Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5258_Библиотеки_им_академика_М_И_Перельмана.pdf
106
87. Bakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P, etal. Effect of nerenone
on chronic kidney disease outcomes in type 2 diabetes. N Engl J Med. 2020;383(23):2219–29.
https://doi.org/10.1056/NEJMoa2025845.
88. Mortensen LA, Jespersen B, Helligsoe ASL, Tougaard B, Cibulskyte-Ninkovic D, Egfjord
M, etal. Effect of spironolactone on kidney function in kidney transplant recipients (the
SPIREN trial): a randomized placebo-controlled clinical trial. Clin J Am Soc Nephrol.
2024;19(6):755–66. https://doi.org/10.2215/cjn.0000000000000439.
89. Sharif A, Chakkera H, de Vries APJ, Eller K, Guthoff M, Haller MC, etal. International
consensus on post-transplantation diabetes mellitus. Nephrol Dial Transplant.
2024;39(3):531–49. https://doi.org/10.1093/ndt/gfad258.
90. Heisel O, Heisel R, Balshaw R, Keown P.New onset diabetes mellitus in patients receiv-
ing calcineurin inhibitors: a systematic review and meta-analysis. Am J Transplant.
2004;4(4):583–95.
https://doi.org/10.1046/j.1600- 6143.2003.00372.x.
91. Mahmoud T, Yagan J, Hasan A, Gheith OA, Mostafa M, Rida S, etal. Sodium-glucose co-
transporter 2 inhibitors & glucagon-like peptide-1 receptor agonists, efcacy & safety in dia-
betic kidney transplant recipients. Clin Transpl. 2023;37(12):e15144. https://doi.org/10.1111/
ctr.15144.
92. Watson KE, Dhaliwal K, Robertshaw S, Verdin N, Benterud E, Lamont N, etal. Consensus
recommendations for sick day medication guidance for people with diabetes, kidney, or car-
diovascular disease: a modied delphi process. Am J Kidney Dis. 2023;81(5):564–74. https://
doi.org/10.1053/j.ajkd.2022.10.012.
93. Krisanapan P, Suppadungsuk S, Sanpawithayakul K, Thongprayoon C, Pattharanitima P,
Tangpanithandee S, et al. Safety and efcacy of glucagon-like peptide-1 receptor agonists
among kidney transplant recipients: a systematic review and meta-analysis. Clin Kidney
J. 2024;17(2):sfae018. https://doi.org/10.1093/ckj/sfae018.
94. Torres A, Hernández D, Moreso F, Serón D, Burgos MD, Pallardó LM, etal. Randomized
controlled trial assessing the impact of tacrolimus versus cyclosporine on the incidence
of posttransplant diabetes mellitus. Kidney Int Rep. 2018;3(6):1304–15. https://doi.
org/10.1016/j.ekir.2018.07.009.
95. Lentine KL, Rocca-Rey LA, Bacchi G, Wasi N, Schmitz L, Salvalaggio PR, etal. Obesity and
cardiac risk after kidney transplantation: experience at one center and comprehensive literature
review. Transplantation. 2008;86(2):303–12. https://doi.org/10.1097/TP.0b013e31817ef0f9.
96. Attallah N, Yassine L.SAT-323 use of liraglutide for weight loss in kidney transplant recipi-
ents: report of 14 cases. Kidney Int Rep. 2020;5(3):S135–S6. https://doi.org/10.1016/j.
ekir.2020.02.343.
97. Sarno G, Frias-Toral E, Ceriani F, Montalván M, Quintero B, Suárez R, etal. The impact and
effectiveness of weight loss on kidney transplant outcomes: a narrative review. Nutrients.
2023;15(11):2508. https://doi.org/10.3390/nu15112508.
98. Ritz E.Bariatric surgery and the kidney—much benet, but also potential harm. Clin Kidney
J. 2012;6(4):368–72. https://doi.org/10.1093/ckj/sfs161.
99. Salazar M, Taber D, O’Neill T, Thomas B, Kannabhiran D, Curry L, etal. Post gastric bypass
oxalosis in renal transplants: clinicopathologic correlates. Transplantation. 2014;98:575–6.
