1
|
Russo MW, Wheless W, Vrochides D. Management of long-term complications from immunosuppression. Liver Transpl 2024; 30:647-658. [PMID: 38315054 DOI: 10.1097/lvt.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
This review discusses long-term complications from immunosuppressants after liver transplantation and the management of these complications. Common complications of calcineurin inhibitors include nephrotoxicity and metabolic diseases. Nephrotoxicity can be managed by targeting a lower drug level and/or adding an immunosuppressant of a different class. Metabolic disorders can be managed by treating the underlying condition and targeting a lower drug level. Gastrointestinal adverse effects and myelosuppression are common complications of antimetabolites that are initially managed with dose reduction or discontinuation if adverse events persist. Mammalian targets of rapamycin inhibitors are associated with myelosuppression, proteinuria, impaired wound healing, and stomatitis, which may require dose reduction or discontinuation. Induction agents and agents used for steroid-refractory rejection or antibody-mediated rejection are reviewed. Other rare complications of immunosuppressants are discussed as well.
Collapse
Affiliation(s)
- Mark W Russo
- Division of Hepatology, Department of Medicine, Carolinas Medical Center Wake Forest, University School of Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - William Wheless
- Division of Hepatology, Department of Medicine, Carolinas Medical Center Wake Forest, University School of Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Transplant Surgery, Carolinas Medical Center Wake Forest, University School of Medicine, Atrium Health, Charlotte, North Carolina, USA
| |
Collapse
|
2
|
Liu HX, Wang X, Xu MM, Wang Y, Lai M, Li GM, Meng QH. A new prediction model for acute kidney injury following liver transplantation using grafts from donors after cardiac death. Front Med (Lausanne) 2024; 11:1389695. [PMID: 38873211 PMCID: PMC11169688 DOI: 10.3389/fmed.2024.1389695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/30/2024] [Indexed: 06/15/2024] Open
Abstract
Acute kidney injury (AKI) is a major complication following liver transplantation (LT), which utilizes grafts from donors after cardiac death (DCD). We developed a machine-learning-based model to predict AKI, using data from 894 LT recipients (January 2015-March 2021), split into training and testing sets. Five machine learning algorithms were employed to construct the prediction models using 17 clinical variables. The performance of the models was assessed by the area under the receiver operating characteristic curve (AUC), accuracy, F1-score, sensitivity and specificity. The best-performing model was further validated in an independent cohort of 195 LT recipients who received DCD grafts between April 2021 and December 2021. The Shapley additive explanations method was utilized to elucidate the predictions and identify the most crucial features. The gradient boosting machine (GBM) model demonstrated the highest AUC (0.76, 95% CI: 0.70-0.82), F1-score (0.73, 95% CI: 0.66-0.79) and sensitivity (0.74, 95% CI: 0.66-0.80) in the testing set and a comparable AUC (0.75, 95% CI: 0.67-0.81) in the validation set. The GBM model identified high preoperative indirect bilirubin, low intraoperative urine output, prolonged anesthesia duration, low preoperative platelet count and graft steatosis graded NASH Clinical Research Network 1 and above as the top five important features for predicting AKI following LT using DCD grafts. The GBM model is a reliable and interpretable tool for predicting AKI in recipients of LT using DCD grafts. This model can assist clinicians in identifying patients at high risk and providing timely interventions to prevent or mitigate AKI.
