1
|
Mehtani R, Saigal S. Long Term Complications of Immunosuppression Post Liver Transplant. J Clin Exp Hepatol 2023; 13:1103-1115. [PMID: 37975039 PMCID: PMC10643541 DOI: 10.1016/j.jceh.2023.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/18/2023] [Indexed: 11/19/2023] Open
Abstract
Improvement in immunosuppression has led to a remarkable improvement in short-term and long-term outcomes post-liver transplant (LT). However, with improvements in long-term survival, complications related to immunosuppressive drugs, either directly or indirectly, have also increased. The adverse events could be drug-specific, class-specific, or generic. Calcineurin inhibitors (cyclosporine and tacrolimus) are the backbone of the immunosuppression after LT and the main culprit associated with most of the complications, including renal failure, post-transplant diabetes mellitus (PTDM), and metabolic syndrome. Steroids are also implicated in the development of diabetes, osteoporosis, and metabolic syndrome post-LT. The development of infections and de novo malignancies (DNMs) is a generic effect linked to the overall cumulative immunosuppression. The development of these complications significantly hampers the quality of life and leads to increased morbidity and mortality post-LT. Thus, it is important to minimize the cumulative immunosuppression dose while simultaneously preventing allograft rejection. This review provides up-to-date, comprehensive knowledge of the complications of long-term immunosuppression post-LT along with associated risk factors and strategies to minimize the risk of complications.
Collapse
Affiliation(s)
- Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, Haryana - 121001, India
| | - Sanjiv Saigal
- Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Superspecialty Hospital, Saket, New Delhi, India
| |
Collapse
|
2
|
Richardson B, Khan MQ, Brown SA, Watt KD, Izzy M. Personalizing Diabetes Management in Liver Transplant Recipients: The New Era for Optimizing Risk Management. Hepatol Commun 2022; 6:1250-1261. [PMID: 34921530 PMCID: PMC9134800 DOI: 10.1002/hep4.1876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/18/2021] [Accepted: 11/18/2021] [Indexed: 12/12/2022] Open
Abstract
Post-transplant diabetes mellitus (PTDM) is a significant contributor to morbidity and mortality in liver transplant recipients (LTRs). With concurrent comorbidities and use of various immunosuppression medications, identifying a safe and personalized regimen for management of PTDM is needed. There are many comorbidities associated with the post-transplant course including chronic kidney disease, cardiovascular disease, allograft steatosis, obesity, and de novo malignancy. Emerging data suggest that available diabetes medications may carry beneficial or, in some cases, harmful effects in the setting of these co-existing conditions. Sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists have shown the most promising beneficial results. Although there is a deficiency of LTR-specific data, they appear to be generally safe. Effects of other medications are varied. Metformin may reduce the risk of malignancy. Pioglitazone may be harmful in patients combatting obesity or heart failure. Insulin may exacerbate obesity and increase the risk of developing malignancy. This review thoroughly discusses the roles of these extra-glycemic effects and safety considerations in LTRs. Through weighing the risks and benefits, we conclude that alternatives to insulin should be strongly considered, when feasible, for personalized long-term management based on risk factors and co-morbidities.
Collapse
Affiliation(s)
- Brooks Richardson
- Department of Internal MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | | | - Sara A Brown
- Division of Gastroenterology, Hepatology and NutritionVanderbilt University Medical CenterNashvilleTNUSA
| | - Kymberly D Watt
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMNUSA
| | - Manhal Izzy
- Division of Gastroenterology, Hepatology and NutritionVanderbilt University Medical CenterNashvilleTNUSA
| |
Collapse
|
3
|
Ayvazoğlu Soy EH, Akdur A, Karakaya E, Moray G, Haberal M. Liver Transplant Recipients Who Survive for More Than 10 Years: A Long-Term Survey. EXP CLIN TRANSPLANT 2022; 20:20-23. [PMID: 35384803 DOI: 10.6002/ect.mesot2021.o8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Liver transplant is the gold standard treatment for end-stage liver failure. Short-term and midterm surveys have been published, but there are few long-term surveys. Here, we report the outcomes of our long-term liver transplant survivors. MATERIALS AND METHODS Since 1988, we have performed 694 liver transplants (366 adult, 328 pediatric), including the first deceased donor transplant in Turkey (December 8, 1988); the first pediatric segmental living related transplant in Turkey, the Middle and Near East, and Europe; the world's first adult segmental living related transplant (April 24, 1990); and the world's first living related donor combined liver-kidney transplant (May 16, 1992). We retrospectively evaluated data from recipients who survived >10 years with normal graft function. RESULTS Of 215 recipients, survival ranges were ≥20 years (n = 13), 15 to 19 years (n = 86), and 10 to 14 years (n = 116); 211 remain alive today with normal liver function. There were 5 retransplants to treat chronic graft rejection, of which 4 recipients are alive with normal graft function after a second liver transplant (15, 20, 22, and 31 years after first transplant). One patient died soon after the second liver transplant (15 years after first transplant). Acute rejection episodes were seen in 72 (34%), and 7 were steroid resistant. There were 48 (22.7%) drug-induced complications. Ten patients had de novo malignancy: 5 lymphoma, 2 squamous cell carcinoma, 1 gastrointestinal stromal tumor, 1 thyroid papillary carcinoma, and 1 multiple myeloma. There were also 31 patients with hepatocellular carcinoma before liver transplant: 13 were beyond Milan criteria, 6 had incidental HCC, and 12 were within Milan. CONCLUSIONS Long-term survival after liver transplant is possible with expert care. Few reports have mentioned long-term surveys; our long-term liver transplant survey is among the largest series in the literature.
Collapse
Affiliation(s)
- Ebru H Ayvazoğlu Soy
- From the General Surgery Department, Division of Transplantation, Baskent University, Ankara, Turkey
| | | | | | | | | |
Collapse
|
4
|
Cerebral Diseases in Liver Transplant Recipients: Systematic Review of Clinical Evidence. J Clin Med 2022; 11:jcm11040979. [PMID: 35207251 PMCID: PMC8878041 DOI: 10.3390/jcm11040979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 12/04/2022] Open
Abstract
This systematic review presents clinical evidence on early and long-term cerebral diseases in liver transplant recipients. The literature search led to the retrieval of 12 relevant studies. Early postoperative cerebral complications include intracranial hemorrhage associated with a coexisting coagulopathy, perioperative hypertension, and higher MELD scores and is more frequent in critically ill recipients; central pontine and extrapontine myelinolysis are associated with notable perioperative changes in the plasma Na+ concentration and massive transfusion. Long-term follow-up cerebral complications include focal brain lesions, cerebrovascular diseases, and posterior reversible encephalopathy; there is no proven relationship between the toxicity immunosuppressive drugs and cerebral complications. This SR confirms a very low incidence of opportunistic cerebral infections.
Collapse
|
5
|
An Essential Guide for Managing Post-Liver Transplant Patients: What Primary Care Physicians Should Know. Am J Med 2022; 135:157-166. [PMID: 34508700 DOI: 10.1016/j.amjmed.2021.08.005] [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: 02/28/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 12/16/2022]
Abstract
With long-term survival after liver transplantation becoming the rule, care for medical problems arising over time in liver-transplanted patients gained increasing importance. The most common causes of death occurring more than 1 year after liver transplantation are unrelated to liver diseases and facilitated by immunosuppressive treatments; examples are malignancies, renal failure, and cardiovascular, metabolic, and infectious diseases. Recipients receive life-long follow-up care at transplant centers, however, the increasing number of liver-transplanted patients is saturating the health care supply that transplant centers have to offer. Primary care physicians are increasingly exposed to liver-transplanted patients, even in the early periods after transplant, and an understanding of the most common risks and complications faced by these patients would enhance their care. This article reviews the long-term care of liver transplant recipients, emphasizing the key internal medicine-related issues that should be known by primary care physicians. A specific section is devoted to implementing strategies to involve these physicians in the long-term follow-up of liver-transplanted patients in close collaboration with transplant hepatologists.
Collapse
|
6
|
Liu ED, Nituleasa A, Amidon RF, Ordookhanian C, Kaloostian P. Hepatic Transplantation Raises Concern for Vascular Infrastructure Compromise: A Case Study of Debilitating Arteriovenous Malformation. Cureus 2021; 13:e18518. [PMID: 34765326 PMCID: PMC8575283 DOI: 10.7759/cureus.18518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
The post-operative realm for hepatic transplant patients presents many challenges, but of them all, we take a deeper dive into an increased risk of associated cerebrovascular events. Cerebrovascular diseases, such as cerebral arteriovenous malformation (AVM), are a leading cause of death following a liver transplant. We present a unique case of a liver transplant patient who presented with no brainstem reflexes three months into the post-transplant period. Imaging studies revealed a ruptured AVM within the foramen magnum and cervicomedullary junction, as well as substantial cerebral hemorrhage. While establishing the exact cause of the AVM is not as trivial as it may appear, side effects associated with post-transplantation management regimens and possible congenital factors do shed some light on notable considerations. Given the potential damage associated with ruptured AVMs, poor patient outcomes are unfortunately not as rare as one would hope. This case highlights a rare but highly possible occurrence for cerebrovascular complications, specifically AVM rupture linked to liver transplantation and the systemic changes associated with a procedure as invasive as liver transplantation.
Collapse
Affiliation(s)
- Elizabeth D Liu
- Biochemistry, University of California Riverside, Riverside, USA
| | | | - Ryan F Amidon
- Medicine, Medical College of Wisconsin, Milwaukee, USA
| | | | - Paul Kaloostian
- Neurological Surgery, Riverside Community Hospital, Riverside, USA.,Neurological Surgery, Paul Kaloostian M.D. Inc., Riverside, USA
| |
Collapse
|
7
|
Kömürkara S, Cengiz Z. Effects of Progressive Relaxation Exercises on Vital Signs and Fatigue in Liver Transplant Patients: A Randomized Controlled Trial. Clin Nurs Res 2021; 31:497-508. [PMID: 34528495 DOI: 10.1177/10547738211045850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This randomized controlled study was conducted to evaluate the effects of progressive relaxation exercises on vital signs and fatigue level. Ninety patients with liver transplantation (experimental group = 45, control group = 45) were included in the study. The patients in the experimental group performed progressive relaxation exercises for 25 to 30 minutes every day for 4 weeks. Before the progressive relaxation exercises, the vital signs and fatigue level of the patients were recorded. Vital signs were recorded again immediately after the progressive relaxation exercises and at the end of the second week. At the end of the fourth week, the final measurement of vital signs was performed along with the second fatigue level assessment. In the experimental group, pulse and respiratory rates, systolic and diastolic blood pressure values, and fatigue severity mean scores were found to be lower and oxygen saturation level was higher than those of the control group. The improvement in vital signs in the experimental group was evident at week 3 (p < .05).
