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127
cardiovascular, infectious, and allograft-related events [21]. Similar to the non-
transplant population, careful control of blood glucose likely decreases both mor-
bidity and mortality. Both DM and PTDM adversely affect long-term survival
following liver transplant. Management of post-transplant diabetes is similar to
management of diabetes in the general population. GLP-1 agonists are safe and do
not interact with immunosuppressive regimens, though they do delay gastric empty-
ing which can impact absorption. Best practices include collaborating with the
transplant hepatologist around the start of a GLP-1 agonist to ensure adequate
immunosuppressive monitoring during titration. Expert guidance has recommended
against sodium-glucose cotransporter 2 (SGLT-2) inhibitors due to increased risk of
genitourinary infection and volume depletion [44, 45], but smaller studies have
shown similar adverse events rates to the general population [46]. Many experts
recommend a hemoglobin A1c target of <7.0% as there appears to be no additional
advantage to tighter glucose control [45] (see Chap. 11).
5.6.3 Systemic Hypertension
Hypertension develops in the majority of liver transplant recipients by 2–3 years
post-transplant. The presence of hypertension is associated with an increased risk of
chronic kidney disease as well as both fatal and nonfatal cardiovascular events.
Management is similar to the non-transplant setting. Lifestyle modications with
weight loss and sodium restriction should be encouraged. When treating hyperten-
sion, calcium channel blockers such as amlodipine and long-acting nifedipine are
preferred as the rst line agents because these drugs counteract the vasoconstrictive
effects of the CNIs; non-dihydropyridine calcium channel blockers are not recom-
mended due to interactions with CNIs [45]. Beta-blockers or thiazide diuretics can
be added as second line therapy, with careful electrolyte monitoring for the latter, as
well as monitoring for symptoms of gout. Angiotensin receptor blockers and
angiotensin- converting enzyme inhibitors should be used cautiously for those with
additional indications (such as chronic kidney disease or diabetes) and should be
avoided altogether in the early post-transplant period due to the risk of hyperkale-
mia and acute kidney injury in combination with calcineurin inhibitors [45]. Goal
blood pressure is <130/80mmHg (see Chap. 11).
5.6.4 Dyslipidemia
Dyslipidemia develops in up to up to 60% of liver transplant recipients, and has been
linked to the use of CNIs and mTOR inhibitors [21]. It is associated with increased car-
diovascular morbidity and mortality. mTOR inhibitors are particularly implicated in
causing markedly elevated triglyceride levels. For isolated hypertriglyceridemia, sh oil
or bric acid derivatives can be considered; brates should be used with caution if the
5 Primary Care oftheAdult Liver Transplant Recipient
128
patient is also receiving statin therapy. Medication therapy should be considered if the
low-density lipoprotein cholesterol level is >100mg/dL, with or without elevated tri-
glycerides. HMG-CoA reductase inhibitors are not contraindicated after liver transplan-
tation if otherwise indicated. However, hydrophilic statins (rosuvastatin and pravastatin)
are preferred due to lower risk of rhabdomyolysis caused by interaction with CNIs. If
lipid control is suboptimal, the addition of ezetimibe to the statin can improve results
[45]. Newer lipid lowering agents such as proprotein convertase subtilisin/kexin type 9
(PCSK-9) inhibitors have been used in liver transplant patients in case studies without
adverse events, but no large trials regarding their effectiveness have been published to
date [47] (see Chap. 11).
5.6.5 Chronic Kidney Disease
The majority of liver transplant recipients will develop chronic kidney disease (CKD),
with a prevalence of up to 80% [21]. Up to 10% will develop renal failure during the rst
10years post-transplant, necessitating hemodialysis. The etiology of CKD is multifacto-
rial, including diabetes mellitus, calcineurin inhibitor use, hypertension, and periopera-
tive acute kidney injury. Patients should have careful monitoring of their renal function.
Many transplant centers require annual 24-h urine collection for creatinine clearance
and proteinuria. At minimum, a spot urine- protein- to-creatinine ratio should be evalu-
ated at least once a year [48] (see Chap. 11).
5.6.6 Infectious Disease
As noted above, recipients of liver transplantation are most at risk of opportunistic
infectious complications in the rst 6months following transplant. Pathogens seen
during this time frame include viruses (CMV, HSV, herpes zoster, herpes simplex),
fungi (Aspergillus, Cryptococcus) and bacteria (Nocardia, Listeria, mycobacteria).