Collapse
Affiliation(s)
- Hai-Xia Liu
- Department of Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xin Wang
- Department of Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Man-Man Xu
- Department of the Forth Wards of Liver Disease, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Yi Wang
- Department of Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Man Lai
- Department of Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Guang-Ming Li
- Department of Liver Transplantation Center, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Qing-Hua Meng
- Department of Medical Oncology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
3
|
Vandewiele S, Herman J, van den Heuvel L, Knops N. A longitudinal study of long-term renal outcome after pediatric liver transplantation in relation to CNI exposure. Pediatr Transplant 2024; 28:e14677. [PMID: 38149466 DOI: 10.1111/petr.14677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 10/08/2023] [Accepted: 11/24/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is reported in 20%-30% of children after liver transplantation (LT). One of the proposed underlying causes is the long-term exposure to tacrolimus, a calcineurin inhibitor (CNI), which is the main immunosuppressive drug used after LT. Variation in tacrolimus absolute exposure and relative dose requirements are believed to be important risk factors for developing CNI-associated nephrotoxicity. AIM To describe the long-term renal outcome of pediatric LT recipients and determine the effects of tacrolimus exposure on renal outcome parameters. METHODS Retrospective single center study of renal function (GFR, proteinuria) and pharmacokinetic parameters (C0 , AUC0-12h ) obtained during annual follow-up in children after liver transplantation, between 1998 and 2019. Relevant pharmacogenetic variants for tacrolimus disposition (CYP3A5 and ABCB1) were determined in recipients and donors. The evolution of individual renal function and tacrolimus exposure was evaluated using linear mixed models for repeated measurements. RESULTS Twenty-six children were included (mean follow-up: 10.4 years (range 2-18.9)). Mean estimated GFR was 109.3 (SE: 7.4), vs. measured: 91.3 mL/min/1.73 m2 (SE: 6.3), which remained stable during follow-up. CKD stage ≥2 was observed in 32.8% of the visits based on eGFR versus 50.0% on mGFR. CKD stage ≥3 was uncommon (4.1% and 6.2% resp.). Mean tacrolimus C0 was 5.3 ng/mL (SE: 2.5) with a AUC0-12h of 72.7 ng*h/mL (SE: 30.3), which demonstrated a small decrease during follow-up. There was a negative correlation between C0 and mGFR (rS = -0.3; p < .001). We found no correlation between GFR and tacrolimus dose requirements ((ng/mL)/(mg/kg)) or pharmacogenetic background. CONCLUSION Renal function during long-term follow-up after pediatric LT remained stable for the majority of our cohort. However, mild CKD was relatively common, warranting follow-up into adulthood. Although absolute tacrolimus exposure has a small depressing effect on concurrent GFR, there is no progressive deterioration of GFR due to long-term exposure, dose requirements or genetic background under the current target levels. These findings should be confirmed in a larger sample set, ideally including data from multiple centers.
Collapse
Affiliation(s)
- Simon Vandewiele
- Department of Pediatric Nephrology and Solid Organ Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Jean Herman
- Department of Pediatric Nephrology and Solid Organ Transplantation, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Catholic University Leuven, Leuven, Belgium
| | - Lambert van den Heuvel
- Department of Pediatric Nephrology and Solid Organ Transplantation, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Catholic University Leuven, Leuven, Belgium
| | - Noël Knops
- Department of Pediatric Nephrology and Solid Organ Transplantation, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatrics, Groene Hart Ziekenhuis, Gouda, The Netherlands
| |
Collapse
|
4
|
Viejo-Boyano I, López-Romero LC, D'Marco L, Checa-Ros A, Peris-Fernández M, Garrigós-Almerich E, Ramos-Tomás MC, Peris-Domingo A, Hernández-Jaras J. Role of the Nephrologist in Non-Kidney Solid Organ Transplant (NKSOT). Healthcare (Basel) 2023; 11:1760. [PMID: 37372878 DOI: 10.3390/healthcare11121760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/02/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a common complication of a non-kidney solid organ transplant (NKSOT). Identifying predisposing factors is crucial for an early approach and correct referral to nephrology. METHODS This is a single-center retrospective observational study of a cohort of CKD patients under follow-up in the Nephrology Department between 2010 to 2020. Statistical analysis was performed between all the risk factors and four dependent variables: end-stage renal disease (ESKD); increased serum creatinine ≥50%; renal replacement therapy (RRT); and death in the pre-transplant, peri-transplant, and post-transplant periods. RESULTS 74 patients were studied (7 heart transplants, 34 liver transplants, and 33 lung transplants). Patients who were not followed-up by a nephrologist in the pre-transplant (p < 0.027) or peri-transplant (p < 0.046) periods and those who had the longest time until an outpatient clinic follow-up (HR 1.032) were associated with a higher risk of creatinine increase ≥50%. Receiving a lung transplant conferred a higher risk than a liver or heart transplant for developing a creatinine increase ≥50% and ESKD. Peri-transplant mechanical ventilation, peri-transplant and post-transplant anticalcineurin overdose, nephrotoxicity, and the number of hospital admissions were significantly associated with a creatinine increase ≥50% and developing ESKD. CONCLUSIONS Early and close follow-up by a nephrologist was associated with a decrease in the worsening of renal function.