Collapse
Affiliation(s)
| | - Zeliha Cengiz
- Inonu University, Nursing Faculty, Department of Fundamentals of Nursing, Malatya, Turkey
| |
Collapse
|
8
|
Berk C, Volk ML. Preventive Care in Adult Liver Transplant Recipients. Clin Liver Dis (Hoboken) 2021; 18:14-17. [PMID: 34484698 PMCID: PMC8405049 DOI: 10.1002/cld.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 11/16/2020] [Accepted: 12/06/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Corrie Berk
- Loma Linda Las Vegas Hepatology & Liver Transplant ClinicsTransplant InstituteLoma Linda University HealthLas Vegas CampusLas VegasNV
| | - Michael L. Volk
- Liver TransplantationGastroenterology and HepatologyRobert and Gladys Mitchell Professor of MedicineLoma Linda University HealthLoma LindaCA
| |
Collapse
|
9
|
Lim WH, Ng CH, Ow ZGW, Ho OTW, Tay PWL, Wong KL, Tan EXX, Tang SY, Teo CML, Muthiah MD. A systematic review and meta-analysis on the incidence of osteoporosis and fractures after liver transplant. Transpl Int 2021; 34:1032-1043. [PMID: 33835638 DOI: 10.1111/tri.13863] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 12/11/2022]
Abstract
Following liver transplant (LT), osteoporosis is a severe complication that causes morbidity. However, the incidence and risk factors of osteoporosis and fractures have not been well described. Single-arm meta-analysis of studies reporting osteopenia, osteoporosis, and fractures post-LT was performed with meta-regression for study period. Dichotomous variables, continuous variables and time-to-event variables were pooled in odds ratio, weighted mean difference and hazard ratio, respectively. For risk factors with limited data, a systematic review of literature was conducted. There was a significant increase in both osteoporosis and fractures compared to non-LT patients. Osteopenia, osteoporosis and incident fractures were newly diagnosed in 34.53% (CI: 0.17-0.56, n = 301), 11.68% (CI: 0.05-0.24, n = 1251) and 20.40% (CI: 0.13-0.30, n = 4322) of LT patients, respectively. Female gender (P = 0.017) increased risks of osteoporosis but not older age and BMI. Older age, lower pre-LT bone mineral density (BMD), presence of bone disease pre-LT were significant risk factors for fractures but not female gender, post-menopausal state, BMI, smoking and alcohol. There is a high incidence of skeletal complications post-LT. Older age, lower pre-LT BMD and presence of bone disease pre-LT are significant risk factors that are associated with incident fractures physicians should be cognisant of in liver transplant recipients.
Collapse
Affiliation(s)
- Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Owen Tsung Wen Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Phoebe Wen Lin Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Keng Lin Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Eunice Xiang Xuan Tan
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Si Ying Tang
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Claire Min-Li Teo
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| |
Collapse
|
10
|
Goosmann L, Buchholz A, Bangert K, Fuhrmann V, Kluge S, Lohse AW, Huber S, Fischer L, Sterneck M, Huebener P. Liver transplantation for acute-on-chronic liver failure predicts post-transplant mortality and impaired long-term quality of life. Liver Int 2021; 41:574-584. [PMID: 34542228 DOI: 10.1111/liv.14756] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/05/2020] [Accepted: 12/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Among patients with cirrhosis, candidate selection and timing of liver transplantation (LT) remain problematic. Acute-on-chronic liver failure (ACLF) is a severe complication of cirrhosis with excessive short-term mortality rates under conservative therapeutic measures. The role of LT in the management of ACLF is uncertain. OBJECTIVE To assess the impact of ACLF on post-LT survival and long-term graft function, morbidity and quality of life (QoL). METHODS We retrospectively analysed all cirrhosis patients undergoing LT at our institution between 01/2009 and 12/2014. Median follow-up was 8.7 years. Long-term LT survivors were interviewed with established QoL questionnaires. RESULTS Of 250 LT recipients, 98 fulfilled the EASL diagnostic ACLF criteria before LT ('ACLF-LT'). ACLF associated with reduced post-LT survival (HR for 6-month survival compared to non-ACLF-LT: 0.18; HR for 10-year-survival: 0.47; both P < .001) depending on ACLF severity before LT, and mainly inferred by infections both in the early and late phases after LT. In ACLF patients, CLIFc-OFs was superior to MELD score in predicting post-LT mortality. Long-term follow-up revealed comparable graft functions and comorbidity burden in ACLF-LT and non-ACLF-LT survivors. ACLF-LT patients reported significantly impaired health and QoL, particularly with regards to anxiety/depression and physical and psychological health (all P < .05). LabMELD score, presence of ACLF at LT and duration of post-LT intensive care associated with poor long-term QoL. CONCLUSION ACLF predicts impaired post-LT survival. While long-term graft function and extrahepatic comorbidities are comparable in ACLF and non-ACLF LT survivors, the strikingly low QoL in many ACLF-LT recipients warrants consideration during follow-up patient care.
Collapse
Affiliation(s)
- Lukas Goosmann
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Angela Buchholz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katrin Bangert
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Samuel Huber
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lutz Fischer
- Department of Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Sterneck
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Huebener
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
11
|
The challenge of offering potentially curative treatment to patients with esophageal cancer and a history of liver transplantation: A literature review and case report. Surgery 2021; 169:1379-1385. [PMID: 33487434 DOI: 10.1016/j.surg.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/18/2020] [Accepted: 12/11/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND With survival after liver transplantation continuing to improve, effective and evidence-based treatment of malignancies in this patient group is needed as a matter of urgency. Treatment outcomes for esophageal cancer, a challenging malignancy to treat in otherwise fit and well patients, after liver transplant are rarely reported. METHODS A systematic literature review was performed according to the PRISMA guidance to identify studies reporting outcomes of radical esophageal cancer treatment in patients with liver transplant. Management strategies and oncological outcomes were compared with a case managed at our institution. RESULTS Six studies were identified for review, and the outcomes of 13 patients were collated. The most common indication for liver transplant was alcohol-related liver disease (62%), and the most common tumor type was adenocarcinoma (54%). Neoadjuvant chemotherapy was delivered safely in 23% of cases in the literature and in the case managed at our institution. The median time from liver transplant to esophagectomy was 46 months, and the majority of patients underwent an Ivor-Lewis esophagectomy. The median follow-up from esophagectomy was 17 months, with a pooled 1-year survival of 77% and recurrence rate of 38%. This was comparable with corresponding rates reported for nontransplanted patients. CONCLUSION This case report and systematic review demonstrates that radical treatment of esophageal cancer after liver transplantation is not only technically feasible when managed by expert multidisciplinary teams but that it also improves survival. Routine surveillance of liver transplant patients with evidence of Barrett's preoperatively should be considered and close involvement of appropriate specialists in individual treatment planning is vital to acceptable outcomes.
Collapse
|
12
|
Tustumi F, de Miranda AA, Silveira S, Fernandes FA, Silva MBDBE, Ernani L, Nacif LS, Coelho FF, Andraus W, Bernardo WM, Herman P, Carneiro-D’Albuquerque LA. Safety and effectiveness of mycophenolate mofetil associated with tacrolimus for liver transplantation immunosuppression: a systematic review and meta-analysis of randomized controlled trials. Clinics (Sao Paulo) 2021; 76:e2597. [PMID: 33681947 PMCID: PMC7920399 DOI: 10.6061/clinics/2021/e2597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/03/2021] [Indexed: 11/18/2022] Open
Abstract
A combination of immunosuppressants may improve outcomes due to the synergistic effect of their different action mechanisms. Currently, there is no consensus regarding the best immunosuppressive protocol after liver transplantation. This review aimed to evaluate the effectiveness and safety of tacrolimus associated with mycophenolate mofetil (MMF) in patients undergoing liver transplantation. We performed a systematic review and meta-analysis of randomized clinical trials. Eight randomized trials were included. The proportion of patients with at least one adverse event related to the immunosuppression scheme with tacrolimus associated with MMF was 39.9%. The tacrolimus with MMF immunosuppression regimen was superior in preventing acute cellular rejection compared with that of tacrolimus alone (risk difference [RD]=-0.11; p =0.001). The tacrolimus plus MMF regimen showed no difference in the risk of adverse events compared to that of tacrolimus alone (RD=0.7; p=0.66) and cyclosporine plus MMF (RD=-0.7; p=0.37). Patients undergoing liver transplantation who received tacrolimus plus MMF had similar adverse events when compared to patients receiving other evaluated immunosuppressive regimens and had a lower risk of acute rejection than those receiving in the monodrug tacrolimus regimen.