100. Campbell SB, Walker R, Tai SS, Jiang Q, Russ GR.Randomized controlled trial of sirolimus
for renal transplant recipients at high risk for nonmelanoma skin cancer. Am J Transplant.
2012;12(5):1146–56.
https://doi.org/10.1111/j.1600- 6143.2012.04004.x.
101. Euvrard S, Morelon E, Rostaing L, Gofn E, Brocard A, Tromme I, etal. Sirolimus and sec-
ondary skin-cancer prevention in kidney transplantation. N Engl J Med. 2012;367(4):329–39.
https://doi.org/10.1056/NEJMoa1204166.
102. Hoogendijk-van den Akker JM, Harden PN, Hoitsma AJ, Proby CM, Wolterbeek R, Bouwes
Bavinck JN, etal. Two-year randomized controlled prospective trial converting treatment of
stable renal transplant recipients with cutaneous invasive squamous cell carcinomas to siroli-
mus. J Clin Oncol. 2013;31(10):1317–23. https://doi.org/10.1200/jco.2012.45.6376.
B. Boonpheng and I. C. De Castro
107
103. Yohannan B, Sridhar A, Kaur H, DeGolovine A, Maithel N. Screening for renal cell car-
cinoma in renal transplant recipients: a single-Centre retrospective study. BMJ Open.
2023;13(9):e071658.
https://doi.org/10.1136/bmjopen- 2023- 071658.
104. Dahle DO, Skauby M, Langberg CW, Brabrand K, Wessel N, Midtvedt K.Renal cell carci-
noma and kidney transplantation: a narrative review. Transplantation. 2022;106(1):e52–63.
https://doi.org/10.1097/tp.0000000000003762.
105. Van Meerhaeghe T, Murakami N, Le Moine A, Brouard S, Sprangers B, Degauque N.Fine-
tuning tumor- and allo-immunity: advances in the use of immune checkpoint inhibitors in kid-
ney transplant recipients. Clin Kidney J. 2024;17(4):61. https://doi.org/10.1093/ckj/sfae061.
106. Allen UD, Preiksaitis JK.Post-transplant lymphoproliferative disorders, Epstein-Barr virus
infection, and disease in solid organ transplantation: guidelines from the American Society of
Transplantation infectious diseases Community of Practice. Clin Transpl. 2019;33(9):e13652.
https://doi.org/10.1111/ctr.13652.
107. Watt KD, Rolak S, Foley DP, Plichta JK, Pruthi S, Farr D, et al. Cancer surveillance in
solid organ transplant recipients with a pretransplant history of malignancy: multidis-
ciplinary collaborative expert opinion. Transplantation. 2024. https://doi.org/10.1097/
tp.0000000000005056.
108. Yarlagadda SGN, Thomas, Quarles LD.Kidney transplantation in adults: persistent hyper-
parathyroidism after kidney transplantation. In: Connor R, editor. UpToDate. Alphen aan den
Rijn: Wolters Kluwer; 2024.
109. Courbebaisse M, Bourmaud A, Souberbielle JC, Sberro-Soussan R, Moal V, Le Meur Y, etal.
Nonskeletal and skeletal effects of high doses versus low doses of vitamin D(3) in renal trans-
plant recipients: results of the VITALE (VITamin D supplementation in renAL transplant
recipients) study, a randomized clinical trial. Am J Transplant. 2023;23(3):366–76. https://
doi.org/10.1016/j.ajt.2022.12.007.
110. Jørgensen HS, Claes K, Smout D, Naesens M, Kuypers D, D’Haese P, et al. Associations
of changes in bone turnover markers with change in bone mineral density in kidney
transplant patients. Clin J Am Soc Nephrol. 2024;19(4):483–93. https://doi.org/10.2215/
cjn.0000000000000368.
111. Nikkel LE, Hollenbeak CS, Fox EJ, Uemura T, Ghahramani N.Risk of fractures after renal
transplantation in the United States. Transplantation. 2009;87(12):1846–51. https://doi.
org/10.1097/TP.0b013e3181a6bbda.
