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Liver transplantation

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 European Association for the Study of the Liver (EASL 2023), the American College of Gastroenterology (ACG 2016), and the American Society of Transplantation (AST/AASLD 2013).


1.Diagnostic investigations

Screening for osteoporosis: 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.
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  • Screening for kidney disease

  • Screening for malignancies

  • Screening for colon cancer

  • Evaluation of suspected infection

  • Evaluation of suspected fungal infections

  • Evaluation of suspected rejection

  • Evaluation of suspected hepatic artery thrombosis or stenosis

2.Medical management

Immunosuppressive therapy: 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.

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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 (adults)

3.Nonpharmacologic interventions

Smoking cessation: advise sustained smoking cessation as the most important preventative intervention, because of the strong association of lung, head, and neck cancers with smoking.

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  • Dietary modification

  • Alcohol use cessation

  • Environmental exposures

  • Protective habits

4.Surgical interventions

Management of hepatocellular carcinoma: perform resection or ablation as the treatment of choice for a solitary extrahepatic metastasis or an intrahepatic recurrence of HCC.

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  • Bariatric surgery

  • Kidney transplantation

  • Retransplantation

  • Management of bilomas and biliary cast syndrome

5.Specific circumstances

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

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  • Pregnant patients (immunosuppressive therapy)

  • Pregnant patients (surveillance)

  • Patients with primary biliary cirrhosis

  • Patients with AIH

  • Patients with NAFLD or nonalcoholic steatohepatitis

  • Patients with HIV

6.Patient education

General counseling: 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.

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  • Hernia care counseling

  • Preconception counseling

7.Preventative measures

Routine immunizations
Provide influenza immunization to all liver transplant recipients on an annual basis.
Avoid providing live virus vaccines in all liver transplant recipients.

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  • CMV prophylaxis

  • Pneumocystis jiroveci pneumonia prophylaxis

  • HBV prophylaxis

  • HCV prophylaxis

8.Follow-up and surveillance

Serial laboratory assessment: as per AASLD 2013 guidelines, individualize the frequency of follow-up laboratory tests according to the time elapsed since LT, prior complications of LT, the stability of serial test results, and the underlying cause of hepatic disease.

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  • Serial imaging assessment

  • Serial liver biopsy

  • Assessment of immunosuppressive therapy

  • Long-term follow-up