Collapse
Affiliation(s)
- Francisco Tustumi
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Antonio Afonso de Miranda
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Sérgio Silveira
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Felipe Alexandre Fernandes
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Miller Barreto de Brito e Silva
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Lucas Ernani
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Lucas Souto Nacif
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fabricio Ferreira Coelho
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Wellington Andraus
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Wanderley Marques Bernardo
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Paulo Herman
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | |
Collapse
|
13
|
Huo Z, Li C, Xu X, Ge F, Wang R, Wen Y, Peng H, Wu X, Liang H, Peng G, Li R, Huang D, Chen Y, Zhong R, Cheng B, Xiong S, Lin W, He J, Liang W. Cancer Risks in Solid Organ Transplant Recipients: Results from a Comprehensive Analysis of 72 Cohort Studies. Oncoimmunology 2020; 9:1848068. [PMID: 33299661 PMCID: PMC7714465 DOI: 10.1080/2162402x.2020.1848068] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Understanding the cancer risks in different transplant recipients helps early detection, evaluation, and treatment of post-transplant malignancies. Therefore, we performed a meta-analysis to determine the cancer risks at multiple sites for solid organ transplant recipients and their associations with tumor mutation burden (TMB), which reflects the immunogenicity. A comprehensive search of PubMed, Web of Science, EMBASE, Medline, and Cochrane Library was conducted. Random effects models were used to calculate the standardized incidence ratios (SIRs) versus the general population and determine the risks of different cancers. Linear regression (LR) was used to analyze the association between the SIRs and TMBs. Finally, seventy-two articles met our criteria, involving 2,105,122 solid organ transplant recipients. Compared with the general population, solid organ transplant recipients displayed a 2.68-fold cancer risk (SIR 2.68; 2.48–2.89; P <.001), renal transplant recipients displayed a 2.56-fold cancer risk (SIR 2.56; 2.31–2.84; P <.001), liver transplant recipients displayed a 2.45-fold cancer risk (SIR 2.45; 2.22–2.70; P <.001), heart and/or lung transplant recipients displayed a 3.72-fold cancer risk (SIR 3.72; 3.04–4.54; P <.001). The correlation coefficients between SIRs and TMBs were 0.68, 0.64, 0.59, 0.79 in solid organ recipients, renal recipients, liver recipients, heart and/or lung recipients, respectively. In conclusion, our study demonstrated that solid organ transplant recipients displayed a higher risk of some site-specific cancers, providing individualized guidance for clinicians to early detect, evaluate, and treat cancer among solid organ transplantation recipients. In addition, the increased cancer risk of solid organ transplant recipients is associated with TMB, suggesting that iatrogenic immunosuppression may contribute to the increased cancer risk in transplant recipients. (PROSPERO ID CRD42020160409).
Collapse
Affiliation(s)
- Zhenyu Huo
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Caichen Li
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xin Xu
- Department of Transplantation, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Fan Ge
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,First Clinical School, Guangzhou Medical University, Guangzhou, China
| | - Runchen Wang
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Yaokai Wen
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Haoxin Peng
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Xiangrong Wu
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Hengrui Liang
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guilin Peng
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Department of Transplantation, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Run Li
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Department of Transplantation, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Danxia Huang
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Department of Transplantation, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Ying Chen
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Department of Transplantation, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Ran Zhong
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bo Cheng
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shan Xiong
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Weiyi Lin
- First Clinical School, Guangzhou Medical University, Guangzhou, China
| | - Jianxing He
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenhua Liang
- Department of Thoracic Surgery and Oncology, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
14
|
Prevalence of cerebrovascular diseases that can cause hemorrhagic stroke in liver transplantation recipients: a 6-year comparative study with 24,681 healthy adults. Neurol Sci 2020; 42:2753-2761. [PMID: 33125597 DOI: 10.1007/s10072-020-04863-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 10/26/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND PURPOSE Cerebrovascular diseases are a leading cause of mortality after liver transplantation (LT). The prevalence of potentially hemorrhagic cerebrovascular diseases (HCVDs) that could cause a hemorrhagic stroke in patients with severe liver diseases has not been reported. We aimed to analyze the underlying prevalence of HCVDs that could lead to hemorrhagic strokes in LT recipients compared with that in previously healthy controls. METHODS A retrospective study with 1,920 consecutive LT recipients and 24,681 adults who underwent a health checkup during the same period was conducted (January 2011-December 2016). The prevalence of cerebral aneurysms (CA), cerebral arteriovenous malformation (AVM), and cavernous malformation (CM) was evaluated using brain imaging, including computed tomography angiography, magnetic resonance imaging, magnetic resonance angiography, and digital subtraction angiography. RESULTS The prevalence of CA and CM were 3.1% and 0.5%, respectively, in the LT group and 3.8% and 0.4%, respectively, in the control group. According to the location of the cerebral artery, paraclinoid internal carotid artery aneurysms (odds ratio [OR] 0.440; P = 0.009) had a lower prevalence in LT recipients than in healthy controls. Anterior communicating artery (OR 3.080; P = 0.002) and superior cerebellar artery (OR 8.767; P = 0.017) aneurysms had a higher prevalence in the LT group than in the control. The prevalence of AVM was significantly higher in LT recipients (0.26%) than in healthy controls (0.06%). CONCLUSION LT recipients showed a different distribution of CA prevalence according to the locations of the cerebral artery and had a higher overall prevalence of AVM than previously healthy controls.
Collapse
|
15
|
Burra P, Becchetti C, Germani G. NAFLD and liver transplantation: Disease burden, current management and future challenges. JHEP Rep 2020; 2:100192. [PMID: 33163950 PMCID: PMC7607500 DOI: 10.1016/j.jhepr.2020.100192] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD), specifically its progressive form non-alcoholic steatohepatitis (NASH), represents the fastest growing indication for liver transplantation in Western countries. Diabetes mellitus, morbid obesity and cardiovascular disease are frequently present in patients with NAFLD who are candidates for liver transplantation. These factors require specific evaluation, including a detailed pre-surgical risk stratification, in order to improve outcomes after liver transplantation. Moreover, in the post-transplantation setting, the incidence of cardiovascular events and metabolic complications can be amplified by immunosuppressive therapy, which is a well-known driver of metabolic alterations. Indeed, patients with NASH are more prone to developing early post-transplant complications and, in the long-term, de novo malignancy and cardiovascular events, corresponding to higher mortality rates. Therefore, a tailored multidisciplinary approach is required for these patients, both before and after liver transplantation. Appropriate candidate selection, lifestyle modifications and specific assessment in the pre-transplant setting, as well as pharmacological strategies, adjustment of immunosuppression and a healthy lifestyle in the post-transplant setting, play a key role in correct management.
Collapse
Key Words
- CKD, chronic kidney disease
- CNI, calcineurin inhibitors
- DM, diabetes mellitus
- DPP-4, dipeptidyl peptidase-4
- ELTR, European Liver Transplant Registry
- ESLD, end-stage liver disease
- GLP1 RAs, glucagon-like peptide-1 receptor agonists
- Graft survival
- HCC, hepatocellular carcinoma
- HR, hazard ratio
- Hypertension
- IRR, incidence rate ratio
- Immunosuppressant
- LT, liver transplant
- MAFLD, metabolic dysfunction-associated fatty liver disease
- Metabolic complication
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- New-onset diabetes after transplantation
- Non-alcoholic fatty liver disease
- Non-alcoholic steatohepatitis
- OR, odds ratio
- Obesity
- Patient survival
- SGLT2, sodium-glucose co-transporter-2
- Solid organ transplantation
- UNOS, United Network for Organ Sharing
- mTORi, mammalian target of rapamycin inhibitors
Collapse
Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
- Corresponding author. Address: Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital. Tel.: +39 0498212892; fax: + 390498217848.
| | - Chiara Becchetti
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
- Hepatology, Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
| |
Collapse
|
16
|
Wang R, Wang W, Ma K, Duan X, Wang F, Huang M, Zhang W, Liang T. Variation in Tacrolimus Trough Concentrations in Liver Transplant Patients Undergoing Endoscopic Retrograde Cholangiopancreatography: A Retrospective, Observational Study. Front Pharmacol 2020; 11:1252. [PMID: 32973503 PMCID: PMC7466563 DOI: 10.3389/fphar.2020.01252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/30/2020] [Indexed: 12/16/2022] Open
Abstract
Objective High variabilities in tacrolimus (TAC) exposure are still problems that confuse physicians. TAC trough levels (TAC Cmin) fluctuated considerably after endoscopic retrograde cholangiopancreatography (ERCP) treatment in several liver transplant (LT) patients. We aimed to investigate the variation regularity of TAC Cmin post-ERCP and related factors. Methods This study was a retrospective, observational study conducted at the First Affiliated Hospital of Zhejiang University in China. From October 2017 to January 2019, 26 LT patients that received ERCP were included (73 TAC Cmin measures). The absolute difference and the variation extent in TAC Cmin pre- and post-ERCP were analyzed. Patients were divided into mild and obvious variation groups, and the differences were compared. Results The TAC Cmin in LT patients significantly increased in the first three days post-ERCP (p<0.05) and increased by more than 20% in 18 out of 26 (69.2%) patients. The mean extent of variation in TAC Cmin was 45.1% (95% confidence interval [CI]: 28.3–81.3%) and 31.4% (95% CI: 9.7–53.1%) on days 1 and 3 post-ERCP, respectively. The increasing TAC Cmin gradually returned to baseline within a week (p>0.05). The daily TAC dose and total bile acid (TBA) level were significantly higher (p<0.05) in patients with obvious variation in TAC Cmin. The differences in other demographics, clinical characteristics, variation in laboratory data, and serum amylase levels between the two groups were not significant. Conclusion The TAC Cmin significantly increased in LT patients during the first three days after ERCP, and the level returned to baseline within a week. The daily TAC dose and TBA levels may be related to this increase. Frequent drug concentration monitoring should be executed in the early phase post-ERCP, especially in patients with related factors.