112. Iseri K, Carrero JJ, Evans M, Felländer-Tsai L, Berg HE, Runesson B, et al. Fractures
after kidney transplantation: incidence, predictors, and association with mortality. Bone.
2020;140:115554. https://doi.org/10.1016/j.bone.2020.115554.
113. Felten R, Perrin P, Caillard S, Moulin B, Javier RM.Avascular osteonecrosis in kidney trans-
plant recipients: risk factors in a recent cohort study and evaluation of the role of second-
ary hyperparathyroidism. PLoS One. 2019;14(2):e0212931. https://doi.org/10.1371/journal.
pone.0212931.
114. Mekraksakit P, Boonpheng B, Leelaviwat N, Duangkham S, Deb A, Kewcharoen J, et al.
Risk factors and outcomes of post-transplant erythrocytosis among adult kidney transplant
recipients: a systematic review and meta-analysis. Transpl Int. 2021;34(11):2071–86. https://
doi.org/10.1111/tri.14016.
115. Lo CKL, Kumar D.Respiratory viral infections including COVID-19in solid organ trans-
plantation. Curr Opin Organ Transplant. 2023;28(6):471–82. https://doi.org/10.1097/
mot.0000000000001106.
116. Klomjit N, Zand L, Cornell LD, Alexander MP.COVID-19 and glomerular diseases. Kidney
Int Rep. 2023;8(6):1137–50. https://doi.org/10.1016/j.ekir.2023.03.016.
117. Lentine KL, Alhamad T.Kidney transplantation from SARS-CoV-2-infected deceased donors:
comfort or caution in contemporary practice? Clin J Am Soc Nephrol. 2023;18(11):1393–5.
https://doi.org/10.2215/cjn.0000000000000325.
118. Dean PG, Lund WJ, Larson TS, Prieto M, Nyberg SL, Ishitani MB, et al. Wound-healing
complications after kidney transplantation: a prospective, randomized comparison of siro-
4 Primary Care of the Adult Kidney Transplant and Kidney-Pancreas Transplant…
108
limus and tacrolimus. Transplantation. 2004;77(10):1555–61. https://doi.org/10.1097/01.
tp.0000123082.31092.53.
119. Pennington CA, Park JM.Sublingual tacrolimus as an alternative to oral administration for
solid organ transplant recipients. Am J Health Syst Pharm. 2015;72(4):277–84. https://doi.
org/10.2146/ajhp140322.
120. Foster BJ, Dahhou M, Zhang X, Platt RW, Samuel SM, Hanley JA. Association between
age and graft failure rates in young kidney transplant recipients. Transplantation.
2011;92(11):1237–43. https://doi.org/10.1097/TP.0b013e31823411d7.
121. Chen A.Mitigating risk associated with the transition from pediatric to adult kidney trans-
plant care: strategies to promote success. Adv Chronic Kidney Dis. 2021;28(6):570–6.
https://doi.org/10.1053/j.ackd.2021.10.002.
122. Chaturvedi S, Jones CL, Walker RG, Sawyer SM.The transition of kidney transplant recipi-
ents: a work in progress. Pediatr Nephrol. 2009;24(5):1055–60. https://doi.org/10.1007/
s00467- 009- 1124- y.
123. Dobbels F, Ruppar T, De Geest S, Decorte A, Van Damme-Lombaerts R, Fine RN.Adherence
to the immunosuppressive regimen in pediatric kidney transplant recipients: a systematic
review. Pediatr Transplant. 2010;14(5):603–13.
https://doi.org/10.1111/j.1399- 3046.2010.
01299.x.
124. Klein CL, Josephson MA. Post-transplant pregnancy and contraception. Clin J Am Soc
Nephrol. 2022;17(1):114–20. https://doi.org/10.2215/cjn.14100820.
125. Coscia L, Cohen D, Dube GK, Hofmann RM, Moritz MJ, Gattis S, etal. Outcomes with
belatacept exposure during pregnancy in kidney transplant recipients: a case series.
