TABLE 2.
Summary Recommendations for the Primary Care of the Liver Transplant Recipient
| Hypertension |
| Target blood pressure is <140/90 or <130/80 mm Hg for OLT patients with diabetes, renal disease, or history of CAD |
| Dihydropyridine CCBs (amlodipine, nifedipine) and/or angiotensin-converting enzyme inhibitors (lisinopril, enalapril)/angiotensin receptor blockers (losartan, valsartan) are first-line agents for management of hypertension; the latter 2 may be preferred in patients with diabetes or proteinuria and may benefit patients with recurrent hepatitis C virus or nonalcoholic steatohepatitis |
| Avoid nondihydropyridine CCBs (diltiazem, verapamil) and use diuretics (hydrochlorothiazide, furosemide) with caution |
| Diabetes |
| Annual screening for diabetes with random or fasting blood glucose measurement is recommended; the diagnosis is based on American Diabetes Association guidelines |
| The management is similar to that of the nontransplant general population; insulin may be required in the early posttransplant period. Oral hypoglycemic agents are safe and effective at later stages |
| Dyslipidemia |
| Liver transplant is considered a risk factor for coronary heart disease; hence, the target low-density lipoprotein cholesterol is <130 mg/dL in the absence of any other associated risk factor, <100 mg/dL in the presence of any other associated coronary heart disease risk factor (smoking, hypertension, low high-density lipoprotein cholesterol, family history of early CAD, advanced age, and preexisting NAFLD), and <70 mg/dL if preexisting or current coronary heart disease |
| Statins are safe and effective; pravastatin and atorvastatin are preferred agents. Fish oil can be used for management of hypertriglyceridemia. Fibrates, niacin, and ezetimibe appear safe. All agents require close follow-up |
| Cardiovascular disease |
| Strict management of CAD risk factors is recommended |
| Aspirin prophylaxis is recommended (also prevents late hepatic artery thrombosis) |
| Chronic kidney disease |
| Optimal management of diabetes and hypertension can reduce the rate of renal damage |
| Careful monitoring for nephrotoxic medications and judicious use of contrast dye is advised |
| Follow serum trough levels of CNIs and monitor for drug interactions |
| Osteoporosis |
| Dual-energy x-ray absorptiometry is recommended every 2-3 y post OLT |
| Management of osteoporosis is similar to that for the nontransplant general population |
| Pregnancy |
| Pregnancies are considered high risk in OLT recipients |
| Conception should generally be delayed for 1 y post OLT; barrier contraceptives and low-dose oral contraceptives are safe and effective |
| CNIs should be continued and monitored during pregnancy |
| Breastfeeding is controversial, but benefit may outweigh the risk with low-dose CNI |
| Vaccinations15 |
| The ideal time to vaccinate OLT recipients is before immunosuppression, recognizing the probable need for booster immunizations post OLT |
| Vaccinations post OLT should be delayed until prednisone dose is lowered to less than 10 mg/d |
| Live-attenuated vaccines should be avoided after OLT |
| Prophylactic pneumococcal and influenza vaccine for all OLT patients and Haemophilus influenzae b vaccine for patients with splenectomy |
CAD = coronary artery disease; CCB = calcium channel blocker; CNI = calcineurin inhibitor; NAFLD = nonalcoholic fatty liver disease; OLT = orthotopic liver transplant.