Collapse
Affiliation(s)
- Rongrong Wang
- Department of Clinical Pharmacy, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Weili Wang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kuifen Ma
- Department of Clinical Pharmacy, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xin Duan
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fangfang Wang
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mingzhu Huang
- Department of Clinical Pharmacy, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| |
Collapse
|
17
|
Shah H, Ramineni G, Varghese R, Thwe EE, Hassan M, Abdul-Lattif E, Shah P, Sarker K, Patel A, Gandhi D, Solanki S. Outcomes of percutaneous coronary interventions in patients with liver transplant. Catheter Cardiovasc Interv 2020; 96:E576-E584. [PMID: 32725872 DOI: 10.1002/ccd.29168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/11/2020] [Accepted: 07/09/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Our aim is to describe characteristics of liver transplant patients undergoing percutaneous coronary interventions (PCI) as well as in-hospital outcomes including the mortality and peri-procedural complications from the largest publicly available inpatient database in the United States from 2002 to 2014. BACKGROUND Outcomes of PCI are well studied in patients with end-stage liver disease but not well studied in patients who receive liver transplant (LT). METHODS Data derived from Nationwide Inpatient Sample (NIS) were analyzed for years 2002-2014. Adult Hospitalizations with PCI were identified using ICD-9-CM procedure codes. LT status and various complications were identified by using previously validated ICD-9-CM diagnosis codes. Endpoints were in-hospital mortality and peri-procedural complications. Propensity match analysis was performed to compare the endpoints between two groups. RESULTS During the study period, 8,595,836 patients underwent PCI; 4,080 (0.04%) patients had prior LT status. 93% of patients were above age 59 years, 79% were males and 69% were nonwhites. Out of the total patients with LT status, 73% had hypertension, 57% had diabetes mellitus, and 47% had renal failure. Post-PCI complications were studied further in both liver and non-LT patients after 1:1 propensity match which showed the incidence of acute kidney injury (AKI) was higher in LT group (12.3 vs 10.7%, p = .024) but dialysis requiring AKI was similar. CONCLUSION Among the LT recipients undergoing PCI, majority were nonwhite males. Almost more than half of the recipients had diabetes mellitus and renal failure. Incidence of AKI was higher in LT group, but other peri-procedural complications were comparable.
Collapse
Affiliation(s)
| | | | | | - Ei Ei Thwe
- University of Medicine, Mandalay, Myanmar
| | | | | | - Priyal Shah
- The Medical Center, Navicent Health, Macon, Georgia
| | | | | | | | | |
Collapse
|
18
|
Sehrawat TS, Liu M, Shah VH. The knowns and unknowns of treatment for alcoholic hepatitis. Lancet Gastroenterol Hepatol 2020; 5:494-506. [PMID: 32277902 DOI: 10.1016/s2468-1253(19)30326-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/26/2019] [Accepted: 08/29/2019] [Indexed: 02/06/2023]
Abstract
Alcoholic hepatitis is an acute, inflammatory liver disease associated with high morbidity and mortality both in the short term and long term. Alcoholic hepatitis often arises in patients with a background of chronic liver disease and it is characterised by the rapid onset of jaundice and the development of myriad complications. Medical therapy for severe alcoholic hepatitis relies on corticosteroids, which have modest effectiveness. Abstinence from alcohol is critically important in patients with alcoholic hepatitis, but recidivism is high. Because of the absence of effective medical treatments for alcoholic hepatitis and alcohol dependency, there is a pressing need to develop new and effective therapeutics. Supported by promising preliminary and preclinical studies, many ongoing clinical trials of new therapies for alcoholic hepatitis are currently underway and are discussed further in this Series paper.
Collapse
Affiliation(s)
- Tejasav S Sehrawat
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mengfei Liu
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
19
|
Management of metabolic syndrome and cardiovascular risk after liver transplantation. Lancet Gastroenterol Hepatol 2020; 4:731-741. [PMID: 31387736 DOI: 10.1016/s2468-1253(19)30181-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022]
Abstract
Cardiovascular events are the second most prevalent cause of non-hepatic mortality in liver transplant recipients. The incidence of these events is projected to rise because of the growing prevalence of non-alcoholic steatohepatitis as a transplant indication and the ageing population of liver transplant recipients. Recipients with metabolic syndrome are up to four times more likely to have a cardiovascular event than recipients without, therefore prevention and optimal treatment of the components of metabolic syndrome are key in reducing the risk of these events. Although data on the treatment of metabolic comorbidities specifically in liver transplant recipients are scarce, there is detailed guidance from learned societies that mostly mirrors the guidance for patients at increased cardiovascular risk in the general population. In this Review, we discuss the management of the components of metabolic syndrome following liver transplantation and provide practical stepwise guidance. We also emphasise the need for adequately powered studies for the treatment of metabolic comorbidities in liver transplant recipients.
Collapse
|
20
|
Becchetti C, Dirchwolf M, Banz V, Dufour JF. Medical management of metabolic and cardiovascular complications after liver transplantation. World J Gastroenterol 2020; 26:2138-2154. [PMID: 32476781 PMCID: PMC7235200 DOI: 10.3748/wjg.v26.i18.2138] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/26/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation represents the only curative option for patients with end-stage liver disease, fulminant hepatitis and advanced hepatocellular carcinoma. Even though major advances in transplantation in the last decades have achieved excellent survival rates in the early post-transplantation period, long-term survival is hampered by the lack of improvement in survival in the late post transplantation period (over 5 years after transplantation). The main etiologies for late mortality are malignancies and cardiovascular complications. The latter are increasingly prevalent in liver transplant recipients due to the development or worsening of metabolic syndrome and all its components (arterial hypertension, dyslipidemia, obesity, renal injury, etc.). These comorbidities result from a combination of pre-liver transplant features, immunosuppressive agent side-effects, changes in metabolism and hemodynamics after liver transplantation and the adoption of a sedentary lifestyle. In this review we describe the most prevalent metabolic and cardiovascular complications present after liver transplantation, as well as proposing management strategies.
Collapse
Affiliation(s)
- Chiara Becchetti
- Hepatology, Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern CH-3008, Switzerland
- Department of Biomedical Research, University of Bern, Bern CH-3008, Switzerland
| | - Melisa Dirchwolf
- Hepatology, Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern CH-3008, Switzerland
- Department of Biomedical Research, University of Bern, Bern CH-3008, Switzerland
- Hepatology, Hepatobiliary Surgery and Liver Transplant Unit, Hospital Privado de Rosario, Rosario S2000GAP, Santa Fe, Argentina
| | - Vanessa Banz
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern CH-3008, Switzerland
- Department of Clinical Research, University of Bern, Bern CH-3008, Switzerland
| | - Jean-François Dufour
- Hepatology, Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Bern CH-3008, Switzerland
- Department of Biomedical Research, University of Bern, Bern CH-3008, Switzerland
| |
Collapse
|
21
|
Lin SD, Lee Krishnamoorthy T, Kumar R, Lim RT. Tacrolimus Monotherapy in Recipients of Liver Transplant: A Single-Center Experience. Transplant Proc 2019; 51:1920-1922. [DOI: 10.1016/j.transproceed.2019.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/27/2019] [Accepted: 05/07/2019] [Indexed: 02/07/2023]
|
22
|
International Liver Transplantation Society Consensus Statement on Immunosuppression in Liver Transplant Recipients. Transplantation 2019; 102:727-743. [PMID: 29485508 DOI: 10.1097/tp.0000000000002147] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Effective immunosupression management is central to achieving optimal outcomes in liver transplant recipients. Current immunosuppression regimens and agents are highly effective in minimizing graft loss due to acute and chronic rejection but can also produce a substantial array of toxicities. The utilization of immunosuppression varies widely, contributing to the wide disparities in posttransplant outcomes reported between transplant centers. The International Liver Transplantation Society (ILTS) convened a consensus conference, comprised of a global panel of expert hepatologists, transplant surgeons, nephrologists, and pharmacologists to review the literature and experience pertaining to immunosuppression management to develop guidelines on key aspects of immunosuppression. The consensus findings and recommendations of the ILTS Consensus guidelines on immunosuppression in liver transplant recipients are presented in this article.
Collapse
|
23
|
Kang SH, Cho H, Cho EJ, Lee JH, Yu SJ, Kim YJ, Yi NJ, Lee KW, Suh KS, Yoon JH. Efficacy of Sorafenib for the Treatment of Post-Transplant Hepatocellular Carcinoma Recurrence. J Korean Med Sci 2018; 33:e283. [PMID: 30402048 PMCID: PMC6209769 DOI: 10.3346/jkms.2018.33.e283] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The role of sorafenib in patients with hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) has been rarely studied. The aim of this study was to evaluate the efficacy of sorafenib in post-LT era. METHODS Consecutive patients with post-transplant HCC recurrence not eligible to resection or locoregional therapy were included. Patients receiving best supportive care (BSC) until 2007 were compared with those treated by sorafenib thereafter. RESULTS Of a total of 65 patients, 20 patients received BSC and 45 received sorafenib. Clinical characteristics were similar between two groups except that sorafenib group received tacrolimus and mammalian target-of-rapamycin inhibitors more frequently than BSC group. Treatment with sorafenib conferred a survival advantage as compared with BSC for survival after recurrence (median, 14.2 vs. 6.8 months; P = 0.01). In multivariate analyses, high serum α-fetoprotein level, synchronous intrahepatic recurrence and distant metastasis at the time of recurrence, and BSC were independently associated with poorer survival after recurrence. Sorafenib treatment was associated with better survival after recurrence as compared with BSC (hazard ratio, 0.25; 95% confidence interval, 0.10-0.62; P = 0.002). In addition, sorafenib group showed tolerable toxicity in the post-transplant setting. CONCLUSION Sorafenib may be beneficial in patients with post-transplant HCC recurrence.
Collapse
Affiliation(s)
- Seong Hee Kang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyeki Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Ju Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Su Jong Yu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Jun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
24
|
Serper M, Reese PP, Patzer RR, Levitsky J, Wolf MS. The prevalence, risk factors, and outcomes of medication trade-offs in kidney and liver transplant recipients: a pilot study. Transpl Int 2017; 31:870-879. [PMID: 29178601 DOI: 10.1111/tri.13098] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/03/2017] [Accepted: 11/19/2017] [Indexed: 11/30/2022]
Abstract
High out-of-pocket medication costs negatively impact adherence in transplantation. We evaluated the association of "medication trade-offs"-defined as choosing to spend money on other expenses over medications-with medication nonadherence and transplant outcomes. From 2011 to 2012, we performed a prospective study of 201 transplanted recipients (n = 103 liver, n = 98 kidney and) at two large US transplant centers. Structured interviews assessed socio-demographics, medication adherence, and medication trade-offs. Multivariable models assessing risk factors for medications trade-offs and the association between medications trade-offs and post-transplant hospital admissions were performed. A total of 17% of patients reported medication trade-offs; the most common trade-offs were inability to afford a prescription in the past 12 months and making choices between prescriptions and food. In multivariable analysis, insurance type (RR: 2.97, 95% CI: 1.19-7.40), limited health literacy (RR: 2.64, 95% CI: 1.23-5.64), and ≥3 comorbid conditions (RR: 2.48, 95% CI: 1.09-5.62; all P < 0.05) were associated with trade-offs. Patients with trade-offs were more likely to report nonadherence to medications (mean adherence: 77 ± 23% with trade-offs vs. 89 ± 19% without trade-offs, P < 0.01). The presence of medication trade-offs was associated with post-transplant hospital admissions (RR 1.64, 95% CI 1.14-2.35, P < 0.01). Assessments of financial barriers are warranted in clinical practice to identify nonadherence and improve post-transplant outcomes.
