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Liver transplantation

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of liver transplantation are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2024), the European Association for the Study of the Liver (EASL 2024,2023), the European Society of Anaesthesiology and Intensive Care (ESAIC 2023), the American College of Gastroenterology (ACG 2016), the American Association for ...
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Diagnostic investigations

Screening for osteoporosis: as per AASLD/AST 2013 guidelines, obtain bone mineral density (BMD) testing yearly for patients with osteopenia, and every 2 to 3 years for patients with normal BMD in the first 5 years after transplantation; thereafter, screen on the basis of progression of BMD and risk factors.
B
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  • Screening for kidney disease

  • Screening for malignancies

  • Screening for colon cancer

  • Evaluation of suspected infection

  • Evaluation of suspected hepatic artery thrombosis or stenosis

Medical management

Immunosuppressive therapy: as per AASLD/AST 2013 guidelines, ensure that immunosuppressive drugs for LT recipients are prescribed and monitored only by physicians with knowledge and expertise in that area. The choice of agents will depend on many factors, and no one regimen can be recommended for any patient.
B

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  • De-escalation of immunosuppressive therapy

  • Management of hypertension

  • Management of dyslipidemia

  • Management of diabetes mellitus

  • Management of osteoporosis

  • Management of fungal infections

  • Management of tuberculosis

  • Management of HCV infection

  • Management of HBV infection

  • Management of CMV infection

Nonpharmacologic interventions

Smoking cessation: as per AASLD/AST 2013 guidelines, advise sustained smoking cessation as the most important preventative intervention, because of the strong association of lung, head, and neck cancers with smoking.
B

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  • Dietary modifications

  • Alcohol use cessation

  • Environmental exposures

  • Protective habits

Perioperative care

Management of perioperative bleeding: as per ESAIC 2023 guidelines, recognize that higher intraoperative blood loss and transfusion requirements are associated with decreased survival after LT.
B
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Surgical interventions

Management of HCC: as per AASLD/AST 2013 guidelines, perform resection or ablation as the treatment of choice for a solitary extrahepatic metastasis or an intrahepatic recurrence of HCC.
B

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  • Bariatric surgery

  • Kidney transplantation

  • Retransplantation

  • Management of bilomas and biliary cast syndrome

Specific circumstances

Pregnant patients, timing of pregnancy: as per EASL 2023 guidelines, advise liver transplant recipients that delaying pregnancy for at least 1 year after transplant is associated with improved maternal and fetal outcomes.
B

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  • Pregnant patients (immunosuppressive therapy)

  • Pregnant patients (surveillance)

  • Patients with primary biliary cirrhosis

  • Patients with AIH

  • Patients with MASLD or MASH

  • Patients with AAT deficiency (LT)

  • Patients with AAT deficiency (liver donation)

  • Patients with HIV infection

Patient education

General counseling: as per AASLD/AST 2013 guidelines, educate all LT recipients about the importance of sun avoidance and sun protection through the use of a sun block with a sun protection factor of at least 15 and protective clothing. Encourage them to examine their skin on a regular basis and report any suspicious or concerning lesions to their physicians.
B

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  • Hernia care counseling

  • Preconception counseling

Preventative measures

Routine immunizations
As per AASLD/AST 2013 guidelines:
Provide influenza immunization to all liver transplant recipients on an annual basis.
B
Avoid providing live virus vaccines in all liver transplant recipients.
D

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  • CMV prophylaxis

  • Pneumocystis jiroveci pneumonia prophylaxis

  • HBV prophylaxis

  • HCV prophylaxis

Follow-up and surveillance

Serial laboratory assessment
As per ADA 2024 guidelines:
Obtain screening for hyperglycemia after organ transplantation. Make a formal diagnosis of post-transplantation diabetes mellitus once the patient is stable on an immunosuppressive plan and in the absence of an acute infection.
B
Obtain oral glucose tolerance test as the preferred test to make a diagnosis of post-transplantation diabetes mellitus.
B

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  • Serial imaging assessment

  • Serial liver biopsy

  • Assessment of immunosuppressive therapy

  • Evaluation of suspected rejection

  • Long-term follow-up