The use of prophylactic anti-infective medications minimizes the risk during this
time period. Infectious risk declines after this time period and the most common
infections are due to community-acquired pathogens. If the patient is treated for
rejection with an increase in immunosuppression intensity, then their risk for oppor-
tunistic infection increases (see Chap. 8).
5.6.7 Mental Health
Depression is common both before and after liver transplantation—screening is rec-
ommended twice in the rst year post-transplant, and then yearly. Selective sero-
tonin reuptake inhibitors may be used post-transplant, but side effects and drug
interactions should be taken into consideration [32] (see Chaps. 3 and 12).
C. L. Tuegel et al.
129
5.6.8 Pain Management
Pain is a frequent symptom after liver transplant. Once liver function has been
restored, a wide range of pain medications may be used as indicated. Acetaminophen
is safe in doses up to 2000mg per day. Non-steroidal anti-inammatory drugs inter-
act with calcineurin inhibitors and should be avoided or used with extreme caution
to avoid nephrotoxicity [49]. Opioid pain relievers are discouraged for chronic use
in most patients due to tolerance concerns and an unfavorable side effect prole, but
they will be metabolized normally by a well-functioning transplanted liver. Patients
are frequently severely deconditioned prior to transplantation due to the muscle
wasting that occurs in liver failure, as well as the effects of malnutrition and pro-
longed hospitalizations. Physical therapy and rehabilitation is often benecial after
transplantation to promote improvement in function as well as pain management.
For patients with severe, chronic pain post-liver transplantation, therapy should be
directed to treat the underlying cause, with consideration for referral to a multidis-
ciplinary pain center familiar with transplant recipients.
5.7 COVID-19 andtheLiver Transplant Recipient
Studies of liver transplant recipient outcomes during the COVID-19 pandemic have
been mixed. A retrospective cohort study from 2019 to 2020 of liver transplant
recipients in the USA showed similar hospitalization rates before and during the
pandemic, with higher rates of in-hospital mortality and transplant rejection during
the pandemic than prior [50].
Liver transplant recipients who acquire COVID-19 infection present similarly to
the general population with fever, cough, dyspnea, fatigue, and myalgias but also
have a higher proportion of gastrointestinal symptoms such as abdominal pain, nau-
sea, vomiting, or diarrhea [51]. Studies have shown similar rates of hospitalization
and mortality due to COVID-19in liver transplant recipients as compared to the
general population, with the causes of death largely lung-related [51].
Once a liver transplant recipient has a conrmed case of COVID-19 infection,
adjustment of their immunosuppressive regimen is individualized based on severity
of COVID-19 disease, type of immunosuppressive regimen, risk of allograft rejec-
tion, and time post-transplant. Liver transplant recipients can receive antiviral treat-
ments for COVID-19 such as nirmaltrelvir/ritonavir. However, caution is needed
due to potential drug–drug interactions with several immunosuppressives (i.e., cal-
cineurin inhibitors) that necessitate close monitoring of levels and potential toxici-
ties. The transplant center should be contacted prior to prescribing nirmaltrelvir/
ritonavir as most centers have a protocol for managing the immunosuppression in
this setting (see Chap. 8).
Liver transplant recipients are encouraged to obtain and stay current on
COVID-19 vaccinations. While transplant recipients may have suboptimal antispike
5 Primary Care oftheAdult Liver Transplant Recipient
130
antibody responses to COVID-19 mRNA vaccines, vaccination still provides pro-
tection, with one study showing full vaccination decreasing COVID-19 infection by
64% and decreasing COVID-19 related death by 87% [52].
5.8 Summary
Liver transplantation is a lifesaving and life-prolonging treatment for patients with
liver failure. Long-term survival following transplant is outstanding and patients
now routinely live beyond 10 years. Primary care providers are more likely than
ever to have liver transplant recipients in their practice and are key to their overall
management. In addition to close collaboration between the transplant center and
the primary care provider, familiarity with common acute and chronic health issues
in the liver transplant recipient is essential for all primary care providers who care
for these patients.
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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_6
Chapter 6
Primary Care oftheAdult Heart
Transplant Recipient
VidangP.Nguyen, AndyY.Lee, ArisKaratasakis, andRichardK.Cheng
6.1 Introduction
Heart failure (HF) is one of the most common causes of morbidity and mortality
throughout the world. With an aging population and advances in treatment options,
including revascularization, neurohormonal blockade, and advanced device thera-
pies, the prevalence of individuals living with heart failure is increasing [1, 2]. In the
U.S., the lifetime risk of HF is 24%. Approximately, 6.7 million Americans over
20years of age have HF.The prevalence is anticipated to rise to 8.7 million by 2030.