Collapse
Affiliation(s)
- Iris Viejo-Boyano
- Nephrology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
| | | | - Luis D'Marco
- Grupo de Investigación en Enfermedades Cardiorrenales y Metabólicas, Departamento de Medicina y Cirugía, Facultad de Ciencias de la Salud, Universidad Cardenal Herrera-CEU, 46115 Valencia, Spain
| | - Ana Checa-Ros
- Grupo de Investigación en Enfermedades Cardiorrenales y Metabólicas, Departamento de Medicina y Cirugía, Facultad de Ciencias de la Salud, Universidad Cardenal Herrera-CEU, 46115 Valencia, Spain
| | - María Peris-Fernández
- Nephrology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
| | | | | | - Ana Peris-Domingo
- Nephrology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
| | - Julio Hernández-Jaras
- Nephrology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
| |
Collapse
|
5
|
Neuberger J. Long-term Care of the Adult Liver Transplant Recipient. J Clin Exp Hepatol 2022; 12:1547-1556. [PMID: 36340310 PMCID: PMC9630008 DOI: 10.1016/j.jceh.2022.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/31/2022] [Indexed: 02/05/2023] Open
Abstract
While outcomes after liver transplantation have increased over the last two decades, this is primarily as a consequence of a reduction in early deaths and survival of those who survive the first 6 months has not significantly changed. Causes of premature death and graft loss include cardiovascular disease, renal impairment, malignancy and some infections. As the number of transplant recipients increase, care is being given by primary and secondary care clinicians. Management of the well patient is crucially dependent on careful assessment and where appropriate intervention, especially of cardiovascular risk - such as advice about avoidance of weight gain; management of hypertension, hyperlipidaemia and diabetes; and provision of appropriate lifestyle advice. Other interventions include surveillance for de novo malignancies, active management of immunosuppressive regimen with the need to tailor immunosuppression to the individual. Prompt investigation of abnormalities of liver function is essential. Immune-mediated graft damage still occurs but is less common as a cause for graft loss. Adherence is sometimes an issue, especially in teenagers and young adults, and should be considered and support given where needed. Immunisations (avoiding live and attenuated vaccines) should be encouraged. Recurrence of disease remains an issue, and some interventions (such as appropriate use of antiviral therapy for those grafted with viral hepatitis, use of ursodeoxycholic acid for those grafted for primary biliary cholangitis or long-term steroids for those grafted for autoimmune disease) may improve and maintain graft function. Close collaboration between recipient and the attending clinicians in primary, secondary and tertiary care and close attention to modifiable conditions will lead to improved outcomes.
Collapse
Key Words
- CMV, Cytomegalovirus
- CNI, Calcineurin inhibitor
- DRR-4i, dipeptidyl peptidase-4 inhibitor
- GLP 1RA, glucagon-like peptide-1 receptor agonists
- HBIG, Hepatitis B Immunoglobulin
- HBV, Hepatitis B Virus
- HCC, Hepatocellular carcinoma
- HCV, Hepatitis C virus
- LDL-C, Low-density lipoprotein cholesterol
- LT, Liver transplant
- MDRD, Modification of Diet in Renal Disease
- MRC, Magnetic resonance cholangiography
- NAFLD, Non-alcoholic fatty liver disease
- NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases
- NODAT, New onset diabetes after transplant
- NUC, Nucleos(t)ide analogues
- PBC, Primary Biliary Cholangitis
- PSC, Primary Sclerosing Cholangitis
- SGLT2i, sodium–glucose cotransporter 2 inhibitors
- SRTR, Scientific Registry of Transplant Recipients
- TMPT, Thiopurine S-methyltransferase
- USA, United States of America
- cardiovascular disease
- follow-up
- liver transplant
- mRNA, messenger Ribonucleic acid
- mTORi, mammalian Target of rapamycin inhibitor
- malignancy
- recurrent disease
Collapse
Affiliation(s)
- James Neuberger
- Liver Unit, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK
| |
Collapse
|
6
|
Sastre L, García R, Viñals C, Amor AJ, Yago G, Hervás A, Sánchez L, Trabal J, Molero J, Escudé L, Pagano G, Blasco M, Gilabert R, Ruiz P, Colmenero J, Navasa M, Ortega E, Crespo G. Results of a multidisciplinary strategy to improve the management of cardiovascular risk factors after liver transplantation. Liver Transpl 2022; 28:1332-1344. [PMID: 35224857 DOI: 10.1002/lt.26443] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 02/07/2023]
Abstract