Transplantation. 2023;107(9):2047–54. https://doi.org/10.1097/tp.0000000000004634.
126. Zuber J, Anglicheau D, Elie C, Bererhi L, Timsit MO, Mamzer-Bruneel MF, etal. Sirolimus
may reduce fertility in male renal transplant recipients. Am J Transplant. 2008;8(7):1471–9.
https://doi.org/10.1111/j.1600- 6143.2008.02267.x.
127. Kelly WD, Lillehei RC, Merkel FK, Idezuki Y, Goetz FC. Allotransplantation of
the pancreas and duodenum along with the kidney in diabetic nephropathy. Surgery.
1967;61(6):827–37.
128. Kandaswamy R, Stock PG, Miller JM, Booker SE, White J, Israni AK, et al. OPTN/
SRTR 2022 annual data report: pancreas. Am J Transplant. 2024;24(2s1):S119. https://doi.
org/10.1016/j.ajt.2024.01.013.
129. Gruessner RW, Sutherland DE, Kandaswamy R, Gruessner AC. Over 500 solitary pan-
creas transplants in nonuremic patients with brittle diabetes mellitus. Transplantation.
2008;85(1):42–7. https://doi.org/10.1097/01.tp.0000296820.46978.3f.
130. Nathan DM, Fogel H, Norman D, Russell PS, Tolkoff-Rubin N, Delmonico FL, et al.
Long-term metabolic and quality of life results with pancreatic/renal transplantation
in insulin-dependent diabetes mellitus. Transplantation. 1991;52(1):85–91. https://doi.
org/10.1097/00007890- 199107000- 00018.
131. Gruessner AC, Sutherland DE, Gruessner RW. Long-term outcome after pancreas trans-
plantation. Curr Opin Organ Transplant. 2012;17(1):100–5. https://doi.org/10.1097/
MOT.0b013e32834ee700.
132. Gruessner RW, Sutherland DE, Gruessner AC.Mortality assessment for pancreas transplants.
Am J Transplant. 2004;4(12):2018–26.
https://doi.org/10.1111/j.1600- 6143.2004.00667.x.
133. Owda AK, Abdallah AH, Haleem A, Hawas FA, Mousa D, Fedail H, etal. De novo dia-
betes mellitus in kidney allografts: nodular sclerosis and diffuse glomerulosclerosis lead-
ing to graft failure. Nephrol Dial Transplant. 1999;14(8):2004–7. https://doi.org/10.1093/
ndt/14.8.2004.
134. Fioretto P, Steffes MW, Sutherland DE, Goetz FC, Mauer M.Reversal of lesions of diabetic
nephropathy after pancreas transplantation. N Engl J Med. 1998;339(2):69–75. https://doi.
org/10.1056/nejm199807093390202.
135. Navarro X, Sutherland DE, Kennedy WR. Long-term effects of pancreatic transplanta-
tion on diabetic neuropathy. Ann Neurol. 1997;42(5):727–36. https://doi.org/10.1002/
ana.410420509.
B. Boonpheng and I. C. De Castro
109
136. Jukema JW, Smets YF, van der Pijl JW, Zwinderman AH, Vliegen HW, Ringers J, et al.
Impact of simultaneous pancreas and kidney transplantation on progression of coronary ath-
erosclerosis in patients with end-stage renal failure due to type 1 diabetes. Diabetes Care.
2002;25(5):906–11. https://doi.org/10.2337/diacare.25.5.906.
137. Danovitch GM. Handbook of kidney transplantation. 6th ed. Philadelphia: Lippincott
Williams & Wilkins; 2017.
138. Aref A, Zayan T, Pararajasingam R, Sharma A, Halawa A.Pancreatic transplantation: brief
review of the current evidence. World J Transplant. 2019;9(4):81–93. https://doi.org/10.5500/
wjt.v9.i4.81.
139. Robertson RP, Davis C, Larsen J, Stratta R, Sutherland DE.Pancreas and islet transplantation
in type 1 diabetes. Diabetes Care. 2006;29(4):935. https://doi.org/10.2337/diacare.29.04.06.
dc06- 9908.
