Primary care management of the liver transplant patient

The patient referred for liver transplantation typically has complications from a progressive, irreversible liver injury. Less traditional complications of end-stage liver disease, such as bone disease and some hepatobiliary malignancies, may also prompt referral. However, there are contraindications to liver transplantation, such as metastatic malignancy and persistent substance abuse. Each patient should be referred as early as possible. The evaluation process includes a complete physical examination and social and psychologic evaluations. If transplantation is agreed upon, the patient is listed by clinical status and enters a waiting period for a donor liver. Following transplantation, the patient is maintained on a regimen of immunosuppressive drugs to prevent allograft rejection. Each patient is also maintained on prophylactic medications, to decrease the risk of opportunistic infection. Many of the postoperative problems in liver transplantation are a result of immunosuppression, either as side effects of the medications used to prevent and control rejection or from the intensity of the resulting immunosuppression. These problems include headaches, systemic hypertension, acute and chronic allograft rejection, renal dysfunction, opportunistic infection with cytomegalovirus or Pneumocystis carinii, disease recurrence, and neoplasia. Routine, long-term care includes systematic clinical follow-up and repetitive blood tests. Communication among the transplant center, the patient, and the referring physician are essential to a successful outcome over the long term.