For example, hyperacute rejection of a liver transplant does not occur invariably in patients who were presensitized to HLA antigens or ABO incompatibilities. The reasons for this are unknown. However, when either fulminant acute rejection or chronic rejection is refractory to immunosuppressive therapy, retransplantation is the treatment. The vanishing bile duct syndrome, characterized by intrahepatic cholestasis with preserved hepatocellular function, is a pattern of chronic rejection. Doses are adjusted downward if renal dysfunction occurs, and blood levels are used as approximate measures of adequate dosage.
Children often require higher doses to maintain adequate blood levels.
If biliary drainage via a T tube is used postoperatively, then higher doses may be required because of the loss of cyclosporine via the bile. Mild acute rejection episodes may be self-limited. Jaundice and elevated serum levels of hepatic enzymes are corroborative findings. Needle biopsy can provide pathologic confirmation. A variety of complications must be expected, including those attributable to the complex operation itself, in addition to rejection and the consequences of attempts to control it.