High Iron Levels – High Liver Enzymes
May 11, 2005 at 7:44 pm #6143
Anyone out there have information regarding post transplant complications? My wife is at day 203 and is doing well except she still has a high level of iron (needs to be bled at times) and the Doctor says her liver enzymes are high. He has her on prograf, steroids and an antibiotic. She was down to 1 prograf and 1 steroid pill per day, but he called today and increased her dosage. She tolerates the prograf well, but she has had some issues with the steroids. I would appreciate any information anyone has on alternatives to the steroids. Thanks!May 12, 2005 at 4:08 pm #6144
Found some info on post transplant liver complications…the good news is mild or moderate damage is usually temporary and completely reversible.
Liver disorders fall into three categories: (1) those that affect the liver cells (2) those that affect the vessels that transport blood through the liver and (3) those affecting the bile ducts that carry bile from the liver to the gallbladder and intestines. A BMT patient may experience more than one liver disorder at the same time. While some are serious and sometimes fatal, the majority result in only mild or moderate liver damage that is temporary and completely reversible.
The existence of liver disorders pre-transplant can increase the risk of developing severe liver disorders post-transplant. Patients are therefore tested before their BMT for evidence of fungal liver infections, hepatitis (inflammation of the liver usually caused by a virus), and gallstones or other obstructions of the bile duct that may need to be removed before the transplant proceeds. These tests also equip physicians with informa- tion that may help prevent serious liver problems from developing post-BMT.
A variety of tests are used before, during and after the transplant to determine whether a liver disease is present and whether the disease affects the liver cells, blood vessels, or bile ducts. These tests include a physical examination of the patient to determine the size of the liver, blood tests that measure the level in the bloodstream of bilirubin and proteins produced by the liver, “imaging tests such as ultrasound and CT X-rays (“CAT scans”) that provide a picture of the liver, its blood vessels and bile ducts, and liver biopsy.
While in the hospital, daily measurements of a patient’s abdominal girth, weight, and blood levels of bilirubin and other liver enzymes aid in the early detection of liver problems. Daily examination of the patient for signs of jaundice or swelling also helps the medical staff detect liver problems.
SIGNS OF LIVER PROBLEMS
Jaundice (yellowing of skin and eyes)
Tender or swollen liver
Rapid weight gain Swelling in arms or legs
Fluid accumulation in abdominal cavity
High levels of bilirubin in the blood
High levels of liver enzymes in the blood (SGOT, SGPT and alkaline phosphatase)
DURING THE FIRST THREE MONTHS AFTER A BMT
VENO-OCCLUSIVE DISEASE (VOD)
Veno-occlusive disease is a potentially serious liver problem caused by the high dose of chemotherapy and/or radiation given to patients before the transplant. In patients with VOD, the blood vessels that carry blood through the liver become swollen and obstructed. This impairs the liver’s ability to remove toxins, drugs and other waste products from the bloodstream. Pressure and fluids build up in the liver, causing swelling and tenderness of the liver. The kidneys may retain excess water and salt, causing fluid to build up in the body and swelling of the legs, arms and abdomen to occur.
In severe cases of VOD, build up of fluid that has leaked into the abdominal cavity may also put pressure on the lungs and impair breathing. Toxins that are not processed out of the blood by the liver may affect how the brain functions and confusion may result (although confusion is a symptom of other, less serious post-BMT problems as well). The kidneys, heart and lungs may also fail.
Symptoms of VOD are usually first seen one to four weeks after the start of the “conditioning” or “preparative” regimen-the chemotherapy and/or radiation administered to patients immediately before the transplant. VOD can be difficult to diagnose, however, since its symp toms are signs of other liver disorders as well. The symptoms include jaundice, an enlarged liver, pain or tenderness in the area of the liver (located on the right side of the body under the lower rib cage), rapid weight gain, swelling (edema), and accumulation of fluid in the abdominal cavity (ascites). If an enlarged liver AND sudden weight gain AND jaundice occur early after transplant and cannot be explained by other causes, VOD probably exists.
There currently is no proven preventive therapy for VOD. When VOD is diagnosed, the medical team will take steps to prevent the more serious complications from developing. These include minimizing or eliminating the use of certain drugs that can worsen the problem, relieving the buildup of fluids in tissues and organs with diuretics or dialysis restricting the intake of salt, carefully monitoring the volume of fluids in the body, and transfusing the patient with packed red blood cells to keep the circulating blood volume high until VOD has run its course.
