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5.3.5 Biliary Complications
Biliary complications develop in 10–15% of recipients and include bile leaks,
bilomas (bile-lled uid collections resulting from a biliary leak), strictures, and
recurrent cholestatic liver disease [14]. They can be intimately associated with
hepatic arterial disease but may be related to technical aspects of the operation
itself. Biliary complications may develop at any time post-transplant and often pres-
ent with abnormal liver studies, fever and/or abdominal pain. Abdominal imaging,
magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde
cholangiopancreatography (ERCP) can all be helpful in determining the correct
diagnosis. Strictures may be either anastomotic (up to 86%) or non-anastomotic,
with anastomotic strictures more often associated with biliary leakage [14]. Hepatic
arterial disease is causally associated with many cases of refractory biliary disease,
as hypoperfusion of the bile ducts leads to biliary strictures. Additionally, biliary
complications are associated with an increased risk of infection.
5.3.6 Allograft Rejection
Early rejection is dened as the development of acute cellular rejection (ACR) within
the rst year after liver transplantation. This type of rejection is cell- mediated and can
frequently be reversed with appropriate immunosuppressive therapy. One or more epi-
sodes of ACR occur in 8.4%–19.1% of recipients, with higher rates in recipients of
younger age. ACR most commonly occurs within the rst 3-months post-liver trans-
plantation [4, 15]. Patients experiencing ACR are frequently asymptomatic but may
rarely present with fever, malaise, or abdominal symptoms. Ongoing laboratory surveil-
lance is performed regularly to identify early signs of hepatocellular injury namely by
rising liver biochemical tests (serum amiontransferases, alkaline phosphatase, gamma-
glutamyl transpeptidase, bilirubin). Timing of testing varies by center, but in general it is
twice weekly for the rst several weeks post-transplant, decreasing in frequency to
every 3months over the rst year. Liver biopsy remains the gold standard for diagnosis
if ACR is suspected. If conrmed, it is treated with high-dose corticosteroids followed
by intensication of the patient’s baseline immunosuppressive regimen. If corticoste-
roid-resistant ACR develops, T-cell directed therapies such as IL-2 inhibitors or antithy-
mocyte globulin may be used.
Less common, but with growing recognition, is antibody-mediated rejection
(AMR) with an incidence of <1% of transplant recipients [15]. AMR can manifest
as rapid allograft failure with hemorrhagic necrosis, graft injury with refractory
thrombocytopenia, hyperbilirubinemia, and low serum complement, or it can pres-
ent similar to ACR with elevated transaminases [16]. It is diagnosed based on liver
histology, elevated donor specic antibodies, diffuse CD4 microvasculature deposi-
tion, and after the exclusion of other liver diseases or complications [16]. AMR has
no standardized treatment due to low level of evidence.
5 Primary Care oftheAdult Liver Transplant Recipient
118
Acute rejection is associated with increased risk of graft failure (up to 10%), all-
cause mortality, and transplant-related mortality [15].
5.4 Late Post-transplant Period—After 12Months
5.4.1 Survival andCause ofDeath
Long-term survival continues to improve due to ongoing advancements in trans-
plant technique and management. In addition to disease recurrence, long-term com-
plications are generally associated with the use of immunosuppression. These
complications in recipients at 10-years post-transplant include diabetes mellitus
(21%), systemic hypertension (64%), dyslipidemia (43%), obesity, de novo cancers
(25%), and nephrotoxicity (40%). The most common cause of death in recipients
<1year post-transplant or between 1 and 5years post-transplant is infection, with
rates of 32% and 25%, respectively [17]. In the recipient who has survived 5years
or more after transplant, the primary cause of death is de novo malignancy (17.5%),
sepsis (15.7%) most commonly from bacterial infection, and cardiovascular disease
(11.8%) [18]. There has been a decline in recurrence of primary liver disease as
cause of late post-transplant death, and it is widely anticipated that liver-related
disease as a cause of post-transplant death will diminish with the eradication of
HCV in the DAA era.