The proportion of younger individuals with HF is increasing relative to the propor-
tion of older individuals, with an increased incidence and prevalence among Black
individuals compared to other racial and ethnic groups [3].
V. P. Nguyen
Providence Heart Institute, Portland, OR, USA
e-mail: vidang.nguyen@providence.org
A. Y. Lee
Division of Cardiology, Department of Medicine, University of California, Irvine, CA, USA
e-mail: aytlee@hs.uci.edu
A. Karatasakis
Division of Cardiology, Department of Medicine, University of Washington Medical Center,
Seattle, WA, USA
e-mail: arkar@uw.edu
R. K. Cheng (
*)
Division of Cardiology, Department of Medicine, Department of Radiology,
University of Washington Medical Center, Seattle, WA, USA
e-mail: rkcheng@uw.edu
134
The New York Heart Association (NYHA) functional classication system
describes patient symptoms: NYHA class I includes asymptomatic patients, NYHA
class II and III indicate progressive limitations, and NYHA class IV includes
patients with heart failure symptoms at rest and who are unable to perform activities
of daily living. In contrast to the NYHA classication, the American College of
Cardiology (ACC) and the American Heart Association (AHA) have described
stages that outline structural changes of chronic heart failure [4]. ACC/AHA stage
A and stage B heart failure include asymptomatic patients without and with struc-
tural heart changes, respectively. Stage C heart failure patients are those with symp-
toms of heart failure, and stage D with refractory end-stage heart failure. In 2019,
the Society for Cardiovascular Angiography and Interventions (SCAI) developed
shock stage classications that have been widely used in clinical practice and
research. The SCAI shock stages for cardiogenic shock (CS) range from A to E,
with A describing those at risk for CS, B beginning CS, C classic CS, D deteriorat-
ing CS, and E extremis. During the years that this model was validated, this classi-
cation scheme has been applauded for its ease of use and ability to discriminate the
different stages [5].
When patients with heart failure progress to stage D heart failure or present to the
hospital in cardiogenic shock, specialist intervention is often required due to the
high morbidity and mortality in this population. There is increasing use of mechani-
cal circulatory support (MCS) devices, both temporary and durable. Temporary
MCS are used in acute shock, post-cardiotomy shock, or as a bridge to advanced
heart failure therapies and include devices such as the intraaortic balloon pump and
the Impella
®
left ventricular assist device (Abiomed, Danvers MA). The use of tem-
porary MCS has been increasing over time [6, 7]. If the patient is unable to wean
from temporary support, they can bridge to either heart transplantation or durable
MCS if deemed an appropriate candidate [8]. Durable MCS most commonly refers
to the left ventricular assist device (LVAD) and has been used as both “destination
therapy” (not eligible for heart transplantation) as well as “bridge-to- transplantation”
(BTT) for those who may become heart transplant candidates in the future [9].
While successive generations of MCS devices have improved outcomes since the
rst LVAD was approved in 2004, the overall survival for heart transplantation
exceeds that of destination therapy. Therefore, heart transplantation remains a criti-
cally important option for patients with stage D heart failure.
Heart transplantation was rst made possible with the development of vascular
anastomosis for the transplanted heart. Alexis Carrel and Charles Guthrie rst
described this technique in 1905 when they succeeded in transplanting a heart from
one dog to another by connecting the donor’s heart vessels to the recipient’s carotid
artery and jugular vein [10, 11]. Despite a successful anastomosis with adequate
coronary artery perfusion, the heart was not able to provide adequate circulatory
assistance [12].
The surgical technique was continuously rened, leading to the rst orthotopic
heart transplantation by Dr. Christiaan Barnard in 1967. With evolving surgical
techniques and advances in immunosuppression, post-heart transplant survival has
improved to approximately 90% at 1year, with a median survival of greater than
V. P. Nguyen et al.
135
15years [13–15]. Heart transplantation volumes continue to grow with >4600 trans-
plants in the United States in 2023 [16]. Ongoing progress in the understanding of
transplant immunology, technological advancement in temporary and durable MCS,
and novel evidence in other aspects of transplant cardiology created the need for an
update of the International Society for Heart and Lung Transplantation (ISHLT)
guideline for the care of heart transplant recipients in 2022. The resource can be
found here: https://www.ishlt.org/education- and- publications [17, 18]. The increas-
ing numbers of patients who have received heart transplantation, combined with
improving survival, will lead to a growing population of heart transplant recipients
expected to be at least partly evaluated and treated in the primary care setting.