Although liver transplantation (LT) recipients are at high cardiovascular risk (CVR), the management of CVR factors (CVRF) after LT is far from optimal and needs to be improved. For this reason, we developed a multidisciplinary protocol to standardize the identification, risk stratification, management, and targets of therapy of CVRF during the first post-LT year. The grade of identification and control of CVRF 12 months after LT in the postintervention cohort (LT January 2018-January 2020, n = 150) were compared with a control cohort who underwent LT between July 2015 and December 2016 (n = 100). Before LT, the prevalence of metabolic-associated fatty liver disease as the indication of LT and the presence of obesity were significantly higher in the postintervention cohort, whereas the prevalence of other CVRF and renal dysfunction tended to be higher. Cyclosporine A was used less frequently in the postintervention cohort, whereas everolimus tended to increase. At 12 months after LT, the proportion of patients with measured blood pressure (88% vs. 56%), glycosilated hemoglobin (HbA1c; 96% vs. 72%), and high-density lipoprotein/low-density lipoprotein cholesterol (67% vs. 33%) was higher in the postintervention than in the control cohort (all p < 0.001). Blood pressure (64% vs. 36%, p = 0.02) and HbA1c (85% vs. 70%, p = 0.1) were within target in more individuals with hypertension and diabetes mellitus, respectively, in the postintervention cohort. Median total cholesterol levels were lower in the postintervention (184 mg/dl; interquartile range [IQR], 160-210 mg/dl) than in the control cohort (212 mg/dl; IQR, 186-240 mg/dl; p = 0.02). At 2 years after LT, the incidence of cardiovascular events was 14% in the control cohort and 6% in the postintervention cohort (p = 0.063). In conclusion, a multidisciplinary, multiprofessional strategy can achieve a higher grade of assessment and management of post-LT CVR despite a worsening metabolic profile of LT recipients.
Collapse
Affiliation(s)
- Lydia Sastre
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Department of Gastroenterology and Hepatology, Hospital Son Espases, Palma de Mallorca, Spain
| | - Raquel García
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Clara Viñals
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Antonio J Amor
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Gema Yago
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Alicia Hervás
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Lorena Sánchez
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Joan Trabal
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Judit Molero
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Laia Escudé
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Giulia Pagano
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
| | - Rosa Gilabert
- Radiology Department, Hospital Clinic, Barcelona, Spain
| | - Pablo Ruiz
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Jordi Colmenero
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
| | - Miquel Navasa
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
| | - Emilio Ortega
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain
| | - Gonzalo Crespo
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
| |
Collapse
|
7
|
Saunders EA, Engel B, Höfer A, Hartleben B, Vondran FWR, Richter N, Potthoff A, Zender S, Wedemeyer H, Jaeckel E, Taubert R. Outcome and safety of a surveillance biopsy guided personalized immunosuppression program after liver transplantation. Am J Transplant 2022; 22:519-531. [PMID: 34455702 DOI: 10.1111/ajt.16817] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/08/2021] [Accepted: 08/19/2021] [Indexed: 01/25/2023]
Abstract
Graft survival beyond year 1 has not changed after orthotopic liver transplantation (OLT) over the last decades. Likewise, OLT causes comorbidities such as infection, renal impairment and cancer. We evaluated our single-center real-world individualized immunosuppression program after OLT, based on 211 baseline surveillance biopsies (svLbx) without any procedural complications. Patients were classified as low, intermediate and high rejection risk based on graft injury in svLbx and anti-HLA donor-specific antibodies. While 32% of patients had minimal histological inflammation, 57% showed histological inflammation and 23% advanced fibrosis (>F2), which was not predicted by lab parameters. IS was modified in 79% of patients after svLbx. After immunosuppression reduction in 69 patients, only 5 patients showed ALT elevations and three of these patients had a biopsy-proven acute rejection, two of them related to lethal comorbidities. The rate of liver enzyme elevation including rejection was not significantly increased compared to a svLbx control cohort prior to the initiation of our structured program. Immunosuppression reduction led to significantly better kidney function compared to this control cohort. In conclusion, a biopsy guided personalized immunosuppression protocol after OLT can identify patients requiring lower immunosuppression or patients with graft injury in which IS should not be further reduced.