Collapse
Affiliation(s)
- Marina Serper
- Division of Gastroenterology, Department of Medicine, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter P Reese
- Department of Medicine, Renal Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel R Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
| | - Josh Levitsky
- Comprehensive Transplant Center (CTC), Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael S Wolf
- Department of Learning Sciences, School of Education and Social Policy, Northwestern University, Evanston, IL, USA.,Health Literacy and Learning Program, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
25
|
Oral health-related quality of life depending on dental and periodontal health in different patients before and after liver transplantation. Clin Oral Investig 2017; 22:2039-2045. [DOI: 10.1007/s00784-017-2298-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 12/06/2017] [Indexed: 12/12/2022]
|
26
|
Xia ZN, Hou R, Zhu W, Yao R, Lu Z, Qiu HZ, Lin GL. Laparoscopic-Assisted Resection for Advanced Colorectal Cancer in Solid Organ Transplant Recipients. J INVEST SURG 2017; 31:483-490. [PMID: 28925783 DOI: 10.1080/08941939.2017.1359707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
AIM To evaluate the feasibility, short- and long-term outcomes, and safety of laparoscopic resection for advanced colorectal cancer (CRC) in solid organ transplant recipients. METHODS Between September 2001 and April 2016, five patients who underwent laparoscopic-assisted resection for CRC after solid organ transplantation were included in this study. Their clinical data were retrospectively analyzed with regard to patient demographics, immunosuppressive therapy, tumor characteristics, surgical outcomes, and follow-up data. RESULTS Four kidney and one heart transplant recipients were included. Laparoscopic-assisted low anterior resection was performed in four patients with rectal or rectosigmoid junction cancer, and sigmoidectomy was done in one with sigmoid colon cancer. One kidney transplant patient received a protective loop transverse colostomy. All resections achieved complete tumor removal with tumor-free margins and total mesorectal excision, with an average number of 14 lymph nodes harvested. Most tumors were in stage III (n = 3), one was in stage II, and one in stage IV. The mean duration of surgery, intraoperative blood loss, and postoperative hospital stay were 144 min, 105 mL, and 8.8 days, respectively. No major complications occurred and graft function stayed well. During a mean follow-up period of 62 months, two patients developed metastasis and died eventually. CONCLUSION Laparoscopic resection for advanced CRC in organ transplant recipients is technically feasible and therapeutically safe, and seems to have the advantages of few postoperative complications, short recovery time, and acceptable oncological outcomes.
Collapse
Affiliation(s)
- Ze-Nan Xia
- a Department of Surgery , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences , Beijing , China
| | - Rui Hou
- a Department of Surgery , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences , Beijing , China
| | - Wei Zhu
- b Peking Union Medical College Hospital , Chinese Academy of Medical Sciences , Beijing , China
| | - Ru Yao
- a Department of Surgery , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences , Beijing , China
| | - Zhao Lu
- a Department of Surgery , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences , Beijing , China
| | - Hui-Zhong Qiu
- c Department of General Surgery , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences , Beijing , China
| | - Guo-Le Lin
- c Department of General Surgery , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences , Beijing , China
| |
Collapse
|
27
|
Resting and Exercise Energy Metabolism After Liver Transplantation for Nonalcoholic Steatohepatitis. Transplant Direct 2017; 3:e188. [PMID: 28795140 PMCID: PMC5540626 DOI: 10.1097/txd.0000000000000701] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 05/11/2017] [Indexed: 01/11/2023] Open
Abstract
Background Nonalcoholic steatohepatitis (NASH) is a leading indication for liver transplantation (LT). We hypothesized that weight gain after LT may be exacerbated by reduced metabolic rates due to the LT procedure, particularly during exercise. We aimed to compare resting and exercise energy expenditure between patients transplanted for NASH and nontransplant nonalcoholic fatty liver disease (NAFLD) subjects. Methods NASH LT recipients (>1-year post, n = 14) and NAFLD controls (n = 13) underwent analysis of body composition, resting energy expenditure (REE), and exercise energy expenditure (VO2max), the latter using a ramped-Bruce protocol assessed by expired gas analysis and peak heart rate. Results Participants were mean 61.5 ± 7.9 years, 48.1% men, and 66.7% white. Baseline comorbidities were similar between groups. Among men, mean REE adjusted for total (17.7 vs 18.8, P = 0.87) and lean body mass (23.5 vs 26.9, P = 0.26), as well as VO2 (20.1 vs 23.9, P = 0.29), was lower in NASH LT recipients compared with NAFLD controls, respectively, although not statistically significant. However, female NASH LT recipients had significantly lower mean REE than NAFLD controls when adjusted for total (14.2 vs 18.9, P = 0.01) and lean body mass (19.3 vs 26.5, P = 0.002), as well as significantly lower VO2max (14.4 vs 20.6, P = 0.017). Conclusions NASH LT recipients, particularly women, have lower REE and exercise energy expenditure compared with nontransplant NAFLD patients. More aggressive diet and exercise programs for post-LT NASH recipients to account for reduced resting and exercise metabolic rates may attenuate weight gain in this vulnerable population.
Collapse
|
28
|
Outcome of Liver Transplant Recipients With Revascularized Coronary Artery Disease: A Comparative Analysis With and Without Cardiovascular Risk Factors. Transplantation 2017; 101:793-803. [PMID: 28099403 DOI: 10.1097/tp.0000000000001647] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) is a significant problem during evaluation for liver transplantation (LT). We aim to assess survival in LT recipients based on presence, severity, extent of CAD, and cardiac events within 90 days of LT. METHODS Eighty-seven LT recipients with history of pre-LT angiogram (December 2005 to December 2012) were compared with 2 control groups without prior angiogram, 72 LT recipients matched for cardiovascular risk factors (control group I), and 119 consecutive LT recipients without any CV risk factors (control group II). CAD was assessed by (1) vessel score (≥50% reduction in luminal diameter), and (2) Extent score (Reardon scoring system). RESULTS Of the 87 LT recipients (study group), 58 (66.7%) had none or less than 50% stenosis, 29 (33.3%) had obstructive CAD (≥50% stenosis), 7 (8%) with single-vessel disease, and 22 (25.3%) with multivessel disease. In the study group, irrespective of prerevascularization severity of CAD (P = 0.357), number of segments involved (0, 1-2, > 2 segments, P = 0.304) and extent of CAD based on Reardon score (0, 1-9, >10, P = 0.224), comparable posttransplant survival was noted. Overall, patient survival in the revascularized CAD group was comparable to angiogram group without obstructive CAD, and both control group I and control group II (P = 0.184, Log Rank). Postoperative cardiac events within 90 days of LT predicted poor survival in study group as well as control groups. CONCLUSIONS Severity or extent of CAD does not impact post-LT survival, if appropriately revascularized. Early postoperative cardiac events are associated with inferior survival in LT recipients, irrespective of underlying CAD.
Collapse
|
29
|
Abstract
OPINION STATEMENT The long-term survival in liver transplant recipients (LTRs) is currently at an historical high level stemming from improvement in perioperative care, infection control, and immunosuppression medications. However, compared to the general population, LTRs have decreased survival. Metabolic diseases like hypertension, dyslipidemia, type 2 diabetes, and obesity are key determinants of long-term mortality in LTRs. The incidence and prevalence of these metabolic comorbidities is considerably higher in LTRs and likely results from a combination of factors including exposure to chronic immunosuppression, weight gain, and recurrence of chronic liver disease after liver transplantation (LT). Although there is currently little guidance in managing these metabolic conditions post-LT, recommendations are often extrapolated from non-transplant cohorts. In the current review, we explore the relationship between metabolic syndrome and its comorbidities in LTRs.
Collapse
|
30
|
Unique Considerations When Managing Hypertension in the Transplant Patient. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016. [PMID: 27815930 DOI: 10.1007/5584_2016_87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
For the select fortunate recipients of organ transplants, transplantation affords the rare opportunity for a new life. Given the scarcity of organs for transplantation, it is imperative that the health of transplant recipients be optimized in order to fully benefit from this gift of life. Unfortunately, hypertension is highly prevalent in the transplant population and it is considered a major cardiovascular risk factor contributing to mortality and morbidity in this population. In this chapter, we expound on the epidemiology, unique pathophysiology, evaluation, and management of hypertension as it pertains to the solid organ transplant recipient. In addition, a brief commentary is made on the subject of hypertension following living kidney donation, and practical aspects of management of hypertension in the solid organ recipient are summarized at the end of the chapter.
Collapse
|
31
|
Kizilisik AT, Grewal HP, Shokouh-Amiri MH, Vera SR, Hathaway DK, Gaber AO. Impact of Long-Term Immunosuppressive Therapy on Psychosocial and Physical Well Being in Liver Transplant Recipients. Prog Transplant 2016; 13:278-83. [PMID: 14765720 DOI: 10.1177/152692480301300407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
To achieve the fullest potential of transplantation, continuing concern for the recipients' quality of life must be a part of the process. Database records of patients who are currently alive and received transplants between 1982 and 1991 were retrospectively analyzed. Recipients were contacted and asked to answer a quality-of-life questionnaire. Of 105 liver transplant recipients, 51 died within 10 years after transplantation; 47 were contacted. Posttransplant complications included hypertension (64%), posttransplant diabetes mellitus (17%), osteopenia (40%), osteoporosis (26%), and heart disease (17%). Most recipients reported all aspects of their life to be average, if not better than their age-matched peers. Although most recipients complained about side effects of immunosuppressive agents, they were all happy to be alive and agreed that their quality of life showed an impressive favorable change to a level exceeding that of the general population. These results suggest that liver transplantation not only improved survival but also quality of life.