5.4.2 Typical Immunosuppressive Course
In general, after the initial induction period, the backbone of maintenance immu-
nosuppressive regimens includes the calcineurin inhibitor (CNI), tacrolimus,
which has largely replaced cyclosporine. Because of the long-term toxicities of
calcineurin inhibitors, anti-rejection regimens may include an antimetabolite
medication to minimize the dose of the calcineurin inhibitor. The antimetabolite,
azathioprine, has almost universally been replaced by either mycophenolate
mofetil or mycophenolic acid. If calcineurin inhibitors are contraindicated or
intolerable side effects develop, alternative agents such as the mammalian target
of rapamycin (mTOR) inhibitors (sirolimus or everolimus) can be substituted as
second line options. The most common immunosuppressive regimens in adult
liver transplant recipients in the United States include tacrolimus, mycopheno-
late mofetil and corticosteroids, or tacrolimus plus mycophenolate mofetil [4]. It
is now much more common to avoid use of long- term corticosteroids. Sample
immunosuppressant drug targets are given in Table5.1
C. L. Tuegel et al.
119
Table 5.1
Sample immunosuppressant trough targets
a
by time post-liver transplant
Regimen
Time post-liver transplant
0–3 mo 3–6 mo 6–12 mo 12–24 mo >24 mo
Tacrolimus
level
Tacrolimus
5–8ng/mL
5ng/mL 3–5ng/
mL
Tacrolimus-MMF
(or AZA)- steroid
≤8ng/mL 5ng/mL 3–5ng/
mL
Tacrolimus-
sirolimus
5–8ng/mL 5ng/mL 3–5ng/
mL
Sirolimus
level
Sirolimus-MMF-
steroid
5–10ng/mL
Sirolimus-
tacrolimus
5–8ng/mL 5ng/mL 3–5ng/
mL
Cyclosporine
level
CsA-MMF (or
AZA)-steroid
150–200ng/
mL
150ng/
mL
100ng/
mL
80–100ng/
mL
60–80ng/
mL
MMF, mycophenolate mofetil; AZA, azathioprine; CsA, cyclosporine; ng/mL, nanograms per mil-
liliter; mo, month
a
Immunosuppressive drug targets are individualized and generally managed by the patient’s liver
transplant center. The targets shown are for general information, not meant to guide clinical care
5.4.3 Evaluation ofLiver Test Abnormalities
Any liver test abnormality in the post-liver transplant setting must be thoroughly
evaluated. The necessary follow-up testing will depend on the severity and type of
abnormality. After the rst post-transplant year, liver tests are typically monitored
every 3 months or if new symptoms develop. Evaluation should be conducted in
conjunction with the transplant center.
In the asymptomatic patient with mildly elevated transaminases or bilirubin:
• If found on routine testing, the patient should be evaluated in person to conrm
that he or she is asymptomatic, and to evaluate medication use, including new
medications or supplements and adherence to immunosuppressive medications,
substance use (including alcohol), and for symptoms of recent infections.
• If truly asymptomatic and elevations in liver enzymes are mild, it may be reason-
able to recheck liver tests in 1–2weeks. If they normalize, further evaluation is
unnecessary.
• Otherwise, liver test abnormalities should be investigated with an ultrasound and
duplex to evaluate the liver, biliary tree and the hepatic vessels. Additional test-
ing may include immunosuppressive drug levels or tests for infection, such as
hepatitis B virus (HBV), CMV, or EBV PCR.
• Any biliary abnormalities should prompt further evaluation of the biliary tree,
such as magnetic resonance cholangiopancreatography or endoscopic retrograde
cholangiopancreatography.
• Liver biopsy is often required to determine whether the test abnormality is sec-
ondary to rejection versus another cause. With appropriate immunosuppression
management after transplant (Table5.1), rejection episodes are generally mini-
mized in the majority of patients.
5 Primary Care oftheAdult Liver Transplant Recipient
120
Patients with severe transaminase or bilirubin elevation, or who are symptom-
atic, should immediately be referred for urgent evaluation either to the managing
hepatologist or the emergency department, depending on the patient’s clinical sta-
bility. If uncertain, then the hepatologist should be contacted to assist with triage
and initial management.
5.4.4 Chronic (Ductopenic) Rejection
Chronic rejection can occur at any time post-liver transplantation, but generally
presents more than 6months after transplantation. Its pathogenesis remains unclear.
This type of rejection leads to obliterative angiopathy and loss of the intrahepatic
bile ducts (ductopenia). It presents predominantly with clinical and biochemical
cholestasis. It is more common in patients with a history of steroid-refractory ACR
and in patients with chronic viral hepatitis or autoimmune hepatitis [19, 20].
