not typically used in the immediate postoperative period given its potential impact on wound healing There are case reports of serious complications with sirolimus as a primary agent in liver (e.g., HAT) and lung (e.g., bronchial anastomotic breakdown) transplant recipients Sirolimus is effective for long-term maintenance and adjunct therapy because it spares the renal system It is useful as an antiproliferative agent and may arrest the progression of post heart transplant graft coronary artery disease Some studies have suggested a role of sirolimus for the treatment of de novo autoimmune hepatitis in the transplanted allograft Common adverse effects include mouth ulcers, hyperlipidemia, abdominal pain, marrow suppression, and hypercholesterolemia OTHER EMERGENCIES CLINICAL PEARLS AND PITFALLS Biliary complications occur in approximately 10% of pediatric liver transplant recipients and include biliary leaks (early) and biliary strictures (late) Recurrence of primary disease can occur in liver or renal transplant recipients BILIARY COMPLICATIONS Early biliary complications occur in roughly 10% of transplant recipients The type of allograft and biliary anastomosis and the status of the hepatic artery determine the spectrum of complications Biliary leaks are an early complication and are more common in recipients of split livers and reduced allografts with multiple bile duct anastomoses Later complications typically include biliary stricture that can lead to biliary sludge formation and recurrent cholangitis Biliary strictures can occur in isolation or multiple Isolated biliary strictures usually occur at the biliary anastomosis and are more commonly seen with a ductto-duct anastomosis (choledochocholedochostomy) Graft ischemia can lead to ischemic biliary strictures that may affect all areas of the biliary tree Biliary strictures may present with jaundice and pruritus Early laboratory findings include elevated bilirubin, GGT, or alkaline phosphatase, often in the setting of normal or mildly elevated transaminases Suspicion for biliary complications should prompt imaging via ultrasound with Doppler to assess for biliary leaks and hepatic vascular flow Additional imaging with CT or MRI may be indicated Management of biliary strictures may require cholangiography for placement of a stent to decompress the biliary tree RECURRENCE OF PRIMARY DISEASE The risk of recurrent primary disease is prominent in liver and renal transplant recipients Most notable liver diseases with risk of recurrence include autoimmune hepatitis and bile salt excretory pump (BSEP) disease For patients transplanted for autoimmune hepatitis, elevation of transaminases should also prompt screening for autoimmune hepatitis antibodies including anti-smooth muscle antibody, anti–liver-kidney microsomal antibody, and antinuclear antibody Following transplantation for BSEP, recurrent cholestasis associated with immunoglobulin G antibodies can develop Management with rituximab, a monoclonal anti-CD20 antibody, in combination with intravenous immunoglobulin and plasmapheresis has been used, but retransplantation may be indicated in some cases The risk of recurrence of primary disease in renal transplant patients depends on the primary disease Diseases that commonly recur are membranoproliferative glomerulonephritis, IgA nephropathy, and focal segmental glomerulosclerosis Graft loss due to recurrent glomerulonephritis is the third most common cause of graft failure, yet the impact of recurrence greatly varies according to the primary disease ACKNOWLEDGMENT The authors of this chapter acknowledge Anne Bernis, RPh, for her contributions to Table 125.1 , interactions between transplant immunosuppressents and other commonly used medications Suggested Readings and Key References Posttransplant Infections Arslan H, Inci EK, Azap O, et al Etiologic agents of diarrhea in solid organ transplant recipients Transpl Infect Dis 2007;9(4):270–275 Haddad J Jr, Inglesby T, Addonizio L Head and neck infections in pediatric cardiac