140. Jarmi T, Brennan E, Clendenon J, Spaulding AC.Mortality assessment for pancreas transplants
in the United States over the decade 2008-2018. World J Transplant. 2023;13(4):147–56.
https://doi.org/10.5500/wjt.v13.i4.147.
141. Dillman JR, Elsayes KM.Imaging of pancreas transplant. In: Elsayes KM, editor. Cross-
sectional imaging of the abdomen and pelvis: a practical algorithmic approach. NewYork:
Springer; 2015. p.741–59.
142. Rogers J, Farney AC, Orlando G, Farooq U, Al-Shraideh Y, Stratta RJ.Pancreas transplan-
tation with portal venous drainage with an emphasis on technical aspects. Clin Transpl.
2014;28(1):16–26. https://doi.org/10.1111/ctr.12275.
143. El-Hennawy H, Stratta RJ, Smith F.Exocrine drainage in vascularized pancreas transplanta-
tion in the new millennium. World J Transplant. 2016;6(2):255–71. https://doi.org/10.5500/
wjt.v6.i2.255.
144. Bloom RD, Olivares M, Rehman L, Raja RM, Yang S, Badosa F. Long-term pan-
creas allograft outcome in simultaneous pancreas-kidney transplantation: a compari-
son of enteric and bladder drainage. Transplantation. 1997;64(12):1689–95. https://doi.
org/10.1097/00007890- 199712270- 00010.
145. Bazerbachi F, Selzner M, Boehnert MU, Marquez MA, Norgate A, McGilvray ID, etal.
Thymoglobulin versus basiliximab induction therapy for simultaneous kidney-pancreas
transplantation: impact on rejection, graft function, and long-term outcome. Transplantation.
2011;92(9):1039–43. https://doi.org/10.1097/TP.0b013e3182313e4f.
146. Kandaswamy R, Stock PG, Gustafson SK, Skeans MA, Urban R, Fox A, etal. OPTN/SRTR
2017 annual data report: pancreas. Am J Transplant. 2019;19(Suppl 2):124–83. https://doi.
org/10.1111/ajt.15275.
147. Bechstein WO, Malaise J, Saudek F, Land W, Fernandez-Cruz L, Margreiter R, etal. Efcacy
and safety of tacrolimus compared with cyclosporine microemulsion in primary simultaneous
pancreas-kidney transplantation: 1-year results of a large multicenter trial. Transplantation.
2004;77(8):1221–8. https://doi.org/10.1097/01.tp.0000120865.96360.df.
148. Escobar EMM, Rodriguez RSS, Jaurretche JSS, Barranco BVV, Cerri CEE, Rodenas
RMM, et al. P12.04: switch from calcineurin inhibitor to belatacept in kidney-pancreas
transplant recipients: single-center retrospective study from Argentina. Transplantation.
2022;106(9S):S691. https://doi.org/10.1097/01.tp.0000889400.91730.cc.
149. Redeld RR, Kaufman DB, Odorico JS.Diagnosis and treatment of pancreas rejection. Curr
Transplant Rep. 2015;2(2):169–75.
https://doi.org/10.1007/s40472- 015- 0061- x.
150. Dong M, Parsaik AK, Kremers W, Sun A, Dean P, Prieto M, etal. Acute pancreas allograft
rejection is associated with increased risk of graft failure in pancreas transplantation. Am J
Transplant. 2013;13(4):1019–25. https://doi.org/10.1111/ajt.12167.
151. Niederhaus SV, Leverson GE, Lorentzen DF, Robillard DJ, Sollinger HW, Pirsch JD, etal.
Acute cellular and antibody-mediated rejection of the pancreas allograft: incidence, risk
factors and outcomes. Am J Transplant. 2013;13(11):2945–55. https://doi.org/10.1111/
ajt.12443.