Treatment remains difcult and retransplantation may be required.
5.4.5 Recurrence ofChronic Liver Disease
The underlying disease that resulted in liver failure may still be present after trans-
plantation. Recurrence can lead to signicant morbidity and mortality following
transplantation and must be managed appropriately.
• Viral Hepatitis: Viral hepatitis invariably returns after liver transplantation.
In the past, recurrent HCV resulted in accelerated liver damage, cirrhosis,
and rapid deterioration of the graft. With the advent of direct acting antiviral
(DAA) therapies, patients are either treated for HCV in anticipation of trans-
plant or treated immediately afterwards. HCV treatment should only be car-
ried out in collaboration with the transplant center since some DAAs may
alter the levels of calcineurin inhibitors. HBV infection makes up less than
10% of liver transplants in the USA, whereas it is the most common indica-
tion in Asia. Patients with HBV infection must remain virally suppressed
indenitely post-liver transplantation to prevent damage to the allograft. The
combination of hepatitis B immune globulin at the time of transplantation,
plus chronic HBV antiviral medication prevents liver injury in nearly all liver
transplant patients with chronic HBV.
• Metabolic Dysfunction-Associated Steatohepatitis (MASH): MASH is the
fastest- growing etiology leading to liver transplantation, predicted to be the lead-
ing cause of liver transplantation by 2030 (Fig.5.1) [4, 5]. Many comorbidities
associated with MASH (e.g., obesity, diabetes, dyslipidemia, and hypertension)
not only remain present post-transplant but may be exacerbated by anti-rejection
medications. Diabetes may result from corticosteroids or tacrolimus. CNIs can
C. L. Tuegel et al.
121
lead to systemic hypertension and sirolimus can cause hyperlipidemia.
Additionally, up to 70% of recipients will gain excessive weight over the rst-
year post- transplant [21]. As a result, metabolic syndrome is estimated to occur
in 40–60% of patients post-liver transplant, and MASH can recur or develop de
novo [21, 22]. MASH may cause elevated liver tests and can lead to brosis;
however, cirrhosis is uncommon in the rst 5years following liver transplanta-
tion. Primary care providers, therefore, have a critical role in helping to manage
obesity and metabolic conditions post-liver transplantation to prevent recurrence
or development of MASH.
• Autoimmune Liver Disease: The recurrence of autoimmune liver disease (pri-
mary sclerosing cholangitis [PSC], autoimmune hepatitis [AIH], and primary
biliary cholangitis [PBC]) varies from patient to patient. Recurrence of PSC has
been reported in up to 50% of recipients by 5-years post-transplant, with graft
loss seen in up to 25% [23, 24]. Patients with PSC and inammatory bowel dis-
ease require annual colonoscopy after liver transplantation to screen for colon
cancer. Recurrence of PBC develops in about 17% of liver transplant recipients
and can be treated with ursodiol, similar to that used pre-transplant [25].
Autoimmune hepatitis recurs in 17–33% of patients post-transplant, with 6%
requiring retransplantation [26]. Liver biopsy is often necessary to distinguish
recurrent autoimmune liver disease from rejection.
• Hepatocellular Carcinoma: Hepatocellular carcinoma (HCC) is a leading indica-
tion for liver transplantation. Patients with HCC must meet stringent criteria for
the size and number of HCC lesions to be eligible for liver transplantation [27].
However, in many cases, liver transplantation is an ideal choice to cure both
HCC as well as underlying cirrhosis, if present. Patients with HCC who are
transplanted within select criteria have been shown to have equivalent 5-year
survival rates compared to liver transplant recipients overall [28]. Patients with a
history of HCC must be screened carefully for recurrence after transplant, typi-
cally with multiphase CT or MRI of the liver every 6months for at least 3years.
Post-transplant HCC recurs in 6–18% of patients and may behave aggressively
in the immunocompromised patient [29]. Management of post-transplant recur-
rent HCC requires a multidisciplinary approach.