Collapse
Affiliation(s)
- Emily A Saunders
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Bastian Engel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Anne Höfer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Björn Hartleben
- Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Florian W R Vondran
- Department for General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Nicolas Richter
- Department for General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Andrej Potthoff
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Steffen Zender
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| |
Collapse
|
8
|
Pacheco MP, Carneiro-D'Albuquerque LA, Mazo DF. Current aspects of renal dysfunction after liver transplantation. World J Hepatol 2022; 14:45-61. [PMID: 35126839 PMCID: PMC8790396 DOI: 10.4254/wjh.v14.i1.45] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 10/24/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
Abstract
The development of chronic kidney disease (CKD) after liver transplantation (LT) exerts a severe effect on the survival of patients. The widespread adoption of the model for end-stage liver disease score strongly impacted CKD incidence after the procedure, as several patients are transplanted with previously deteriorated renal function. Due to its multifactorial nature, encompassing pre-transplantation conditions, perioperative events, and nephrotoxic immunosuppressor therapies, the accurate identification of patients under risk of renal disease, and the implementation of preventive approaches, are extremely important. Methods for the evaluation of renal function in this setting range from formulas that estimate the glomerular filtration rate, to non-invasive markers, although no option has yet proved efficient in early detection of kidney injury. Considering the nephrotoxicity of calcineurin inhibitors (CNI) as a factor of utmost importance after LT, early nephroprotective strategies are highly recommended. They are based mainly on delaying the application of CNI during the immediate postoperative-period, reducing their dosage, and associating them with other less nephrotoxic drugs, such as mycophenolate mofetil and everolimus. This review provides a critical assessment of the causes of renal dysfunction after LT, the methods of its evaluation, and the interventions aimed at preserving renal function early and belatedly after LT.
Collapse
Affiliation(s)
- Mariana P Pacheco
- Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, Sao Paulo 05403-900, Sao Paulo, Brazil
| | - Luiz Augusto Carneiro-D'Albuquerque
- Division of Digestive Organs Transplant, Department of Gastroenterology, University of São Paulo School of Medicine, Sao Paulo 05403-900, Sao Paulo, Brazil
| | - Daniel F Mazo
- Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, Sao Paulo 05403-900, Sao Paulo, Brazil
- Division of Gastroenterology, Department of Internal Medicine, School of Medical Sciences of University of Campinas, Campinas 13083-878, Sao Paulo, Brazil
| |
Collapse
|
9
|
Koc ÖM, Pierco M, Remans K, Van den Hende T, Verbeek J, Van Malenstein H, Van der Merwe S, Robaeys G, Monbaliu D, Pirenne J, Van den Bosch B, Dobbels F, Nevens F. Telemedicine based remote monitoring after liver transplantation: Feasible in a select group and a more stringent control of immunosuppression. Clin Transplant 2021; 36:e14494. [PMID: 34596918 PMCID: PMC9285405 DOI: 10.1111/ctr.14494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/04/2021] [Accepted: 09/16/2021] [Indexed: 12/17/2022]
Abstract
Telemedicine gained interest in liver transplant patients but focused until now on the early post‐operative period. This prospective cohort study assessed feasibility, safety, and clinical beneficial effects of a telemedicine based remote monitoring program (TRMP) for the chronic follow‐up of adult liver transplant recipients. Between November 2017 and August 2019, a total of 87 of the 115 selected patients (76%) started the TRMP. Over the 2 years study period, none of the patients switched to standard follow‐up: 39/87 (45%) continued to do this autonomously and 48/87 (55%) stopped to report their data personally but communicated their lab values to the nurse. The other 28/115 (11%) patients who did not accept the TRMP continued the standard follow‐up. There was no difference in educational level between the three groups. Remote monitoring did not result in an increase in liver graft rejection and need of hospitalization. TRMP was associated with a higher number of tacrolimus level determinations and tacrolimus blood level concentrations could be kept lower. In conclusion, our results show that in patients with a stable clinical condition there is a high willingness to participate in TRMP and that this approach is safe. Remote monitoring allowed a stringent follow‐up of tacrolimus levels.
Collapse
Affiliation(s)
- Özgür Muhammet Koc
- Department of Gastroenterology and Hepatology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Department of Medical Microbiology, Maastricht University Medical Centre, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM), University Maastricht, Maastricht, The Netherlands
| | - Marleen Pierco
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Kathleen Remans
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Thijs Van den Hende
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Jef Verbeek
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Hannah Van Malenstein
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Schalk Van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Geert Robaeys
- Department of Gastroenterology and Hepatology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplantation Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplantation Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | | | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Belgium
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|