4 Primary Care of the Adult Kidney Transplant and Kidney-Pancreas Transplant…
111© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
C. J. Wong (ed.), Primary Care of the Solid Organ Transplant Recipient,
https://doi.org/10.1007/978-3-031-98076-3_5
Chapter 5
Primary Care oftheAdult Liver
Transplant Recipient
CourtneyL.Tuegel, LaurenA.Beste, andAnneM.Larson
5.1 Introduction
Cirrhosis and chronic liver disease affects 1.7 billion individuals worldwide as of
2021, a 22.4% increase since 2010 [1]. Chronic liver disease and cirrhosis was the
tenth leading cause of death in the USA in 2022 [2]. The liver is the second most
commonly transplanted solid organ in the USA, representing roughly one-fth of
solid organ transplants since 1999 [3]. Liver transplant activity has increased 52%
in the past decade, with the demand for liver transplantation—just over 25,000 can-
didates on the wait list in 2022—far exceeding the supply of ~9800 deceased donor
organs [4]. Despite the high demand, the number of newly listed liver transplant
candidates has decreased in recent years and 54.5% of candidates on the wait list
receive a transplant within 1year, with 61% of transplant recipients having waited
less than 90days [4]. Contrasting with dialysis for kidney failure, no mechanical
organ substitutes exist for end-stage liver failure.
The most common indications for adult liver transplantation include chronic
liver failure, hepatocellular carcinoma, and acute liver failure (most often
due to toxic ingestion). The most common etiologies of chronic liver disease in the
United States include hepatitis C virus infection (HCV), metabolic associated
C. L. Tuegel (*) · L. A. Beste
Division of General Internal Medicine, Department of Medicine, University of Washington,
Seattle, WA, USA
General Medicine Service, VA Puget Sound Healthcare System, Seattle, WA, USA
e-mail: courtly@uw.edu; Lab25@uw.edu
A. M. Larson
Division of Gastroenterology, Department of Hepatology and Liver Transplantation,
University of Washington, Seattle, WA, USA
e-mail: amlarson@uw.edu
112
0
5
10
15
20
25
30
35
40
45
2010 2012 2014 2016 2018 2020 2022 2024
Percentage
Year
Total liver transplants by clinical diagnosis
Acute Liver Failure
HCV
ALD
Chol
HCC
Other/unknown
Fig. 5.1 Total liver transplants by clinical diagnosis. ALD: alcoholic liver disease; HCV: hepatitis
C virus, Chol: cholestatic, HCC: hepatocellular carcinoma, other: includes metabolic associated
steatohepatitis. (Data from: Scientic Registry of Transplant Recipients. Available at: https://srtr.
transplant.hrsa.gov/annual_reports/Default.aspx. Accessed September 9, 2024)
steatohepatitis (MASH), and alcohol-related liver disease (ALD). HCV has histori-
cally been the leading indication for liver transplantation, but the advent of direct
acting antiviral therapies has led to a decline in the proportion of transplants per-
formed for HCV, surpassed by ALD (40.8% of adult liver transplants in 2022) and
MASH (at least 19.9% of adult liver transplants in 2022) [4–6]. Recent trends sug-
gest that MASH is the most rapidly increasing indication for liver transplantation
[6] (Fig.5.1).
Survival after liver transplantation is generally excellent, with 1- and 5-year post-
transplant survival at 93.2% and 80.2%, respectively, while the rate of 10-year sur-
vival is 64.3% [4]. Post-liver transplant complications are divided into acute
(3–6months post-liver transplant) and chronic or long term. Liver transplant centers
typically bear responsibility for managing the patient’s immunosuppressive regi-
men and any hepatic or biliary complications that arise after liver transplantation
[7]. Primary care providers (PCPs) should expect to manage the long-term meta-
bolic side effects of immunosuppression, and preventive care such as vaccinations
and cancer screenings. In addition, PCPs may be the rst point of contact for patients
when new symptoms arise.
5.2 Liver Transplant Anatomy
Deceased donor transplants comprise 93.7% of all liver transplants in the US [4].
• The donor liver is placed in the orthotopic position (same location as the
native organ).
C. L. Tuegel et al.
113
Fig. 5.2 Anatomy and
blood supply of the
transplanted liver.