Patients with malignant diseases such as leukemia, lymphomas and solid tumors are more likely to develop severe veno-occlusive disease post-transplant than patients with non-malignant disorders such as aplastic anemia or an immune deficiency disease. This is because the conditioning regimen for these patients usually involves stronger doses of chemotherapy and/or radiation than those administered to patients with non-malignant disorders. While the stronger doses of chemothera- py and/or radiation increase the likelihood that cancerous cells will be destroyed, they are also much more toxic to the liver.
Other factors that increase the risk of developing severe VOD include pre-transplant hepatitis, the presence of a fever resulting from an infection anywhere in the body immediately before or during the course of the preparative regimen, and use of mis-matched or unrelated donor marrow. Patients undergoing a second transplant also may be at higher risk of developing VOD than others.
In most cases, VOD is mild or moderate, and the liver damage is completely reversible. Severe VOD, however, is usually fatal.
Acute GVHD of the liver
Patients undergoing allogeneic BMTs are at risk of developing liver damage from acute graft-versus-host disease. In GVHD, the bone marrow provided by a donor (the graft) attacks the tissues and organs of the BMT patient (the host).
Acute GVHD occurs during the first three months post-transplant. Chronic GVHD, a separate disease, occurs after the third month post-transplant Acute GVHD of the liver affects small bile ducts, interfering with the flow of bile out of the liver. Bile duct damage may be mild, moderate or severe. Doctors measure the level of bilirubin and an enzyme called alkaline phosphatase in the bloodstream to determine the severity of the disease.
The signs of acute GVHD of the liver include jaundice, mild liver tenderness, and increased levels of bilirubin and alkaline phosphatase in the bloodstream.
To prevent the development of acute GVHD, patients undergoing an allogeneic BMT are usually given drugs such as methotrexate, cyclosporine and occasionally prednisone. Some centers use a procedure called “T-cell depletion” to remove certain types of lymphocytes (white blood cells) from donor marrow before the BMT to prevent acute GVHD. If acute GVHD occurs, cyclosporine and increased dosages of prednisone are the usual treatment.
Use of unrelated donor marrow increases the risk of developing acute GVHD of the liver. Patients transplanted with donor marrow that is not a perfect (~antigen) match are also at increased risk of developing acute GVHD of the liver.
Abnormalities in bile flow are sometimes triggered by infections in the bloodstream. This condition (sometimes called cholangitis lenta) is not an infection of the liver itself, but t
he liver’s response to an infection elsewhere in the body. Symptoms include jaundice, an increased level of bilirubin and sometimes alkaline phosphatase in the blood.
The bile flow abnormalities resulting from cholangitis lenta can usually be reversed by treating the underlying bloodstream infection with antibiotics.
Fungal Liver Disease
Fungal liver disease is a serious post-transplant complication. The Candida species of fungus, which resides in the intestines, is the usual cause of fungal liver disease. Normally, the spread of this fungus is kept in check by beneficial bacteria that reside in the body and by the immune system.
In the first few weeks post-transplant, antibiotics given to BMT patients to destroy harmful bacteria also destroy the beneficial bacteria that keep the spread of Candida fungi in check. The fungi may multiply and get into the bloodstream. If the patient’s immune system isn’t strong enough to destroy them, the fungi may set up housekeeping in the liver, spleen or kidneys.
Symptoms of fungal liver infection include persistent fever, a tender swollen liver, and an elevated level of alkaline phosphatase in the blood. Patients with fungal infections in their intestine or bloodstream after transplant are at greatest risk of developing fungal liver disease.
Patients who have persistent low granulocyte (a type of white blood cell) counts and those receiving prednisone therapy for graft-versus-host disease are also more likely to develop fungal liver infections than others.
Fungal infections are very difficult to treat, particularly when the immune system is weak. Amphotericin B and fluconazole are two drugs that have shown some effectiveness in treating fungal liver infection.
Drug-induced liver Injury
Several drugs administered to BMT patients to treat infections, GVHD, nausea, and high blood pressure as well as some sedatives and pain medications can cause or aggravate liver injury. While a frequent cause of mild liver injury, these drugs seldom cause severe liver damage. The signs of drug injury are jaundice and abnormal levels of biliru- bin and liver enzymes (SGOT, SGPT and alkaline phosphatase) in the blood.
Prolonged periods of intravenous feeding (also called hyperalimentation or total parenteral nutrition [TPN]) can also cause mild liver problems in BMT patients. These problems are temporary and include liver inflammation, abnormal bile flow and fat accumulation in the liver. The problems are usually corrected by reducing the patient’s intravenous caloric intake and returning the patient to oral feeding. If oral feeding is not possible, varying the content of the intravenous feeding may help.
JodyMay 12, 2005 at 5:58 pm #6145
Great information! Thanks for the help!
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