What types of vaccinations should I give to a liver transplant patient?
Because liver transplant recipients are immunocompromised, they should receive no live virus vaccinations, such asMMR and varicella vaccines. Should a post-transplant patient have a varicella exposure, he or she must receive treatment within 96 hours of exposure (preferably 72 hours).
Immunizations children awaiting a liver transplant should receive:
- accelerated immunization schedule as delineated in the Red Book
- If younger than 3, the child should receive monthly Synagis® injections during the RSV season (typically November through April)
- Please contact us at 877-TX4-PEDS prior to giving any live vaccine pre-transplant, as it may require deactivating the child from the transplant list temporarily.
Immunizations that liver transplant recipients should receive:
- full vaccination series for Hepatitis B, DTaP, HIB, IPV, Pneumococcal (recommend conjugate vaccine followed by polysaccharide-23 valent-vaccine to complete the series), Hepatitis A and Meningococcal.
- yearly flu vaccinations (for entire family as well). Neither the patient nor the family members can receive the nasal form of the influenza vaccine.
- If the child is younger than three years, he should receive monthly Synagis® injections during the RSV season (typically November through April)
No vaccine should be administered at the time of presumed rejection episodes with attendant increased immunosuppression.
Are there any nutritional restrictions?
Most liver transplant recipients resume a regular diet within a week of surgery.
What should I know about medication interactions for liver transplant recipients?
Some medications significantly alter the levels of immunosuppressant medications taken by transplant recipients, especially tacrolimus and cyclosporine.
The following medications increase the effective level of tacrolimus:
- antifungal agents such as ketoconazole, fluconazole and itraconazole
- calcium channel blockers.
Drugs which decrease levels include the anti-seizure medications in general and most of the anti-tuberculosis medications.
If you must prescribe any of these medications, please closely monitor the child's tacrolimus trough levels.
It is safe for liver transplant patients to receive acetaminophen and ibuprofen in weight-appropriate doses following the recommended intervals.
Typically, what medications will the child be receiving post liver transplant?
Most children receive basilixumab for induction therapy immediately after transplant while in the hospital.Following induction, medication will likely include:
- tacrolimus (lifetime immunosuppression)
- prednisone (during rejection episodes with tapering schedule off)
- nystatin (to prevent thrush)
- atovaquone (PCP prophylaxis for several years after transplant)
- acyclovir or valganciclovir (to prevent viral transmission for 90 days after transplant and during any rejection episodes)
- a medication to suppress stomach acid, such as a proton pump inhibitor or H-2 blocker
- aspirin (to prevent hepatic artery and portal vein thrombosis for 90 days after transplant).
Some children require supplements of bicarbonate and magnesium due to losses associated with tacrolimus.
Are there any physical restrictions for a child after liver transplant?
Generally, there are no physical restrictions after the transplant. If the child is involved in contact sports, he or she should not participate for six weeks.
For the first six weeks after transplant, we ask the liver transplant patient to stay away from any crowded areas such as malls, grocery stores, school, church, movie theaters (just to name a few).
We ask the family to limit their contacts with sick children and adults.
Patients should always avoid bright sunlight and use sun-protecting lotions.
Should I look for anything in particular when examining a liver transplant patient?
Meticulous general care is extremely important for our liver transplant patients. Being proactive in the search for potential complications is the key.
Because of the risk of post-transplant lymphoproliferative disease (PTLD), careful examination of lymph nodes at each visit is important.
Because of their constant immunosuppressive state and thus risk for melanoma, careful dermatological examination is important.
Renal dysfunction secondary to chronic tacrolimus or cyclosporine use has been a concern in long-term survivors. Therefore, BUN and creatinine levels must be monitored, and patients should have yearly determination of urine protein and creatinine. Nephrotoxic medications should be used sparingly.
When should I contact the Liver Transplant Program at Boston Children's?
For patients waiting for a liver transplant:
We ask you to keep us informed of any changes in medical condition, any admissions to the hospital, any acute or chronic infections and any psychosocial concerns. All of these may affect the patient's listing and will help us identify the best opportunity for successful transplantation.
For liver transplant recipients:
We would like to be notified of any significant illness, jaundice, fever (>100.5 degrees), abdominal pain, lymphadenopathy, and excessive diarrhea/vomiting or compliance issues, hospitalizations or recurrent problems.
Hours: Monday-Friday, 8:30 a.m. to 5p.m.
Phone: 888-CH-LIVER or locally 617-35-LIVER (617-355-4837)
If it is an urgent matter during off-hours or weekends, please page the GI fellow at 617-355-6363. They will contact a member of the Liver Transplant Service.