Collapse
|
32
|
Schoening W, Buescher N, Neidel N, Helbig M, Andreou A, Pascher A, Bahra M, Pratschke J, Seehofer D. Cerebrovascular events in 20 years of follow-up after liver transplantation: an underestimated issue? Clin Transplant 2016; 30:1276-1282. [DOI: 10.1111/ctr.12819] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2016] [Indexed: 01/16/2023]
Affiliation(s)
- Wenzel Schoening
- Department of General-, Visceral- and Transplantation Surgery; Charité, Campus Virchow Klinikum; Berlin Germany
- Department of General-, Visceral- and Transplantation Surgery; University Hospital of RWTH Aachen; Aachen Germany
| | - Niklas Buescher
- Department of General-, Visceral- and Transplantation Surgery; Charité, Campus Virchow Klinikum; Berlin Germany
| | - Nadja Neidel
- Department of General-, Visceral- and Transplantation Surgery; Charité, Campus Virchow Klinikum; Berlin Germany
| | - Michael Helbig
- Department of General-, Visceral- and Transplantation Surgery; Charité, Campus Virchow Klinikum; Berlin Germany
| | - Andreas Andreou
- Department of General-, Visceral- and Transplantation Surgery; Charité, Campus Virchow Klinikum; Berlin Germany
| | - Andreas Pascher
- Department of General-, Visceral- and Transplantation Surgery; Charité, Campus Virchow Klinikum; Berlin Germany
| | - Marcus Bahra
- Department of General-, Visceral- and Transplantation Surgery; Charité, Campus Virchow Klinikum; Berlin Germany
| | - Johann Pratschke
- Department of General-, Visceral- and Transplantation Surgery; Charité, Campus Virchow Klinikum; Berlin Germany
| | - Daniel Seehofer
- Department of General-, Visceral- and Transplantation Surgery; Charité, Campus Virchow Klinikum; Berlin Germany
| |
Collapse
|
33
|
Khan RS, Newsome PN. Non-alcoholic fatty liver disease and liver transplantation. Metabolism 2016; 65:1208-23. [PMID: 26997540 DOI: 10.1016/j.metabol.2016.02.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 02/01/2016] [Accepted: 02/23/2016] [Indexed: 02/07/2023]
Abstract
Cirrhosis secondary to non-alcoholic steatohepatitis (NASH) is a common indication for liver transplant. In comparison to other cirrhotic patients, patients with NASH cirrhosis are more likely to be older and have the metabolic syndrome. Pre-transplant, patients require careful evaluation of cardiovascular risk. As the incidence of non-alcoholic fatty liver disease (NAFLD) is rising, a greater proportion of donor grafts have steatosis greater than 30%, which is associated with poor outcomes. Grafts with steatosis greater than 60% are unsuitable for transplant. Overall, post-transplant survival outcomes for patients with NASH cirrhosis are similar to those with cirrhosis without NASH. However, NASH cirrhosis is associated with a higher 30-day mortality, predominantly from an increase in cardiovascular events and infections. Following liver transplant, there is a significant risk of NASH recurrence, although this seldom results in allograft loss. Furthermore, a significant number of patients who had a liver transplant for other reasons develop NASH de novo. When patients with NASH cirrhosis are considered for transplant, one of the major challenges lies in identifying which patients are too high risk for surgery. This review aims to provide information to aid this decision making process, and to provide guidance on the peri-operative care strategies that can modify risk.
Collapse
Affiliation(s)
- Reenam S Khan
- Gastroenterology and Hepatology, NIHR Birmingham Liver BRU and Centre for Liver Research, University of Birmingham, Birmingham, UK, B15 2TH.
| | - Philip N Newsome
- Hepatology, NIHR Birmingham Liver BRU and Centre for Liver Research, University of Birmingham, Birmingham, UK, B15 2TH.
| |
Collapse
|
34
|
Corticosteroid-Sparing and Optimization of Mycophenolic Acid Exposure in Liver Transplant Recipients Receiving Mycophenolate Mofetil and Tacrolimus. Transplantation 2016; 100:1705-13. [DOI: 10.1097/tp.0000000000001228] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
35
|
Boga S, Munoz-Abraham AS, Rodriguez-Davalos MI, Emre SH, Jain D, Schilsky ML. Host factors are dominant in the development of post-liver transplant non-alcoholic steatohepatitis. World J Hepatol 2016; 8:659-664. [PMID: 27239259 PMCID: PMC4876289 DOI: 10.4254/wjh.v8.i15.659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/30/2016] [Accepted: 05/09/2016] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a recognized problem in patients after orthotopic liver transplantation and may lead to recurrent graft injury. As the increased demand for liver allografts fail to match the available supply of donor organs, split liver transplantation (SLT) has emerged as an important technique to increase the supply of liver grafts. SLT allows two transplants to occur from one donor organ, and provides a unique model for observing the pathogenesis of NAFLD with respect to the role of recipient environmental and genetic factors. Here we report on two recipients of a SLT from the same deceased donor where only one developed non-alcoholic steatohepatitis (NASH), suggesting that host factors are critical for the development of NASH.
Collapse
|
36
|
Au KP, Chan SC, Chok KSH, Sharr WW, Dai WC, Sin SL, Wong TCL, Lo CM. Clinical factors affecting rejection rates in liver transplantation. Hepatobiliary Pancreat Dis Int 2015; 14:367-73. [PMID: 26256080 DOI: 10.1016/s1499-3872(15)60391-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND With improvements in survival, liver transplant recipients now suffer more morbidity from long-term immunosuppression. Considerations were given to develop individualized immunosuppression based on their risk of rejection. METHOD We retrospectively analyzed the data of 788 liver transplants performed during the period from October 1991 to December 2011 to study the relationship between acute cellular rejection (ACR) and various clinical factors. RESULTS Multivariate analysis showed that older age (P=0.04, OR=0.982), chronic hepatitis B virus infection (P=0.005, OR= 0.574), living donor liver transplantation (P=0.02, OR=0.648) and use of interleukin-2 receptor antagonist on induction (P<0.001, OR=0.401) were associated with fewer ACRs. Patients with fulminant liver failure (P=0.004, OR=4.05) were more likely to develop moderate to severe grade ACR. CONCLUSIONS Liver transplant recipients with older age, chronic hepatitis B virus infection, living donor liver transplantation and use of interleukin-2 receptor antagonist on induction have fewer ACR. Patients transplanted for fulminant liver failure are at higher risk of moderate to severe grade ACR. These results provide theoretical framework for developing individualized immunosuppression.
Collapse
Affiliation(s)
- Kin Pan Au
- Department of Surgery, the University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong SAR, China.
| | | | | | | | | | | | | | | |
Collapse
|
37
|
Hara Y, Kawagishi N, Nakanishi W, Tokodai K, Nakanishi C, Miyagi S, Ohuchi N. Prevalence and risk factors of obesity, hypertension, dyslipidemia and diabetes mellitus before and after adult living donor liver transplantation. Hepatol Res 2015; 45:764-70. [PMID: 25196899 DOI: 10.1111/hepr.12418] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/30/2014] [Accepted: 09/02/2014] [Indexed: 02/08/2023]
Abstract
AIM The development of metabolic abnormalities after liver transplantation (LTx) contributes to cardiovascular events and mortality. We analyzed the prevalence and risk factors of obesity, hypertension, dyslipidemia and diabetes mellitus (DM) after adult living donor liver transplantation. METHODS Fifty-four adult recipients with a minimum follow up of 6 months receiving living donor liver transplantation between 2001 and 2012 at the Tohoku University Hospital were retrospectively analyzed. RESULTS The prevalence of hypertension increased from 18.5% before transplantation to 35.2% post-transplantation, and new-onset hypertension after transplantation was 57.9% of post-transplant hypertension. Univariate analysis showed that risk factors of post-transplant hypertension were age (>50 years, P = 0.0023), pretransplant body mass index (BMI) of 25 or more (P = 0.0123), pretransplant hypertension (P = 0.0012) and cyclosporin A (61.5% vs tacrolimus 25.0%, P = 0.0248). The incidence of obesity, dyslipidemia and DM did not change from before to after transplantation. LTx was curative in 77.8% of cases of pretransplant dyslipidemia and 20% of cases of pretransplant DM. Primary biliary cirrhosis cases comprised 85.7% of cases of pretransplant dyslipidemia that were cured by LTx. In univariate analysis, pretransplant BMI of 25 or more was the only risk factor of post-transplant dyslipidemia (P = 0.0098). The incidence of new-onset DM after transplantation was 20%. Risk factors of post-transplant DM were male sex (P = 0.0156), pretransplant DM (P < 0.0001), alcohol abuse (P = 0.0248) and mycophenolate mofetil (P = 0.0181) by univariate analysis. CONCLUSION The prevalence of hypertension increased after LTx and pretransplant obesity was associated with several post-transplant metabolic abnormalities.
