Long-Term Management of the Liver Transplant Recipient: Pearls for the Practicing Gastroenterologist

According to the United States Department of Health and Human Services, from 1988 to 2010, the number of annual liver transplants has increased from 1713 to 6291. Patient survival rates have ranged from 66% to 71% at 7 years and graft survival rates have ranged from 58% to 61% at 7 years. Both the increase in frequency of liver transplantation and the improved survival of transplant recipients are great achievements of modern medicine. With this increase in the number of successful outcomes, there are more liver transplant recipients living both longer and with an improved quality of life. The responsibility for the long-term care for these patients often falls on the shoulders of the practicing gastroenterologist. The identification and treatment of long-term comorbidities such as hypertension, cardiovascular disease, dyslipidemia, obesity, diabetes mellitus, osteoporosis, renal injury, malignancy, rejection, and drug interactions has become a vital element of the management of these patients. One pearl to always remember when initiating treatment for any of these comorbidities is that all medications (prescribed or over the counter) need to be approved by the transplant team.

Renal Dysfunction

Renal injury is a common complication after liver transplantation. The glomerular filtration rate (GFR) can fall as low as 60% of the preoperative GFR measured in the first 6 weeks posttransplantation. It is well known that kidney injury after surgery and long-term chronic renal failure can decrease patient survival. Measurement of the GFR before transplantation is not accurate owing to abnormalities in the fluid status. Creatinine levels may also be inaccurate because they depend on the patient’s muscle mass. Likewise, renal function at the moment of the transplant is not a predictor of postoperative renal function.

The incidence of acute kidney injury after liver transplantation ranges between 48% and 98%. It is very likely that the wide range is secondary to the fact that these studies used different definitions for acute kidney injury. Cabezuelo and colleagues classified acute renal failure after transplantation into early (0–7 days posttransplantation) and late (8–28 days posttransplantation). The most frequent etiologies for early acute renal failure were ischemic acute tubular necrosis and pre-renal azotemia. Sepsis and the use of calcineurin inhibitors were the most common etiologies for patients who developed late acute renal failure.

With the increase in patient survival posttransplantation, chronic kidney disease has become a more common long-term complication. The incidence of chronic kidney disease has been reported as high as 27% at 5 years after transplantation. The most common causes of chronic kidney disease include diabetic nephropathy and calcineurin inhibitor toxicity, with cyclosporine implicated more often than tacrolimus. Focal segmental glomerulosclerosis, acute tubular necrosis, and persistent hepatorenal syndrome have also been implicated. The renal function of all patients after liver transplantation should be monitored regularly. This can be done by screening them for microalbuminuria and measuring GFR regularly. Attention must be given to management of other comorbidities like hypertension, diabetes mellitus, and the use of nephrotoxic drugs.

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