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Orthotopic liver transplantation and what to do during follow-up: recommendations for the practitioner

Nature Clinical Practice Gastroenterology & Hepatology volume 6, pages 23–36 (2009)Cite this article

Abstract

Improvements in surgical technique and the introduction of several new immunosuppressive medications mean that outcome after orthotopic liver transplantation (OLT) has improved continuously over the past 15 years. Given the increasing longevity of patients after OLT, the recognition and prevention of long-term complications after transplantation have become ever more important. With respect to graft function, physicians responsible for the everyday care of patients following transplantation should be particularly aware of the risk of late and chronic rejection episodes and of recurrence of the underlying liver disease. The major challenge of post-transplant care is, however, how best to prevent and manage the long-term adverse effects caused by the immunosuppressive medications prescribed. Screening investigations for early diagnosis of malignancy, strict control of cardiovascular risk factors, preservation of renal function, and prevention of infections are, therefore, fundamental. This Review suggests guidelines for the management of OLT recipients to improve long-term survival, overall outcome and health-related quality of life.

Key Points

  • Long-term mortality after orthotopic liver transplantation (OLT) mainly results from the recurrence of the underlying liver disease and from complications associated with the use of immunosuppressive drugs (in particular malignancy and cardiovascular disease)

  • Thorough management of the metabolic adverse effects of immunosuppressive drugs—such as diabetes mellitus, dyslipidemia, obesity, arterial hypertension and renal dysfunction—is essential for a good long-term outcome after OLT

  • The increased risk of malignancies in OLT recipients, in particular lymphomas and skin tumors, means that patients should undergo regular tumor screening

  • Reinfection with HCV and recurrent development of cirrhosis are serious and as-yet unsolved problems—treatment with pegylated interferon and ribavirin is effective but cumbersome and should be managed by an experienced physician

  • Management and prevention of recurrent HBV infection, autoimmune liver diseases, graft dysfunction and psychological problems requires an interdisciplinary approach and close collaboration among primary care physicians, gastroenterologists and the transplant center

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Figure 1: Differential diagnosis of elevated liver-enzyme levels in orthotopic liver transplantation recipients in the long term.
Figure 2: Diagnostic algorithm used at the Transplant Center of the University Hospital Hamburg-Eppendorf, Hamburg, Germany for orthotopic liver transplantation recipients who have elevated liver-enzyme levels.

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Acknowledgements

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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  1. D Benten is a Medical Fellow in the Department of Gastroenterology/Hepatology, K Staufer is a Surgical Fellow and M Sterneck is Professor of Medicine and Consultant Transplant Hepatologist at the Transplant Center, all at the University Hospital Hamburg-Eppendorf, Hamburg, Germany.,

    Daniel Benten, Katharina Staufer & Martina Sterneck

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Correspondence to Martina Sterneck.

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Benten, D., Staufer, K. & Sterneck, M. Orthotopic liver transplantation and what to do during follow-up: recommendations for the practitioner. Nat Rev Gastroenterol Hepatol 6, 23–36 (2009). https://doi.org/10.1038/ncpgasthep1312

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