Collapse
Affiliation(s)
- Yasuyuki Hara
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Naoki Kawagishi
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Wataru Nakanishi
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Kazuaki Tokodai
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Chikashi Nakanishi
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Shigehito Miyagi
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Noriaki Ohuchi
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| |
Collapse
|
38
|
Cuervas-Mons V, Herrero JI, Gomez MA, González-Pinto I, Serrano T, de la Mata M, Fabregat J, Gastaca M, Bilbao I, Varo E, Sánchez-Antolín G, Rodrigo J, Espinosa MD. Impact of tacrolimus and mycophenolate mofetil regimen vs. a conventional therapy with steroids on cardiovascular risk in liver transplant patients. Clin Transplant 2015; 29:667-77. [DOI: 10.1111/ctr.12557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2015] [Indexed: 01/14/2023]
Affiliation(s)
- Valentín Cuervas-Mons
- Department of Internal Medicine; Liver Transplant Unit; Hospital Puerta de Hierro; Madrid Spain
| | - J. Ignacio Herrero
- Liver Unit; Clínica Universitaria de Navarra; Pamplona Spain
- CIBERehd (Centro de Investigación Biomédica en Red); Instituto de Salud Carlos III (ISCIII); Madrid Spain
| | - Miguel A. Gomez
- Hepatobiliopancreatic Surgery and Transplantation Unit; Hospital Virgen del Rocío; Sevilla Spain
| | | | | | - Manuel de la Mata
- CIBERehd (Centro de Investigación Biomédica en Red); Instituto de Salud Carlos III (ISCIII); Madrid Spain
- Clinical Management Unit of Digestive System; Hepatology Section; Hospital Universitario Reina Sofía; Córdoba Spain
| | - Joan Fabregat
- Hepatobiliopancreatic Surgery and Liver Transplantation Unit; Hospital Universitari de Bellvitge; Barcelona Spain
| | | | - Itxarone Bilbao
- CIBERehd (Centro de Investigación Biomédica en Red); Instituto de Salud Carlos III (ISCIII); Madrid Spain
- Service of Hepatobiliopancreatic Surgery and Liver Transplantation; Hospital Universitario Vall d'Hebrón; Barcelona Spain
| | - Evaristo Varo
- Abdominal Transplantation Unit; Hospital Clínico Universitario de Santiago de Compostela; Santiago de Compostela Spain
| | | | - Juan Rodrigo
- Hepatology and Liver Transplantation Unit; Hospital Regional Universitario de Málaga; Málaga Spain
| | - María Dolores Espinosa
- Hepatology and Liver Transplantation Unit; Service of Digestive System; Hospitales Universitarios de Granada; Granada Spain
| |
Collapse
|
39
|
Jiménez-Romero C, Justo-Alonso I, Cambra-Molero F, Calvo-Pulido J, García-Sesma &A, Abradelo-Usera M, Caso-Maestro O, Manrique-Municio A. Incidence, risk factors and outcome of de novo tumors in liver transplant recipients focusing on alcoholic cirrhosis. World J Hepatol 2015; 7:942-953. [PMID: 25954477 PMCID: PMC4419098 DOI: 10.4254/wjh.v7.i7.942] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 09/15/2014] [Accepted: 02/09/2015] [Indexed: 02/06/2023] Open
Abstract
Orthotopic liver transplantation (OLT) is an established life-saving procedure for alcoholic cirrhotic (AC) patients, but the incidence of de novo tumors ranges between 2.6% and 15.7% and is significantly increased in comparison with patients who undergo OLT for other etiologies. Tobacco, a known carcinogen, has been reported to be between 52% and 83.3% in AC patients before OLT. Other risk factors that contribute to the development of malignancies are dose-dependent immunosuppression, advanced age, viral infections, sun exposure, and premalignant lesions (inflammatory bowel disease, Barrett’s esophagus). A significantly more frequent incidence of upper aerodigestive (UAD) tract, lung, skin, and kidney-bladder tumors has been found in OLT recipients for AC in comparison with other etiologies. Liver transplant recipients who develop de novo non-skin tumors have a decreased long-term survival rate compared with controls. This significantly lower survival rate is more evident in AC recipients who develop UAD tract or lung tumors after OLT mainly because the diagnosis is usually performed at an advanced stage. All transplant candidates, especially AC patients, should be encouraged to cease smoking and alcohol consumption in the pre- and post-OLT periods, use skin protection, avoid sun exposure and over-immunosuppression, and have a yearly otopharyngolaryngeal exploration and chest computed tomography scan in order to prevent or reduce the incidence of de novo malignancies. Although still under investigation, substitution of calcineurin inhibitors for sirolimus or everolimus may reduce the incidence of de novo tumors after OLT.
Collapse
|
40
|
Schoening W, Neidel N, Buescher N, Andreou A, Pascher A, Seehofer D, Bahra M, Schmitz V, Pratschke J, Puhl G. Cardiovascular risk and events after liver transplantation. Experiences from 313 consecutive transplants with a follow-up of 20 years. Clin Transplant 2015; 29:343-50. [DOI: 10.1111/ctr.12520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2015] [Indexed: 01/14/2023]
Affiliation(s)
- Wenzel Schoening
- Department of General-, Visceral- and Transplantation Surgery; Charité; Berlin Germany
| | - Nadja Neidel
- Department of General-, Visceral- and Transplantation Surgery; Charité; Berlin Germany
| | - Niklas Buescher
- Department of General-, Visceral- and Transplantation Surgery; Charité; Berlin Germany
| | - Andreas Andreou
- Department of General-, Visceral- and Transplantation Surgery; Charité; Berlin Germany
| | - Andreas Pascher
- Department of General-, Visceral- and Transplantation Surgery; Charité; Berlin Germany
| | - Daniel Seehofer
- Department of General-, Visceral- and Transplantation Surgery; Charité; Berlin Germany
| | - Marcus Bahra
- Department of General-, Visceral- and Transplantation Surgery; Charité; Berlin Germany
| | - Volker Schmitz
- Department of General-, Visceral- and Transplantation Surgery; Charité; Berlin Germany
| | - Johann Pratschke
- Department of General-, Visceral- and Transplantation Surgery; Charité; Berlin Germany
| | - Gero Puhl
- Department of General-, Visceral- and Transplantation Surgery; Charité; Berlin Germany
| |
Collapse
|
41
|
Gao PJ, Gao J, Li Z, Hu ZP, Zhu JY. De novo malignancy after liver transplantation: a single-center experience of 14 cases. Ann Surg Treat Res 2015; 88:222-8. [PMID: 25844357 PMCID: PMC4384282 DOI: 10.4174/astr.2015.88.4.222] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 08/16/2014] [Accepted: 08/25/2014] [Indexed: 02/08/2023] Open
Abstract
PURPOSE The aim of this study is to evaluate the incidence of de novo malignancy after liver transplantation (LT) and compare with those among the general Chinese population. METHODS A total of 466 patients who had a minimum follow-up time of 6 months were enrolled in the study. All data of medical records and follow up were retrospectively reviewed. RESULTS The incidence rate of de novo malignancy was 3.0% (14 in 466 patients). The median elapsed time from transplant to the diagnosis of de novo malignancy was 42 months (range, 6 to 106 months). The cumulative risk for development of de novo malignancy was 1.6%, 2.7%, and 8.2% at 3, 5 and 10 years after LT, respectively. The patients were all male. The types of de novo tumors included digestive system tumor (8 in 14), lung cancer (2 in 14), urologic neoplasm (2 in 14), and hematologic malignant tumor (2 in 14). Over a mean follow-up of 24 months after diagnosis of de novo malignancy, 7 patients (50.0%) died; the overall 5-year patient survival rate was 54.5%. The relative risk of malignancy following LT was 9.5 folds higher than the general Chinese population. CONCLUSION The relative risk of malignancy following LT was much higher than the general Chinese population. Digestive system tumor is the most common type of de novo malignancy after LT in China.
Collapse
Affiliation(s)
- Peng Ji Gao
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China
| | - Jie Gao
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China
| | - Zhao Li
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China
| | - Zhi Ping Hu
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China
| | - Ji Ye Zhu
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China
| |
Collapse
|
42
|
Guillaud O, Boillot O, Sebbag L, Walter T, Bouffard Y, Dumortier J. Cardiovascular risk 10 years after liver transplant. EXP CLIN TRANSPLANT 2015; 12:55-61. [PMID: 24471725 DOI: 10.6002/ect.2013.0208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES We sought to evaluate the frequency of cardiovascular risk factors in a cohort of patients 10 years after a liver transplant, and to assess their 10-year risk of fatal cardiovascular disease using Systematic COronary Risk Evaluation (SCORE) charts. MATERIALS AND METHODS Between January 1990 and June 1996, one hundred eighty-nine adults underwent a first liver transplant in our center. Fifty-nine patients (31%) died before reaching their tenth year, and 115 patients were available with complete clinical data at 10 years. RESULTS The main indications for liver transplant were alcoholic (38%) and viral cirrhosis (40%). The median age of patients was 56 (range, 29-73 y), 80% were men, 23% were obese, 16% were active smokers, 18% were diabetic, 40% had hypercholesterolemia, and 77% had hypertension. Before the tenth year after transplant, 6 deaths were because of cardiovascular diseases, which represents the third cause of late death (> 1 year after liver transplant). After liver transplant, 5% of the surviving patients underwent ischemic cardiovascular events during the first decade. At a 10-year assessment, the median estimated 10-year risk of fatal cardiovascular disease was 1% (range, 0%-9%) and 10% of the patients had a high risk (ie, SCORE ≥ 5%). CONCLUSIONS Our results suggest that the frequency of cardiovascular events is relatively low after a liver transplant, even if most of the patients had 1 or more cardiovascular risk factors. Nevertheless, clinicians should perform a similar evaluation 15 or 20 years after the liver transplant because cardiovascular risk exponentially increases with age.
Collapse
Affiliation(s)
- Olivier Guillaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Fédération des Spécialités Digestives, Lyon
| | | | | | | | | | | |
Collapse
|
43
|
Sholkamy AA. Liver transplantation for nontransplant physicians. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2014. [DOI: 10.4103/1110-7782.148105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
|
44
|
Yang LS, Shan LL, Saxena A, Morris DL. Liver transplantation: a systematic review of long-term quality of life. Liver Int 2014; 34:1298-313. [PMID: 24703371 DOI: 10.1111/liv.12553] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 03/23/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Liver transplantation is the only curative intervention for terminal liver disease. Accurate long-term quality of life (QOL) data are required in the context of improved surgical outcomes and increasing post-transplant survival. This study reviews the long-term QOL after primary liver transplantation in adult patients surviving 5 or more years after surgery. METHODS A literature search was conducted on PubMed for all studies matching the eligibility criteria between January 2000 and October 2013. Bibliographies of included studies were also reviewed. Two authors independently performed screening of titles and abstracts. Consensus for studies included for review was achieved by discussion between authors based on predetermined eligibility criteria. Quality appraisal and data tabulation were performed using predetermined forms. Results were synthesized by narrative review. RESULTS Twenty-three studies (5402 patients) were included. QOL following liver transplantation remains superior to preoperative status up to 20 years post-operatively. More post-operative complications predicted worse QOL scores especially in physical domains. Benefits in functional domains persist long-term with independence in self-care and mobility. Employment rates recover in the short-term but decline after 5 years, and differ significantly between various aetiologies of liver disease. Overall QOL improves to a similar level as the general population, but physical function remains worse. Participation in post-operative physical activity is associated with superior QOL outcomes in liver transplant recipients compared to the general population. QOL improvements are similar compared to lung, kidney and heart transplantation. Heterogeneity between studies precluded quantitative analysis. CONCLUSIONS Liver transplantation confers specific long-term QOL and functional benefits when compared to preoperative status. This information can assist in providing a more complete estimate of the overall health of liver transplant recipients and the effectiveness of surgery. Guidelines for future studies are provided.