• Alcohol-Related Liver Disease: Patients transplanted for ALD have an overall
survival similar to that of recipients without ALD [30]. To meet transplant eligi-
bility requirements, all prospective liver transplant patients are closely screened
for substance use disorders, insight into their drinking, psychosocial support, and
typically must demonstrate a documented period of sobriety as determined by
the transplant center. Patients with ALD frequently lose the urge to drink while
they have decompensated liver disease but are at risk for return to alcohol use
post-transplant. In meta-analysis of over 8000 cases, the alcohol relapse rate was
22% after liver transplant at mean follow up time of 48.4months (95% CI
19–25%) [31]. All liver transplant recipients are recommended to undergo regu-
lar screening for alcohol use and alcohol use disorder and to engage in substance
use counseling and intervention if indicated.
5 Primary Care oftheAdult Liver Transplant Recipient
122
5.4.6 Late Surgical Complications
Biliary and vascular complications can develop at any time in the post-transplant
period and are managed as discussed above. Incisional hernia may develop after
liver transplantation. If repair is desired, surgeons typically recommend waiting
approximately a year after transplantation to allow for abdominal wall healing, sta-
ble liver function, and reduced risk of infection. In the meantime, abdominal binders
provide symptomatic management until surgery can be performed. Patients should
be educated about the possibility of bowel incarceration.
5.5 Preventive Care fortheLiver Transplant Recipient
Primary care providers are frequently the rst point of contact for liver transplant
recipients when new health concerns arise, especially if the patient resides far from
their transplant center. Adult liver transplant recipients are most commonly between
50 and 64years at the time of transplantation, though the proportion aged 65 or
older is increasing, and many have non-hepatic comorbidities [4]. Among patients
who survive more than 5 years after liver transplantation, the most common causes
of death include malignancy, cardiovascular disease, and renal failure. Close coor-
dination with the transplant center is advised when considering prescribing a new
medication or if concerned about liver-related symptom. A summary of clinical
pearls for outpatient assessment of the liver transplant recipient is given in Table5.2,
and typical testing intervals are given in Table5.3.
5.5.1 Immunosuppression Management
Liver transplant recipients remain on immunosuppression for the rest of their lives,
with rare exception. Immunosuppressive medication adjustment is typically man-
aged by the transplant center (sample trough target levels are described in Table5.1).
PCPs should be aware of drugs that may alter the levels of CNIs, and thus poten-
tially provoke rejection or drug toxicity. Typical culprits include antiseizure medica-
tions (phenobarbital, phenytoin, carbamazepine) and anti-infectives (isoniazid,
uconazole). The use of vitamins and supplements should be assessed at every visit,
as many will interact with calcineurin inhibitors (e.g., St. John’s wort, kava kava,
echinacea) [32] (see Chap. 3). Tobacco and cannabis use are specically assessed in
the pre-transplant setting but may be associated with complications post-transplant.
All patients should be queried regarding use of alcohol, tobacco, and other sub-
stances (including all forms of cannabis) at each post-transplant visit. Liver trans-
plant recipients should be advised to avoid any and all substance use, including
tobacco and alcohol. Most programs recommend complete avoidance of cannabis as
C. L. Tuegel et al.
123
Table 5.2
Clinical pearls for the primary care provider—evaluating liver transplant recipients at
outpatient clinic visits
Initial visit:
Review pre-transplant and initial post-transplant course:
Indication for transplant
Pre-transplant complications
Type of donor
Induction immunosuppression
Early complications (surgical complications, infection, rejection)
Symptoms, exam, medications, laboratory studies similar to follow-up visits
Follow-up visits:
Symptoms: Pain, symptoms of volume depletion or excess, side effects of medications,
symptoms of infection, symptoms of liver dysfunction, including jaundice, confusion,
bleeding
Exam: Blood pressure, heart, lung, abdomen exam, volume status
Medications: Current regimen, adherence, side effects, goal trough levels
Substance use: Assess for alcohol and other substance use
Mental health screening: Screen for and treat depression and other mental health conditions
Laboratory and other studies: Adherence to routine surveillance schedule set forth by the
transplant team; surveillance for rejection (see Table5.3)
Surveillance: adherence to surveillance for underlying conditions, if applicable (e.g., HCC,
