Prolonged delayed graft function in an orthotopic liver transplantation recipient: a case report

Abstract

Background: Patients undergoing orthotopic liver transplantation (OLT) can be a considerably complex population to manage post-operatively, as there are several potential complications that can arise during this period, with etiologies ranging from vascular, biliary, immune-mediated, infectious, or other causes. Any of these complications can be responsible for early graft dysfunction or delayed graft function (DGF). In each of these scenarios, the patient must be worked up in a timely manner, in order for the transplant surgeon to determine feasibility to manage the aforementioned complications conservatively, versus returning to the operating room, or even considering relisting the patient for a new organ. Methods: This is a single center, retrospective chart review of a single patient at Hahnemann University Hospital status post OLT demonstrating significantly prolonged DGF over the course of approximately four months. The data was abstracted retrospectively from the inpatient electronic medical record system, CERNER, to include sociodemographic, clinical, and management information. The primary objective of this case report is to describe the clinical and laboratory changes observed in this patient starting from post-operative day one, until normal graft function was achieved, while focusing on the non-surgical interventions performed during this time period. Results: A 56 year old male with a history of end-stage liver disease due to nonalchololic steatohepatitis with cirrhosis underwent OLT, with allograft obtained through donation after cadiac death and with biopsy proven 5 - 10% microsteatosis with no macrosteatosis, and positive hepatitis B virus and CMV serology. His post-operative course was complicated by persistent C. difficile diarrhea treated with antibiotics and eventual fecal transplantation, and multiple bile leaks originally found at the level of the donor cystic duct remnant, and later at the native cystic stump and at the anastomosis. This was reflected in laboratory results as a persistent cholestatic pattern with total bilirubin levels peaking at about 45 mg/dL with direct bilirubin fraction at about 30 mg/dL over one month after OLT. Biopsy of the allograft showed no signs of acute rejection and imaging consistent with normal vasculature and blood flow. This was managed over the course of the first four months post OLT with up to four ERCP procedures with biliary stents placement, and two visits to interventional radiology for percutaneous biliary drain placement due to hepatic collection and bacteremia. Cholestatic laboratory markers started to slowly decrease around week five after OLT, at which point the patient was deemed ready to be discharged to a local rehabilitation center, and finally they were normalized around the four-month mark. No other surgical interventions were performed during this period of time. Conclusion: Post-operative OLT patients are a complex demographic to manage clinically due to a wide array of potential complications, which can manifest either as early graft dysfunction or DGF. During these complications, there is always a question of whether the patient will need a surgical intervention or if a more conservative approach can be used to overcome said complications. This case report highlights how despite initial graft dysfunction post transplantation, demonstrated by abnormal liver function markers, a new graft can potentially achieve normal function even after prolonged periods of time via medical management and non-surgical interventions. This is clinically significant, as this approach could potentially save this fragile population an unnecessary surgical intervention, and/or prevent relisting. Further research is needed investigating this topic.