Post Transplantation General Medical Care

Key Points:

• General medical care following transplantation includes standard age related/disease specific care that all patients should receive regardless of their transplant status

• Enhanced surveillance for cancer is of paramount importance due to decreased immuno-surveillance due to immunosuppression

• Complications attendant to immunosuppressive medications need to be anticipated, recognized, and treated

• Immunizations

  • Pre-OLT:

    • Pneumococcus

    • Hep A and B

    • Influenza

    • DPT

    • Meningococcal

    • H-Flu

    • Varicella (for pediatrics)

  • Non-routine vaccines post-OLT if clinically indicated

    • Inactivated Polio

    • Cholera

    • Plaque

    • Rabies

    • Anthrax

  • AVOID live virus vaccines post-OLT

    • MMR

    • Oral Polio

    • BCG

    • Yellow fever

    • Typhoid

    • Vaccinia

• Malignancies- general surveillance regimen

  • Survey for skin cancer (most common post-OLT malignancy)

  • PAP/ cervical and pelvic exam q year

  • Prostate exam (?PSA) in men > 40

  • Rectal exam, fecal occult blood testing any pt > 40

  • Flex sig every three years > age 50

  • Consider full colonoscopy every three-five years age > 50

    • Pts with PSC and Ulcerative colitis or any history of colonic neoplasia may require yearly colonoscopy

  • Mamography- at age 40 (consider earlier if family history of breast cancer)

  • Yearly CXR encouraged by many transplant programs

Complications related to Immunosuppression

• Hyperlipidemia

  • May be more common in patients receiving Sirolimus > Cyclosporin > Tacrolimus

  • May improve as Steroids are tapered

  • Consider use of “Statins” HMG-CoA inhibitor if not improved with diet control

• Diabetes

  • Pre-transplant diabetes is associated with a high incidence of post transplant diabetes

  • Majority of these patients are Insulin dependent

  • May improve with steroid taper

  • ? if more associated with Tacrolimus > Cyclosporine

• Renal insufficiency

  • Gradual deterioration of renal function post-OLT often associated with use of Cyclosporine and Tacrolimus

  • May improve by decreasing dose, or using an alternative immunosuppression strategy with low dose Cyclo or Tacrolimus:

    • Mycophenolic acid

    • Sirolimus

• Hypertension

  • Usually due to Cyclosporine and Tacrolimus

  • Calcium channel blockers are usually efficacious

    • Nifedipine used preferentially as Verapamil and Diltiazem may increase Cyclosporine and Tacrolimus levels

    • Beta Blockers may also be required

    • ACE inhibitors may exacerbate hyperkalemia

    • ARB’s (Losartan) may be of benefit

• Osteoporosis/Osteopenia

  • Occurs frequently in cirrhotics, particularly in patients with cholestatic liver disease (PBC, PSC) and Autoimmune hepatitis patients treated with Glucocorticoids

  • In the first 6 months Post-transplant, bone mass further deteriorates

  • Over time post-OLT, bone mass will improve to pre-transplant levels

  • Treatments include:

    • Minimize glucocorticoids

    • Avoid smoking and alcohol

    • Exercise

    • Supplement Ca and Vitamin D

    • Estrogen used but some question of benefit

    • Calcitonin (either intra-nasal, sq, or IM)

    • Bisphosphonates (PO or IV)