(Reproduced with
permission from: Berry
PA, Melendez HV, Wendon
JA. (2010) Postoperative
Care of the Liver
Transplant Patient. In:
O’Donnell JM, Nácul FE
(eds) Surgical Intensive
Care Medicine. Springer,
Boston, MA)
• Four surgical anastomoses must be created between the donor allograft and the
recipient to implant the new liver: inferior vena cava/hepatic veins, hepatic artery,
portal vein, and common bile duct (Fig.5.2).
– There are two predominant caval reconstructions: the traditional technique
(caval replacement, in which the relevant portion of the recipient’s inferior
vena cava is resected and replaced with the donor portion; Fig.5.3a) and the
piggyback technique (Fig.5.3b, c).
– The caval technique has largely been supplanted by the piggyback technique.
The donor vena cava is closed inferiorly. The superior portion of the donor
cava (including the hepatic veins) is anastomosed end-to-end to the recipient
hepatic vein (Fig.5.3b) or side-to-side (Fig. 5.3c) with the recipient vena
cava. This technique reduces the need for veno-venous bypass.
• Both the donor and recipient gallbladder are removed at the time of surgery.
• In some settings, hepaticojejunostomy with Roux-en-Y reconstruction is
necessary.
• Arterial or venous thromboses, stricture, or leakage from any of these anastomo-
ses are a common source of early post-transplant complications.
Living donor liver transplants (i.e., transplanting a portion of a healthy person’s
liver) are performed less often due to risk to the donor, including death. Segmental
living donor liver transplantation is occurring with increasing frequency, however,
accounting for 603 liver transplants in 2022 [4]. The surgical anastomoses vary in
this type of transplant depending on the hepatic segment used. This review will
focus on transplantation from deceased donors in which the entire donor organ is
implanted.
5 Primary Care oftheAdult Liver Transplant Recipient
114
a
b
c
Fig. 5.3 Variations in caval reconstruction. (a) Classic. (b) Piggyback hepatic vein. (c) Side to
side. (Reproduced with permission from: Chan T, DeGiolamo K, Chartier-Plante S, Buczkowski
AK. (2017) Comparison of three caval reconstruction techniques in orthotopic liver transplanta-
tion: a retrospective review. Am J Surg 2013:5:943–949)
5.3 Early Posttransplant Period—First 12Months
Transplant recipients are closely monitored as inpatients during the immediate post-
operative period for hemodynamic stability and acute post-transplant complica-
tions. This management is carried out by a multidisciplinary team that includes
surgeons, hepatologists, intensivists, pharmacists, dietitians, and nursing staff. In
addition to the perioperative complications inherent in any surgery, such as bleed-
ing, infection, or poor wound healing, liver transplant recipients have additional
early risks. Very early post-transplant complications, within 3 months, include
opportunistic infection, graft dysfunction, transplant-related surgical complications
C. L. Tuegel et al.
115
such as hepatic vascular thrombosis or biliary leaks, acute rejection, and other organ
dysfunction (e.g., renal, pulmonary, neurologic) [8].
5.3.1 Typical Immunosuppressive Course
Transplant centers vary in their choice of immunosuppression in the rst-year post-
transplant. Induction therapy is used during the rst week post-liver transplant in
some recipients, depending on the transplant center protocol. Induction therapies
include antilymphocyte sera such as antithymocyte globulin, or monoclonal anti-
bodies (e.g., basiliximab,) which act by blocking interleukin-2 receptors.
Corticosteroids are less commonly used than in the past, and if used are tapered over
the next 3–12months.
5.3.2 Infections
Infection remains a signicant risk in the setting of liver transplantation. Sources of
infection include (a) the donor organ, (b) reactivation of prior infection in the recipi-
ent, and (c) de novo infection by exogenous or endogenous organisms. During the
rst month, infections are typically nosocomial. Viral infections (e.g., cytomegalo-
virus [CMV], Epstein-Barr Virus [EBV]) predominate during the second to sixth
month post-transplant, followed by fungal, bacterial and parasitic infections [9].