Collapse
Affiliation(s)
- Linda S Yang
- Melbourne Medical School, The University of Melbourne, Melbourne, Vic., Australia
| | | | | | | |
Collapse
|
45
|
Abstract
Over the last two decades in particular there has been a remarkable increase in the number of solid organ transplants being performed worldwide alongside improvements in long-term survival rates. However, the infrastructure at transplant centres has been unable to keep pace with the current volume of the transplant patient work load. These pressures on transplant specialist centres has led to calls for an increased role of the general practitioner (GP) managing particular aspects of transplant patients' medical care. Indeed, many aspects of follow-up care such as screening for malignancies, preventing infection through immunisation programmes, and managing cardiovascular risk factors are already important aspects of family practice medicine. This paper aims to review some of the aspects of transplant patient care that is important for healthcare workers in family practice to manage.
Collapse
Affiliation(s)
- Lloyd D. Hughes
- Department of Ageing and Health, Academic Foundation Doctor, NHS Tayside and University of Dundee, 1 Albert Crescent, Newport on Tay, Kingdom of Fife, DD6 8DT, Scotland
| |
Collapse
|
46
|
Dopazo C, Bilbao I, Castells LL, Sapisochin G, Moreiras C, Campos-Varela I, Echeverri J, Caralt M, Lázaro JL, Charco R. Analysis of adult 20-year survivors after liver transplantation. Hepatol Int 2014; 9:461-70. [PMID: 25788182 PMCID: PMC4473278 DOI: 10.1007/s12072-014-9577-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/21/2014] [Indexed: 02/07/2023]
Abstract
Background Liver transplantation (LT) is the treatment of choice for chronic and acute liver failure; however, the status of long-term survivors and allograft function is not well known. Aim To evaluate the clinical outcome and allograft function of survivors 20 years post-LT, cause of death during the same period and risk factors of mortality. Methods A retrospective study was conducted from prospective, longitudinal data collected at a single center of adult LT recipients surviving 20 years. A comparative sub-analysis was made with patients who were not alive 20 years post-transplantation to identify the causes of death and risk factors of mortality. Results Between 1988 and 1994, 132 patients received 151 deceased-donors LT and 28 (21 %) survived more than 20 years. Regarding liver function in this group, medians of AST, ALT and total bilirubin at 20 years post-LT were 33 IU/L (13–135 IU/L), 27 (11–152 IU/L) and 0.6 mg/dL (0.3–1.1 mg/dL). Renal dysfunction was observed in 40 % of patients and median eGFR among 20-year survivors was 64 mL/min/1.73 m2 (6–144 mL/min/1.73 m2). Sixty-one percent of 20-year survivors had arterial hypertension, 43 % dyslipidemia, 25 % de novo tumors and 21 % diabetes mellitus. Infections were the main cause of death during the 1st year post-transplant (32 %) and between the 1st and 5th year post-transplant (25 %). After 5th year from transplant, hepatitis C recurrence (22 %) became the first cause of death. Factors having an impact on long-term patient survival were HCC indication (p = 0.049), pre-transplant renal dysfunction (p = 0.043) and long warm ischemia time (p = 0.016); furthermore, post-transplant factors were diabetes mellitus (p = 0.001) and liver dysfunction (p = 0.05) at 1 year. Conclusion Our results showed the effect of immunosuppression used during decades on long-term outcome in our LT patients in terms of morbidity (arterial hypertension, diabetes mellitus, dyslipidemia and renal dysfunction) and mortality (infections and hepatitis C recurrence).
Collapse
Affiliation(s)
- C Dopazo
- Department of HBP Surgery and Transplants, Hospital Universitario Vall d´Hebron, Universidad Autónoma de Barcelona, Paseo Vall d´Hebron 119-129, 08035, Barcelona, Spain,
| | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
OBJECTIVE To provide an approach to the care of liver transplant (LT) patients, a growing patient population with unique needs. METHODS A literature search of PubMed for guidelines and review articles using the keywords "liver transplantation", "long term complications" and "medical management" was conducted, resulting in 77 articles. RESULTS As a result of being on immunosuppression, LT recipients are at increased risk of infections and must be screened regularly for metabolic complications and malignancies. DISCUSSION Although immunosuppression is key to maintaining allograft health after transplantation, it comes with its own set of medical issues to follow. Physicians following LT recipients must be aware of the greater risk for hypertension, diabetes, dyslipidemia, renal failure, metabolic bone disease and malignancies in these patients, all of whom require regular monitoring and screening. Vaccination, quality of life, sexual function and pregnancy must be specifically addressed in transplant patients.
Collapse
|
48
|
Kuramitsu K, Fukumoto T, Iwasaki T, Tominaga M, Matsumoto I, Ajiki T, Ku Y. Long-term Complications After Liver Transplantation. Transplant Proc 2014; 46:797-803. [DOI: 10.1016/j.transproceed.2013.11.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 11/05/2013] [Indexed: 12/11/2022]
|
49
|
Schrem H, Kurok M, Kaltenborn A, Vogel A, Walter U, Zachau L, Manns MP, Klempnauer J, Kleine M. Incidence and long-term risk of de novo malignancies after liver transplantation with implications for prevention and detection. Liver Transpl 2013; 19:1252-61. [PMID: 24106037 DOI: 10.1002/lt.23722] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 07/31/2013] [Indexed: 12/21/2022]
Abstract
The goal of this study was the characterization of long-term cancer risks after liver transplantation (LT) with implications for prevention and detection. Site-specific cancer incidence rates and characteristics were compared retrospectively for 2000 LT patients from a single institution (January 1, 1983 to December 31, 2010) and the general German population with standardized incidence ratios (SIRs); the total follow-up at December 31, 2011 was 14,490 person-years. The cancer incidence rates for the LT recipients were almost twice as high as those for the age- and sex-matched general population (SIR = 1.94, 95% CI = 1.63-2.31). Significantly increased SIRs were observed for vulvar carcinoma (SIR = 23.80), posttransplant lymphoproliferative disorder/non-Hodgkin lymphoma (SIR = 10.95), renal cell carcinoma (SIR = 2.65), lung cancer (SIR = 1.85), and colorectal cancer (SIR = 1.41). The mean time between transplantation and diagnosis was 6.8 years. The mean age at the time of diagnosis was significantly lower for the cohort versus the general population with similar malignancies [50 years (both sexes) versus 69 and 68 years (males and females), P ≤ 0.006]. Tumors were diagnosed at more advanced stages, and there was a trend of higher grading, which suggested more aggressive tumor growth. Tumor treatment was performed according to accepted guidelines. Surprisingly, 5-year survival was slightly better in the study cohort versus the general population for renal cell carcinoma, lung cancer, colorectal cancer, and thyroid cancer. Long-term immunosuppression with different protocols did not lead to significantly different SIRs, although patients treated with mycophenolate mofetil had the lowest SIR for de novo cancers (1.65, 95% CI = 1.2-2.4). Alcoholic liver disease (SIR = 2.30) and primary sclerosing cholangitis (SIR = 3.40) as indications for LT were associated with an increased risk of de novo malignancies. In conclusion, risk-adapted cancer surveillance is proposed. Tumor treatment performed according to accepted guidelines appears adequate. Mycophenolate may lead to lower long-term risks for de novo cancers.
Collapse
Affiliation(s)
- Harald Schrem
- Department of General, Visceral, and Transplantation Surgery, Hannover Medical School, Hannover, Germany; Integrated Research and Treatment Center Transplantation (IFB-TX), Hannover Medical School, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Pfeiffenberger J, Koschny R, Hoffmann K, Mehrabi A, Schmitz A, Radeleff B, Stremmel W, Schemmer P, Ganten TM. Sorafenib treatment is save and may affect survival of recurrent hepatocellular carcinoma after liver transplantation. Langenbecks Arch Surg 2013; 398:1123-8. [PMID: 24091908 DOI: 10.1007/s00423-013-1114-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 09/02/2013] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Recurrent hepatocellular carcinoma (HCC) after liver transplantation (LT) is a rare but challenging condition. In most cases, the recurrent tumor is presented with extrahepatic spread. Therefore, systemic treatment with sorafenib has to be assessed. Because of a plethora of possible drug interactions, e.g., with immunosuppressant or anti-infective therapy, safety and feasibility of sorafenib treatment requires special attention. MATERIALS AND METHODS We retrospectively analyzed 18 patients who suffered from recurrent advanced HCC after LT between January 2002 and December 2010 at the University Hospital Heidelberg regarding safety of sorafenib treatment and survival. RESULTS Results showed that 8 patients were eligible for treatment with sorafenib showing a median time to progression (TTP) of 4.5 months and an overall survival of 9 months. Most common side effects were grades I and II diarrhea and hand-foot syndrome (HFS) which could be managed by sorafenib dose reduction. No grade III or IV adverse events (AEs) were noticed. No patient had to discontinue treatment due to AEs. The ten patients not amenable for sorafenib treatment, due to initial poor performance status or its deterioration after first line treatment, were treated with surgical resection (n = 3), locoregional therapies (n = 1), or palliative radiation therapy (n = 1). They showed a median overall survival of 2.3 months. CONCLUSION Sorafenib may represent a therapeutic option for recurrent HCC after LT with manageable side effects. The clinical benefit of sorafenib in this setting is promising but needs to be confirmed in a prospective randomized trial.
Collapse
Affiliation(s)
- Jan Pfeiffenberger
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, INF 410, 69120, Heidelberg, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|