Long-term management of the successful adult liver transplant: 2012 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation

Abstract

This practice guideline has been approved by the American Association for the Study of Liver Diseases and the American Society of Transplantation. These recommendations provide a data-supported approach to management of adult patients who have successfully undergone liver transplantation. They are based on the following: (1) a formal review and analysis of recently published world literature on the topic (via a MEDLINE search); (2) A Manual for Assessing Health Practices and Designing Practice Guidelines (American College of Physicians)1; (3) guideline policies,2 including the American Association for the Study of Liver Diseases policy on the development and use of practice guidelines and the American Gastroenterological Association policy statement on guidelines3; and (4) the experience of the authors in the specified topic. Intended for use by physicians and health care providers working with adult recipients of liver transplantation (LT), these recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventive aspects of care. They are intended to be flexible, in contrast to standards of care, which are inflexible policies to be followed in every case. Specific recommendations are based on relevant published information. To more fully characterize the available evidence supporting the recommendations, the American Association for the Study of Liver Diseases Practice Guidelines Committee has adopted the classification used by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) workgroup with minor modifications (Table 1).4 In the GRADE system, the strength of a recommendation is classified as (1) strong or (2) weak. The quality of evidence supporting a strong or weak recommendation is designated by 1 of 3 levels: (A) high, (B) moderate, or (C) low. AIH, autoimmune hepatitis; ALD, alcoholic liver disease; BMD, bone mineral density; CKD, chronic kidney disease; CMV, cytomegalovirus; CNI, calcineurin inhibitor; CUC, chronic ulcerative colitis; DM, diabetes mellitus; EBV, Epstein-Barr virus; ESRD, end-stage renal disease; FDA, Food and Drug Administration; GRADE, Grading of Recommendations Assessment, Development, and Evaluation; HAART, highly active antiretroviral therapy; HbA1c, hemoglobin A1c; HBIG, hepatitis B immune globulin; HBV, hepatitis B virus; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; HIV, human immunodeficiency virus; HLA, human leukocyte antigen; LT, liver transplantation; mTOR, mammalian target of rapamycin; NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis; NODM, new-onset diabetes mellitus; PBC, primary biliary cirrhosis; PSC, primary sclerosing cholangitis; PTLD, posttransplant lymphoproliferative disorder; TB, tuberculosis. LT is the treatment of choice for patients with decompensated cirrhosis, acute liver failure, small hepatocellular carcinomas (HCCs), or acute liver failure. The success of LT has meant that there is a growing cohort of LT recipients throughout the world. From 1985 through 2011, approximately 100,000 persons in the United States underwent LT. On December 30, 2011, there were 30,000 LT recipients who were alive and had survived at least 5 years, and there were more than 16,000 recipients with 10 or more years' survival. These long-term survivors are at risk of early death and increased morbidity. The purpose of this guideline is to assist in the management of adult recipients of LT, identify the barriers to maintaining their health, and make recommendations on the ways to best prevent or ameliorate these barriers. This guideline focuses on management beyond the first 90 days after transplantation. The greatest proportion of deaths or retransplants after LT occur soon after transplantation. The causes of death and graft loss vary according to the interval from transplantation, with infection and intraoperative and perioperative causes accounting for nearly 60% of deaths and graft losses in the first posttransplant year. After the first year, death due to acute and causes for a proportion of The of the hepatitis C or autoimmune liver is of graft loss the the transplantation for these death a for to acute or chronic is throughout the first 10 after transplantation. The liver of the for after the first 90 LT recipients this is patients throughout the of the The use of increased risk of and which be or as diabetes and and or posttransplant lymphoproliferative The of the of and the of the liver a of for LT analysis of a of LT recipients that the of kidney as a of of or or the development of end-stage renal at 5 and at 10 LT recipients have with a of and new-onset diabetes and and renal are the causes of and after LT (Table The of the as a chronic primary biliary primary sclerosing autoimmune hepatitis or HCC, and of the patients LT have a or of to or which with on health, by with risk of the quality of after LT has that quality in LT patients in in with their transplantation, LT recipients to have in with