Because of the risk of opportunistic infection, post-liver transplant patients rou-
tinely receive viral, bacterial and fungal prophylaxis. Protocols vary by institution.
In general, antibacterial prophylaxis is provided for Pneumocystis jirovecii. Fungal
prophylaxis is used against candida species and tailored by the center if endemic
fungi are prominent (i.e., histoplasmosis, cryptococcus). CMV prophylaxis is typi-
cally given for seronegative recipients receiving CMV-positive livers, or those
undergoing induction immunosuppression with a T-cell specic agent such as thy-
moglobulin [10, 11]. Acyclovir prophylaxis for herpes simplex is given if CMV
prophylaxis is not used. The prophylactic agents are generally discontinued over the
next 3–12months, depending upon center protocol. Following the sixth month post-
liver transplantation, infections are predominantly community-acquired and similar
to those of the general population (see Chap. 8).
5.3.3 Graft Dysfunction
Primary nonfunction is one of the most serious immediate post-liver transplant
complications, occurring in up to 10% of recipients. In this circumstance, the graft
fails to function immediately following reperfusion, and the patient develops acute
5 Primary Care oftheAdult Liver Transplant Recipient
116
liver failure and must be urgently retransplanted. Additionally, subacute graft failure
can develop in 6.4% of liver transplant recipients by 6months and 8.4% by 1year
and may require retransplantation [4]. Because early graft dysfunction may be
asymptomatic, liver function is carefully monitored with frequent laboratory studies
and imaging. Timing of studies varies, but in general laboratory testing ranges from
weekly to every 3months depending on time following transplant. Imaging is gen-
erally done every 3–6months the rst year, or for cause, and then yearly. Protocol
liver biopsies, used in the past to assess for rejection, are no longer performed.
Factors associated with graft dysfunction include donation after cardiac death,
donor macrovesicular steatosis, total ischemia time >10h, reperfusion damage,
older donor age (>60years), and recurrent primary liver disease [12].
5.3.4 Vascular Complications
Post-transplant arterial complications include thrombosis, stenosis, pseudoaneu-
rysm, and arterial rupture. Hepatic arterial pseudoaneurysms predispose to life-
threatening hemorrhage and may require urgent endovascular or surgical
intervention. Hepatic artery thrombosis (HAT) occurs in roughly 3.5% of liver
transplant recipients and is a leading cause of early graft failure, requiring retrans-
plantation in up to 83% of cases [13]. The liver has a dual blood supply from both
portal vein and hepatic artery, with only the hepatic artery carrying oxygenated
blood. Even transient interruption of hepatic arterial ow may result in anoxic injury
to the sensitive small bile ducts, especially if occurring within 4 weeks post-
transplant (“early” HAT). The clinical consequences of HAT vary widely. Early
HAT often leads to ischemia and necrosis of the allograft. Thrombolysis, thrombec-
tomy, or surgical intervention may be attempted followed by anticoagulation; how-
ever, failure to recanalize the artery necessitates urgent retransplantation.
If thrombosis occurs later, it typically leads to biliary complications with pre-
served hepatic synthetic function. Complications of HAT include bile duct necrosis,
intrahepatic bilomas, ischemic cholangiopathy, secondary biliary cirrhosis, and
death unless corrected rapidly through surgical or interventional radiologic inter-
vention. Therefore, most centers monitor laboratory results and routine duplex
ultrasounds of the hepatic vessels in the early post-transplant setting (e.g., day 1 and
day 5–7 post-transplant). Late hepatic artery thrombosis can present years after
transplantation, although it may not require retransplantation if a collateral blood
supply has developed. Late hepatic artery thrombosis is most often detected by rou-
tine duplex ultrasound or laboratory studies.
Portal vein thrombosis or stenosis are rare complications, and each occur in <3%
of liver recipients. They are associated with increased risk of graft failure as well as
increased mortality, but are largely treatable with anticoagulation and percutaneous
radiological intervention [13]. Severe cases may result in portal hypertension with
its subsequent complications of ascites and varices. The hepatic veins and inferior
vena cava may also develop thromboses or stenoses, but this is less common.
C. L. Tuegel et al.