Weight loss is critical and often improves glucose tolerance. Transplant centers may switch patients from tacrolimus to cyclosporine to control hyperglycemia. Long-term screening for end organ complications (retinopathy, nephropathy, neuropathy) is as important for this population as it is for in non-transplant diabetics.
FIGURE
Indications for liver transplantation in the US
Renal disease
Up to 20% of OLT recipients develop end-stage renal disease, requiring hemodialysis or renal transplantation within 10 years after transplant. 5 If patients have renal dysfunction before OLT, lower-dose calcineurin inhibitors and using alternative immunosuppression post-OLT may improve renal function in the long term. A rise in creatinine in the first year after OLT is a strong risk factor for long-term development of renal insufficiency, while stable creatinine levels at 1 year usually indicate long-term maintenance of renal function.9,10
Closely monitor patients with early renal dysfunction, avoid nephrotoxic agents, and reduce or withdraw calcineurin inhibitors (as directed by the transplant center). Occasionally renal transplantation will be indicated.
Be aware that all OLT recipients need adequate hydration during acute illnesses (influenza, common colds, gastroenteritis), especially if they have renal dysfunction. Potential nephrotoxic agents, such as nonsteroidal anti-inflammatory drugs (NSAIDs), aminoglycoside antibiotics, and intravenous contrast, should be avoided if possible.
Bone disease
Osteoporosis should be screened for and identified before OLT. Contributing factors for bone disease after transplant include preexisting osteoporosis, immobility, vitamin D deficiency, corticosteroid use, and hypogonadism. In the first 6 months after transplant, bone mineral density (BMD) significantly declines, often accelerated by immunosuppressive medications, corticosteroids, and immobility. 11 - 14 After 6 months, BMD increases rapidly and, by 12 months, approaches pre-OLT values. All patients should have bone densitometry performed before OLT or before hospital discharge and receive calcium (1500 mg/d) and vitamin D (800 IU/d) supplementation (SOR: C).
Unless significant risk factors for osteoporosis are present (eg, continued use of corticosteroids, history of bone loss, fracture, or cholestatic liver disease), it is unclear whether low-risk patients should have serial bone densitometry tests performed in the years following OLT. Patients with T-scores ≥ 2 standard deviations below mean should be considered for antiresorptive therapy. Given the recent concerns regarding estrogen use and cardiovascular disease, bisphosphonates and calcitonin are preferred. For patients who develop fractures or avascular necrosis from corticosteroids, joint replacement surgery appears to be safe and effective post-OLT (SOR: B).15,16
Malignancy
Of all of the complications following OLT, malignancy causes the highest morbidity and mortality. The overall incidence of malignancy is between 2.3% and 12.9% and may be up to 5 times higher than in the general population.17,18 The most common malignancies are post-transplant lymphoproliferative disorder (1% – 4.4%) and nonmelanoma skin cancer (0.5% – 4.3%); less common are gastrointestinal (0.4% – 1.0%), genitourinary (0.2% – 2.2%), lung (0.2% – 0.8%), and oropharyngeal (0.4% – 0.8%) malignancies.17 Many patients with small liver cancers (1 lesion < 5 cm or up to 3 lesions each < 3 cm) are receiving transplants and, despite the risk of recurrence post-OLT, have a similar survival rate as patients receiving OLT for other indications.
Though it is clear that OLT recipients are at higher risk than the general population for malignancy, there are no specific guidelines for screening. However, based on the risk of early malignancy, screening should resume within the first 2 to 3 years after OLT (SOR: B).19- 22 Most transplant centers will recommend either performing a more intense screening protocol than for non-transplant patients or individualizing screening protocols for each patient depending on risk factors.
Advise patients who spend time in the sun to wear sun block with a protective factor > 40 and to have routine skin examinations. It is unclear whether colorectal cancer screening in OLT recipients should occur more frequently than the general population. Colorectal adenomas may be more common among OLT recipients than among healthy controls, 23 but until more data are available, screening should mirror that of the general population (SOR: B). Since hepatocellular carcinoma may recur after OLT, transplant centers typically request imaging (computed tomography, ultrasound, magnetic resonance imaging) at regular intervals after OLT.
Use your discretion when screening for other common malignancies, such as breast, cervical, and prostate cancer. It is unclear whether screening specific groups of patients (such as tobacco smokers) for oropharyngeal, lung, and genitourinary cancer will be cost-effective or impact survival.