stenosis after pediatric living donor liver transplantation: a single institute's experience. J Vasc Interv Radiol. 25(9):1406-12, 2014
                                                  42. Moon SB et al: Graft rotation and late portal vein complications in pediatric living donor liver transplantation using left-sided grafts: Long-term computed tomography observations. Liver Transpl. 17(6):717-22, 2011
                                                  43. Babyn PS: Imaging of the transplant liver. Pediatr Radiol. 40(4):442-6, 2010