PSC) (see Table5.3)
Metabolic complications: Assess and treat
– Address obesity, diet, exercise and other risk factors for MASH
– Hypertension, dyslipidemia, diabetes, osteoporosis
Table 5.3 Typical post-liver transplant monitoring
a
Test Recommended frequency
Laboratory studies
– Liver panel with GGT and INR
– CBC/differential
– Basic metabolic panel
– Immunosuppression trough
levels
Multiple times per week immediately post-transplant,
ultimately every 3months by year 1
Hemoglobin A1c Every 3months for rst year, then annually
Lipid prole Annually
Blood pressure Every visit
24-h urine protein OR urine
protein-to-creatinine ratio
Annual to monitor for proteinuria, especially if treated with
mTOR inhibitor
DEXA Every 2–3years if normal bone density
Annually if low bone density or treated with steroids
Skin survey Annually
Colonoscopy Annually if history of inammatory bowel disease
Every 5–10years if average risk
Cervical cancer screening Annual Papanicolaou test (with HPV co-testing if
≥30years old) for 3 years, then every 3 years if normal
(guidelines vary—see Chap. 14)
Liver biopsy As indicated by transplant center. Routine protocol biopsies
are no longer performed
(continued)
5 Primary Care oftheAdult Liver Transplant Recipient
124
Table 5.3
(continued)
Test Recommended frequency
Abdominal imaging • Yearly to assess vasculature and liver
• If history of HCC before transplant: liver protocol CT or
MRI q6 months for 3–5years
• If recurrent cirrhosis: liver ultrasound and alpha-
fetoprotein every 6months
Visit to transplant hepatologist Every week for rst 1–3months, then every 3–12months
depending on stability and co-management setup
a
Note testing varies by transplant center and by patient indications
well. There is very little data on the use and safety of edible forms of cannabis in
this setting. Patients who continue to use these substances against transplant center
recommendations and require a second transplant may place their candidacy at risk.
5.5.2 Immunizations
Although this book focuses on the care of post-transplant recipients, it is worth not-
ing that primary care providers should encourage potential liver transplant patients
to undergo any necessary vaccinations in the pre-transplant setting since live virus
vaccines are contraindicated post-transplant. Pre-transplant vaccinations include
pneumococcus, hepatitis A virus, HBV, tetanus/diphtheria/pertussis, COVID-19,
human papilloma virus (HPV), varicella virus and herpes zoster (see Chap. 2).
Following transplant, inactivated virus vaccines may be given safely, the excep-
tion being the recombinant shingles (herpes zoster) vaccine, because of potential its
immune response precipitating rejection. The Centers for Disease Control (CDC)
recommends recombinant shingles vaccine be given at least 6–12months after trans-
plant when graft function stable (no recent rejection) and on maintenance immuno-
suppression [33]. All recipients should receive an annual inuenza vaccination and
repeat vaccinations for other diseases at appropriate intervals (e.g., COVID-19,
pneumococcus). Vaccination guidelines are in place for the management of trans-
plant recipients. As vaccination recommendations change frequently, primary care
providers should check the CDC and transplant guidelines regularly (see Chap. 14).
5.5.3 Cancer Screening
As discussed in Chap. 10, solid organ transplant recipients have a dramatically ele-
vated risk of skin cancer, solid organ tumors, and hematologic malignancy. Cancer
may develop de novo or recur from prior disease. The incidence of de novo cancer
is higher than that seen in the non-transplant population, with transplant recipients
twice as likely to develop solid organ cancer and 30 times more likely to develop
C. L. Tuegel et al.
125
hematologic malignancy [21]. Skin cancers—predominantly squamous and basal
cell carcinomas—are the most common malignancy in this population. All liver
transplant recipients should undergo annual skin survey, use sunscreen, and avoid
sun exposure. Post-transplant lymphoproliferative disorder (PTLD) is associated
with EBV.PTLD occurs in 1–5.5% of liver transplant recipients [34]. Screening for
colon, prostate, and breast cancer is consistent with standard guidelines in most
average risk individuals with the exception of yearly colonoscopy for those with
inammatory bowel disease. Women on long-term immunosuppressive therapy are
less likely to clear HPV compared to average women, placing them at increased risk
for cervical dysplasia and cancer. Women should receive annual cervical cancer
screening via Papanicolaou test for 3 years (with HPV co-testing if ≥30years old),
then every 3 years if normal, at minimum through age 65. Surveillance for recurrent
HCC is discussed above. Screening for malignancies in the liver transplant recipient
is summarized in Table5.2.
