Recommendations for Primary Care Doctors Regarding Long-term Management of Liver Transplant Patients

In the September 2009 American Journal of Transplantation, the American Society of Transplantation published recommendations for primary care physicians who provide long-term management of liver transplant recipients. The guidelines address issues including drug interactions and side effects of immunosuppressive agents, dysfunction of the transplanted liver, metabolic problems, and special considerations for children and pregnant women.

By Liz Highleyman

While liver transplant recipients are typically managed by transplant specialists for 6 months or so after the procedure, care then usually returns to a primary care doctor. To date, however, there have been no official guidelines for primary care providers regarding the management of liver transplant patients, and many doctors lack knowledge or confidence in this area.

The newly published guidelines represent the official position of the American Society of Transplantation. Supporting data in the document are based on a formal review and analysis of published literature in the field, as well as the clinical experience of the panel of expert authors.

The issues discussed in the new guidelines include:

	Drug interactions and side effects of immunosuppressive agents;
	Allograft (new liver) dysfunction;
	Kidney dysfunction;
	Metabolic disorders;
	Preventive medicine;
	Post-transplant malignancies;
	Considerations regarding disability and workforce productivity;
	Issues related to sexual function;
	Issues related to pregnancy;
	Care of pediatric patients.

"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," according to the authors. "However, most [primary-care providers] have no formal training in transplantation."

These guidelines, they added, "are intended to provide a bridge between transplant centers and primary care physicians in the long-term management of the liver transplant patient."

The authors recommend that primary care doctors consult a transplant specialist if a patient's liver enzyme levels increase 1.5-fold or more above normal limits, when considering prescribing any new medication, when adjusting medications due to pregnancy, or in case of kidney dysfunction, metabolic problems such as diabetes (which tend to occur at higher rates in transplant recipients), or cancer that requires changes to immunosuppressive therapy.

University of Alabama at Birmingham, Birmingham, AL; University of California San Francisco, San Francisco, CA; Portland Veterans Administration Medical Center, Portland, OR; University of Nebraska, Omaha, NE; Washington University, St. Louis, MO; Children's Hospital of Pittsburgh, Pittsburgh, PA; Henry Ford Hospital, Detroit, MI; Oregon Health and Sciences University, Portland, OR; Mayo Clinic, Rochester, MN; Duke University, Durham, NC.

10/02/09

Reference
BM McGuire, P Rosenthal, CC Brown, and others. Long-term management of the liver transplant patient: recommendations for the primary care doctor. American Journal of Transplantation 9(9): 1988-2003. September 2009. (Abstract).