Not paying enough attention to hypertension, hyperlipidaemia and diabetes in liver transplant recipients
Liver transplant recipients frequently have one or more features of metabolic syndrome, which includes hypertension (40–85%), hyperlipidaemia (40–70%), and diabetes mellitus (10–65%).2,62 Overall, the prevalence of metabolic syndrome in liver transplant recipients is approximately 50–60%.63 The features of metabolic syndrome can pre-exist (liver transplantation does not cure the pre-existing conditions) or be caused and/or worsened by liver transplantation (immobilization, use of steroids, and long-term immunosuppressive therapy). Owing to the high prevalence of metabolic risk factors, the cumulative risk of cardiovascular events is approximately 25% at 10 years post-liver transplantation, which is significantly elevated compared with the age- and gender-matched general population.64 Cardiovascular complications are a leading cause of post-liver tranplantation morbidity and mortality, and account for a third of deaths in the long-term follow-up.65
Gastroenterologists and hepatologists tend to focus very carefully on the management of liver-related issues in transplant recipients (symptoms and signs of liver diseases, recurrence and treatment of primary liver disease, management of immunosuppressive therapy and its complications, HCC recurrence, etc.), but often overlook metabolic comorbidities. A good evaluation of liver transplant recipients should always include analysis of their metabolic profile. Primary care teams should perform a meticulous cardiovascular risk assessment, and treat each of the components of metabolic syndrome aggressively to improve patient outcomes. The timing of the interval follow-up should be based on general population guidelines, as there is no specific guidance for transplanted patients.
European and American guidelines state that management of metabolic complications in liver transplant recipients should start with prevention, as interventions to prevent weight gain and its sequelae (i.e. diet, lifestyle and physical exercise) are more successful than attempts to induce weight loss afterwards.2,62 These interventions should be implemented as soon as possible after liver transplantation, as the biggest weight gain occurs within the first year after transplantation.
The multidisciplinary approach to metabolic syndrome in liver transplantat recipients targets different elements.2,62 First is the introduction of a Mediterranean diet (<60g/day of complex carbohydrates and a reduction of dietary fructose are correlated with a lower risk of insulin resistance and obesity) and physical exercise. Second is pharmacological therapy, including calcium-channel blockers or ACE inhibitors to treat hypertension, statins ± ezetimibe for hypercholesterolaemia, fish oil and fibric acid derivates for isolated hyperlipidaemia, and insulin and/or other agents for diabetes. Third are changes in immunosuppressive therapy, including conversion of ciclosporin to tacrolimus or vice versa, reduction of calcineurin inhibitors with the addition of other drugs (e.g. mycophenolate mofetil), and discontinuation of sirolimus. Fourth is evaluation of the potential benefit of bariatric surgery for those recipients who are, or who become, morbidly obese despite multiple other attempts to lose weight.
Our team usually involves a metabolic disease specialist in the management of liver transplantation recipients with diabetes, especially once insulin therapy is started. From a study from our unit, we have seen that mycophenolate mofetil is protective versus the development of diabetes (Becchetti and Burra, abstract accepted for ILC 2020). New drugs for the treatment of diabetes have recently been approved, and they have shown good results in terms of safety and efficacy in the general population. Hopefully, these drugs will also prove helpful for the treatment of diabetes in liver transplant recipients.
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