transplant patients Ear Nose Throat J 1995;74(6):422–425 Jordan CL, Taber DJ, Kyle MO, et al Incidence, risk factors, and outcomes of opportunistic infections in pediatric renal transplant recipients Pediatr Transplant 2016;20(1):44–48 Zaoutis TE, Webber S, Naftel DC, et al Invasive fungal infections in pediatric heart transplant recipients: incidence, risk factors, and outcomes Pediatr Transplant 2011;15(5):465–469 Graft Rejection Adams DH, Neuberger JM Treatment of acute rejection Semin Liver Dis 1992;12:80–88 Costanzo MR, Dipchand A, Starling R, et al The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients J Heart Lung Transplant 2010;29(8):914–956 doi:10.1016/j.healun.2010.05.034 Posttransplant Lymphoproliferative Disorder Absalon MJ, Khoury RA, Phillips CL Post-transplant lymphoproliferative disorder after solid-organ transplant in children Semin Pediatr Surg 2017;26(4):257–266 Dayton JD, Richmond ME, Weintraub RG, et al Role of immunosuppression regimen in post transplant lymphoproliferative disorder in pediatric heart transplant patients J Heart Lung Transplant 2011;30(4):420–425 Kerkar N, Morotti RA, Madan RP, et al The changing face of posttransplant lymphoproliferative disease in the era of molecular EBV monitoring Pediatr Transplant 2010;14:504–511 Kinch A, Baecklund E, Backlin C, et al A population based study of 135 lymphomas after solid organ transplantation: the role of Epstein Barr Virus, hepatitis C and diffuse large B cell lymphoma subtype in clinical presentation and survival Acta Oncol 2014;53(5):669–679 Narkewicz MR, Green M, Dunn S, et al Decreasing incidence of symptomatic Epstein-Barr virus disease and posttransplant lymphoproliferative disorder in pediatric liver transplant recipients: report of the studies of pediatric liver transplantation experience Liver Transpl 2013;19:730–740 Webber SA, Naftel DC, Fricker FJ, et al Lymphoproliferative disorders after paediatric heart transplantation: a multi institutional study Lancet 2006;367:233–239 Vascular Complications Babyn PS Imaging of the transplant liver Pediatr Radiol 2010;40:442–446 Immunosuppressant Medication–Related Complications Blondet NM, Healey PJ, Hsu E Immunosuppression in the pediatric transplant recipient Semin Pediatr Surg 2017;26(4):193–198 Bucuvalas JC, Alonso E, Magee JC, et al Improving long-term outcomes after liver transplantation in children Am J Transplant 2008;8:2506–2513 Campbell K, Ng V, Martin S, et al; SPLIT Renal Function Working Group Glomerular filtration rate following pediatric liver transplantation—the SPLIT experience Am J Transplant 2010;10:2673–2682 Keogh A, Richardson M, Ruygrok P, et al Sirolimus in de novo heart transplant recipients reduces acute rejection and prevents coronary artery disease at years: a randomized clinical trial Circulation 2004;110:2694–2700 Other D’Alessandro AM, Kalayoglu M, Sollinger HW, et al The predictive value of donor liver biopsies on the development of primary nonfunction after orthotopic liver transplantation Transplant Proc 1991;23:1536–1537 Racadio JM, Kukreja K Pediatric biliary interventions Tech Vasc Interv Radiol 2010;13:244–249 Todo S, Demetris AJ, Makowka L, et al Primary nonfunction of hepatic allografts with preexisting fatty infiltration Transplantation 1989;47:903–905 Yersiz H, Renz JF, Farmer DG, et al One hundred in situ split liver transplantations: a single-center experience Ann Surg 2003;238:496–505; discussion 506–507 ... infections in pediatric cardiac transplant patients Ear Nose Throat J 1995;74(6):422–425 Jordan CL, Taber DJ, Kyle MO, et al Incidence, risk factors, and outcomes of opportunistic infections in pediatric. .. virus disease and posttransplant lymphoproliferative disorder in pediatric liver transplant recipients: report of the studies of pediatric liver transplantation experience Liver Transpl 2013;19:730–740... RG, et al Role of immunosuppression regimen in post transplant lymphoproliferative disorder in pediatric heart transplant patients J Heart Lung Transplant 2011;30(4):420–425 Kerkar N, Morotti