6.2 Pre-Transplant Course
While this chapter focuses on the treatment of post-heart transplant recipients, it is
useful to review the patient’s pre-transplant course. A comprehensive guideline for
the evaluation and care of candidates for heart transplant was updated in 2024 by the
ISHLT [19].
6.2.1 Common Indications
Coronary artery disease is one of the most important contributors to heart failure,
with highly prevalent population-attributable risk factors of hypertension, diabetes
mellitus, obesity, and smoking. Therefore, it is no surprise that ischemic heart dis-
ease is one of the most common diagnoses in patients being evaluated for heart
transplantation in many countries. With improved revascularization techniques over
the last several decades, the proportion of patients with ischemic cardiomyopathy
being transplanted has decreased over time, whereas the non-ischemic cardiomy-
opathy (NICM), valvular cardiomyopathy, and restrictive cardiomyopathy (RCM)
cohorts are increasing [13]. Patients with RCM and congenital heart disease (CHD)
have a higher risk of death on the waitlist for heart transplantation, as they typically
do not benet from MCS therapies due to physiologic limitations [20]. As expected,
the proportion of HF etiology varies by age group, with NICM being the most domi-
nant diagnosis until age 60, after which ischemic cardiomyopathy becomes more
common; this mirrors the ndings of most large heart failure registries. In contrast,
the diagnoses of RCM, CHD, hypertrophic cardiomyopathy, and myocarditis are
more common among heart transplant recipients than the general heart failure popu-
lation [13]. Following heart transplantation, there is a low likelihood of the underly-
ing disease returning in the transplanted heart for most causes of heart failure. The
risk is higher for specic diagnoses, such as giant cell myocarditis, where one-third
of patients will have recurrence of the disease [21]. Even though quality of life and
longevity are generally improved, there is an inherent trade-off to heart
6 Primary Care oftheAdult Heart Transplant Recipient
136
Table 6.1
Indications for
heart transplantation in
transplanted recipients
2009–2017in North
America [22]
Non-ischemic cardiomyopathy 49%
Ischemic cardiomyopathy 35%
Restrictive cardiomyopathy 4%
Retransplant 3%
Congenital heart disease 3%
Hypertrophic cardiomyopathy 3%
Valvular heart disease 2%
Other 1%
transplantation: replacing the symptoms and morbidity of chronic HF with the life-
long need for immunosuppression and its associated risks. Common indications for
transplantation in North America are shown in Table6.1.
6.2.2 Pre-Transplant Workup andTreatment
• Comprehensive cardiac evaluation is performed to identify potentially revers-
ible medical causes prior to referral for heart transplantation. It is worthwhile
reviewing a patient’s indication, their time on the waiting list, and any prior
complications. Specic indications for heart transplantation include cardio-
genic shock requiring inotropic therapy or MCS, refractory NewYork Heart
Association (NYHA) functional class IV heart failure, end-stage congenital
heart disease, poor cardiopulmonary exercise test (CPET) results, an antici-
pated 1-year survival less than 80% due to progressive heart failure, refrac-
tory angina without options for further revascularization, or intractable
life-threatening arrhythmias.
• Comorbid conditions that may be a barrier to heart transplantation are assessed
thoroughly prior to transplantation, including cerebrovascular disease, peripheral
vascular disease, chronic kidney disease (CKD), diabetes, obesity, cancer and
chronic infections. Similarly, a host of psychosocial factors (e.g., prior adherence
to medical care, social support, mental health, and substance use) are evaluated
and optimized prior to ascertaining candidacy for transplantation, as they have
been associated with post-transplant outcomes (2023 ISHLT Guideline Class I,
Level of Evidence [LOE]) C recommendation) [18].
• Durable mechanical circulatory support: LVAD as BTT may be a reasonable
strategy for patients who are either anticipated to have a long wait time on the
transplant list due to blood group and/or body type or as a “bridge-to-candidacy”
for those who are not candidates at the time of evaluation, but have modiable
barriers that can be overcome [23]. Despite a slightly higher 90-day post-
transplant mortality, BTT LVAD patients have a similar survival after 90-days,
functional status, and quality of life in comparison to “de novo” primary heart
transplant patients [24]. Review of the pre-transplant course should include
whether the patient had MCS therapy prior to transplantation.
V. P. Nguyen et al.