Clinical

New guidelines help primary care doctors manage liver transplant recipients

Last Updated: 2009-09-11 18:46:48 -0400 (Reuters Health)

By Karla Gale

NEW YORK (Reuters Health) - A recent survey found that most transplant centers expect primary care doctors to manage the overall care of liver transplant recipients after 6 months of transplantation.

With this in mind, Dr. Brendan M. McGuire, from the University of Alabama at Birmingham, and associates drafted comprehensive guidelines, published in the American Journal of Transplantation for September, to assist the primary care physician in the long-term care of liver transplant recipients.

"In addition to routine health care needs, unrelated to the transplant, primary care physicians are faced with complex management of chronic illness and cancer screening that have unique implications due to chronic immunosuppression," the authors note. "However, most PCPs have no formal training in transplantation."

The guidelines address drug interactions and side effects of immunosuppressive agents and allograft dysfunction. In addition, they cover renal dysfunction, metabolic disorders, and preventive medicine, and malignancies. Other issues include disability and productivity in the workforce, issues specific to pregnancy and sexual function, and pediatric patient concerns.

The tie between transplant centers and primary care providers is not being severed, however. In many instances, physicians are advised to confer with the transplant center.

Such situations include prescription of any new medication or any time liver function tests rise 1.5-times or more above normal; in the event of renal dysfunction or metabolic disease; the development of malignancies that require reductions in immunosuppression; and when medications need to be adjusted in the event of pregnancy,

Dr. McGuire's team includes tables summarizing some of the drugs and substances that may alter levels of cyclosporine, tacrolimus and sirolimus, as well as lists of vaccines that are and are not safe to give to recipients or their household contacts. They also recommend looking for possible drug interactions on www.epocrates.com and www.pdr.net.

In many instances, standard treatment for medical conditions is appropriate, the authors say. For example, in the case of renal dysfunction, they remind physicians to optimize treatment of such conditions as diabetes and hypertension to minimize further renal injury and to evaluate with urine analysis and possible referral to a nephrologist.

According to Dr. McGuire and his associates, many metabolic disorders occur at higher rates in transplant recipients that require special attention. These include diabetes, hypertension, dyslipidemia, obesity, gout, and metabolic bone disease. Standard therapy is called for, except in cases where drug interactions may be problematic.

The report notes that a number of malignancies occur more commonly in liver transplant recipients than in the general population, including various virally mediated cancers, cutaneous cancers, and colon and upper aerodigestive cancers. In some cases, the transplant center should be consulted about lowering the dose of immunosuppressants, since long-term immunosuppression is the basis for the higher incidence.

The rate of spontaneous abortion is high after liver transplantation, and women are advised to wait at least a year after transplantation before becoming pregnant.

In general, quality of life improves after a successful transplant. However, health-related quality of life may be lower than in the general population. Permanent disability is rare, the report indicates, and patients can often return to work after the incision heals and the patient can perform activities of daily living.

Am J Transplant 2009;9:1988-2003.