5.5.4 Fertility, Pregnancy, andBreastfeeding
Liver failure is associated with both reduced fertility and sexual dysfunction. Free
testosterone levels improve and fertility returns in nearly all individuals by 1year
following transplant [35]. Sexual dysfunction may not resolve. Women who con-
ceive after liver transplantation are at increased risk for obstetrical complications
(up to 19%), including pregnancy-induced hypertension, pre-eclampsia, low birth-
weight, and preterm delivery although overall pregnancy outcomes are favorable
[36–39].
All premenopausal liver transplant recipients who are at risk for conception
should receive counseling to prevent unplanned pregnancy. Preferred contraceptive
options include long-acting reversible contraceptives such as intrauterine devices or
progesterone implants, barrier methods, progestin-only hormonal contraceptives,
and tubal ligation. Combined hormonal contraceptives may be options in patients
with stable allograft status and without contraindications such as uncontrolled
hypertension or thromboembolic risks, though this should be discussed with the
managing hepatologist prior to initiation [40]. Estrogen-containing contraceptives
do not appear to signicantly affect immunosuppression levels. Emergency contra-
ception appears to be safe in liver transplant recipients [40].
Liver transplant recipients who desire pregnancy should receive pre-conception
counseling. Ideally, women should avoid pregnancy for 1–2years post-transplant to
ensure stable liver function and a consistent immunosuppressive regimen [40]. A
higher proportion of women who conceive more than a year after transplantation
have live births compared to those who conceive sooner (98% vs. 80%) [39]. All
women who become pregnant after liver transplantation should be referred to a
high-risk obstetrician or maternal-fetal-medicine specialist for management.
Immunosuppression must be continued and managed carefully during pregnancy.
Medications with a category D status (known teratogen) should be avoided, particularly
5 Primary Care oftheAdult Liver Transplant Recipient
126
mycophenolate mofetil. Immunosuppressants that appear relatively safe in pregnancy at
contemporary clinical dosing include corticosteroids, azathioprine, cyclosporine, and
tacrolimus. Pregnancy is not associated with an increased risk for graft failure, but
immunosuppression levels may uctuate during pregnancy. Allograft function and cal-
cineurin inhibitor serum levels should be checked every 4weeks until 32weeks and then
every 2weeks until delivery. Allograft function should be checked weekly for at least
1month after delivery until stability is demonstrated.
Breastfeeding is not contraindicated in the liver transplant recipient. Although no
immunosuppressants are labeled for use in lactation, there have been no infant
adverse effects reported for breastfeeding with azathioprine, cyclosporine, or tacro-
limus, despite trace amounts detectable in breastmilk [41]. Breastfeeding is not rec-
ommended with mycophenolate mofetil, everolimus or sirolimus due to inadequate
data on drug excretion in breastmilk [36]. Guidance can be sought though the
LactMed database maintained by the National Institutes of Health [42].
(See Chap. 13.)
5.6 Systemic Disease andOverall Health
5.6.1 Obesity andNutrition
In 2022, 41.3% of liver transplant recipients were obese at the time of transplanta-
tion (BMI ≥30kg/m
2
) and 17.3% were severely obese (BMI ≥35kg/m
2
) [4]. As
noted above, the rate of the metabolic syndrome (diabetes, hypertension, obesity,
and dyslipidemia) increases after transplant. In the rst 1–3years post-transplant,
30–70% of recipients gain weight [21]. Patients should be counseled regarding
dietary and lifestyle modications, though there is limited data that these modica-
tions alone lead to more weight loss. Weight loss medications that have efcacy in
MASH [43], such as glucagon-like peptide 1 (GLP-1) agonists, show promise, but
have not yet been robustly studied in transplant recipients. Those who are already
obese may require referral to a multidisciplinary weight loss program. Weight loss
surgery is not contraindicated in this setting, although the optimal timing and type
of procedure is unknown.
5.6.2 Diabetes Mellitus
Diabetes in the post-liver transplant setting consists of pre-existing diabetes mellitus
(DM) and post-transplant diabetes mellitus (PTDM) (formally new onset diabetes
after transplant or NODAT). Insulin-requiring diabetes mellitus persists following
transplant and many patients who were treated with oral hypoglycemic medications
pre-transplant may require transition to insulin. The prevalence of PTDM in the
liver transplant recipient is between 7% and 30% [44]. Diabetes is negatively asso-
ciated with all-cause mortality after transplant as well as mortality secondary to
C. L. Tuegel et al.