these are as and a of the of the or of for and the or treatment of liver the and the quality of be In these a to and ameliorate of is to success success for of liver and after LT, and are after the first 3 The is which for is the has The of in a with a liver the development of or a or of the or in a with a infection is a Liver are after LT. liver are for a the of on the and of or liver are in the of graft or in LT The causes of liver in the are in than 1 in the liver are in a LT is to the in 1 to A to be based on the and of the liver a and and of the be that liver and from the of biliary due to or of the or to or biliary to a of to and is with and the use of a including from more from after death with of or The of with liver be by the according to the from LT, the from LT, the of and the on the of liver and be Liver be is as the of liver or the to as or biliary and biliary be in a with in LT and biliary or is by is to the and for the choice of HCV, or autoimmune Drug calcineurin renal of and mammalian target of as are of or experience with the of or risk for of or risk for is for the of the choice of the and be by the and The is by the the target after 3 are 5 to 10 for and to for are The target for is 5 The for for is the used of are in The of LT recipients to graft A small of LT recipients to the and long-term is as that has more than 90 days after transplantation. have been as acute and and as of the and the is through the of liver the be on the of and the have been adopted to the and Liver in patients with with a in and is by the of of the or and a with and in The of be or the is more and as acute from early acute by of or due to autoimmune liver of The and autoimmune and be to from and the In of in of be in or the treatment be a of increased at or at for 3 followed by in the A as a to liver is in approximately of with approximately a of and is in the first occur at suggest that by human leukocyte in with a in the development of as The of is with a in liver with a in and followed by a in In the of and A liver with at least 10 is in to with that to and loss of have In the early of there be a more the the loss of from the and in be and for autoimmune to of a graft to The or and The treatment of is increased and in or to be in early than of the the to graft failure. for LT recipients be and by with and in that The choice of on and be for be at least every and as with the of long-term be on the of liver a be treatment and classified according to the the long-term of be in a small of this be with recipients and the risk of infection with by including and in and be for that and and to of LT recipients to to in as care and be with the to for the of LT recipients the of from and LT recipients and and and and LT recipients which and by LT to be with the a of to for the of LT recipients to prevent These and and LT recipients a review of to with LT recipients be the of and through the use of a with a of at least and They be to their on a and or to their physicians of the strong of and with the of is the LT recipients of a and the and of in the and be after transplantation loss and are with after LT. In the first there is bone loss in liver of the bone mineral that is with the of and After the first with bone and in the there be a in bone the with a in the of In patients with or this bone loss in a to at of bone and in the first after LT, there is a in the of the bone of LT recipients with In the early after LT, be in patients and every to 3 in patients with on risk than or and and risk at is be is or be The of is has been with for 10 for is in In the first 5 after transplantation, by be for patients and every to 3 for patients with on the of and on risk bone is or are patients be for risk for bone in this of and of and a and The LT and and be in LT recipients with or The of LT recipients who the first chronic kidney in this from to The of is due to the used to and the of posttransplant The risk of that or kidney transplantation is to the first 10 after of kidney in the United States are for LT recipients who The of in the LT is (Table and chronic to DM, chronic renal and perioperative acute kidney is with a risk of death more than 1 after LT in with recipients A is a and of in this that has been to have be the of in and the are to and in renal be in the of of the of is best by the of the of to in a and the use of that the are of treatment in the and be to have in LT A in the or a of to after LT is a practice at the of These on or in with to prevent acute use and or is more to be is the is and LT recipients with who a or kidney have a to 60% in long-term in with their of renal in LT recipients for the and management of use to the the of to in a be at least The or of is to the development of in LT recipients transplantation from or is in and be the for LT recipients who The of or in to and The to LT that are in The of after LT and NODM, of which is in the perioperative that is at the of transplantation after LT, and patients on a to early after LT. 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