Systematic investigation of elevated cholestatic enzymes during the third posttransplant month

1. Cholestasis in the third posttransplant month is associated with decreased patient survival and requires prompt investigation and intervention. 2. Bile leaks, biliary strictures, and gall stone/cast formation are major contributors to cholestatic disease. The causes are often complex, and the risk factors include surgical complications, ischemia/ reperfusion injury, hepatic artery thrombosis (HAT), ABO incompatibility, and recurrent primary sclerosing cholangitis (PSC). 3. Late HAT (occurring more than 30 days after transplantation) is observed in approximately one-third of patients with hepatic artery disease. Hepatic vein outflow obstructions are rare and are mainly observed in pediatric transplant recipients. 4. Acute cellular rejection and antibody-mediated rejection most commonly present within the first weeks of liver transplantation (LT), whereas ductopenic rejection is observed in the period ranging from 6 weeks to 6 months. 5. Reinfection of the allograft is known to occur within days of LT in patients with viral hepatitis. Primary biliary cirrhosis and PSC are usually diagnosed in the ensuing months to years, even though signs of recurrent disease may be observed within weeks. 6. Infections with bacteria, fungi, and viruses; drug injuries due to immunosuppression and antimicrobial agents; and extrahepatic malignancies may all contribute to cholestatic liver disease in the third posttransplant month.