Key points are not available for this paper at this time.
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. In LT recipients followed beyond 1 year, of the of vary from to after LT more than and to as are and the is and patients from to to the and in to that LT recipients The of the long-term management of diabetes after LT are from the for patients (Table is the target of hemoglobin and recommendation of a of than the that the more are be is or a be used in LT recipients with renal as and are there is in renal The of in LT recipients is and a small suggest that the of from to in patients with and The treatment of after LT for target of with a of modifications and as are is the and with which to as the interval from LT patients with experience a in and be is or be used in LT recipients with renal as and are there is of renal be to the of from to in LT recipients with in LT recipients the risk of and and there are of in LT is to target a treatment of in LT recipients with the management of LT to as and be the of the including loss in recipients the on and the of are of is and a of the target be as and be more in LT recipients the of The and be used with the of are as as in the treatment of LT and be used as in LT recipients with DM, CKD, of is these are used in with of the increased risk of or be used with The of with of be in LT recipients to the with that in LT The treatment of for a target of with a of modifications and as and be used as in LT recipients with DM, CKD, in to of LT recipients than that and is a risk for and (Table and have and the on the of in LT A and and have (Table The of after a is for LT a for the treatment of after LT. The of after a is for LT with or and are be with be by the of is first with fatty to this is for or be patients be followed for with the use of and is after LT. In American and approximately of patients in the first to 3 after this is by the of health and the of by as LT patients to LT recipients who or and be the and with to transplantation to be The of is LT recipients and (Table The of after LT from to at 1 to 3 to to at 10 after are the of in recipients of are at increased risk of and and the of is increased in patients transplantation for of the risk from The risk due to Epstein-Barr to is in the on The American Society guideline on for that who are on of transplantation to be more every 3 to 5 They the recommendations of their by modifications to the and to for LT The proportion of patients LT for has increased in the of at are for patients with the and to 60% for patients with the long-term after LT for suggest that is the of for a the risk of of Guidelines for after LT, including the choice of the the and the of have been for patients transplantation for or for patients with in the A is for the to and every for 3 after LT. The of is a for patients who had transplantation or on be and be the is in with is the best treatment for small LT recipients a after transplantation to with at least by a 5 or more after transplantation with and or risk for with including be or patients who of the for be with every to that after be for patients transplantation for or is the treatment of choice for a or of and by 10 in of after LT and in patients as early as 1 to in after LT, the of is LT has for in or is and by LT recipients with least 1 after LT. is as diabetes and are is at a The choice of be the and the with and the Food and Drug for in C and to be The be in the more have been in to on or are used in early guidelines for renal recipients at least early of is to be to and of be with for the the of and be the for the of and and with of is including liver in to for The with acute is in the as the are to and be for at least 1 after or the is were the or in the the of the recommendations be of be in with is by the LT is in LT be by a in with the be for 1 after LT and occur at a with with and with of as and diabetes The for is which be at throughout and be used are and are every every and the of of be The interval from the to after LT is a of the of with CMV, and and and and as and The of the of and the of the of these After the posttransplant the risk of infection is and this is to the of From 3 to after LT, in the LT or the are or in the or by as and to as the of in are of for that LT the and for LT the of the of the the and the of and and the of and be to are the LT recipients and and and The bone and of the and in the of a with the use of or with human and or The of the of the in with the of who are and are at increased risk for of a treatment for be for evidence of infection with in the first 3 in the of of after the of in the first or after the of for is patients are After the of have adopted a approach to for in the risk there is evidence to the of patients at this The of by or the is for the of active the with the of and be a of the to with hepatitis or or a infection and for the of to be LT recipients The treatment of be recipients are have a or have or LT recipients with a infection and have their and have with is to of be for are have as and the treatment be for treatment for renal and for renal for to is is approved for use in patients with more or is A of of treatment is for patients with of treatment be there is of and a in be with is in recipients recipients of with or for a of 3 after transplantation The treatment of LT recipients with be and have be LT recipients for the treatment of and be for 1 to 3 after the treatment of The treatment of a infection of the following: of or in with to or a for A of of be to the of and be in patients with a of or who have a or infection treatment with In be and be to the of with or in for is of LT with in of to a primary or and with is the of liver the development of The of with infection is in adult LT is to be of and of the and The of a of and be in who with or or identify of or are The of with is of The treatment of is a of there is to including and be The of has been to be in LT recipients who with or be with the development of PTLD, the of is for a is for after LT of renal and of care LT. The of in LT recipients has the with a in and of The of infection after 90 days is are for the of including for which the is is to with The and of in or from LT recipients with are and is a for the of in The of from a than to and have been for the of and The treatment of as as a of The choice of with the and the of as in The of for and are for the of and of or is for the of and are for the of and A of be to prevent immune for is in LT of the use of after be in with by and The is by the of the by a of or or at in and for renal is the of of or be used in with for patients with of on The of is more of LT recipients with strength or strength 3 for a of to after transplantation and are the preferred for patients who are of is the of choice for the treatment of is the preferred for patients of with more with and or of or with a a or or a to identify the risk for the development of after LT have been a infection with and with CMV, and is The of be by increased of and for of with and followed by of and with bone and or of The use of in LT recipients is by and by the with which to the for with of the risk of a in and with the of to be increased to at the of be for to the on or be the of treatment to be The treatment of active the of a and the of with in with This be to and after the of and for a of for and is LT recipients patients with have undergone transplantation with has been in LT recipients with patients on highly active antiretroviral after transplantation experience in The use of in LT recipients is by with which to a risk of or or LT recipients with have a and of acute The and the of their to be in LT recipients In of LT recipients of of the and LT recipients be followed with and for is for LT recipients HAART, and is the for be used after LT has been by and is in LT recipients of the of has been with LT. LT recipients LT recipients is for the and the or for than of in the United States and in is the for LT. in the there has been a in the primary for LT with more than end-stage liver This the of in of as as the increased of for LT. The for patients transplantation for is and the best of for LT. The in and graft the 10 to the in to prevent and after LT. The of hepatitis B immune and prevent in LT The of and is to The of be on the of and is and with The of is for patients at risk for A infection is with and hepatitis B in and is due to a of Liver is for the of and the of is a in LT recipients and is by of with and a of This the of and is in the of a of and on or at prevent in of recipients In patients with or transplantation and of for be and long-term treatment with or in be used as be used to patients with is to with a to are the of is for patients at risk for for is treatment to prevent or are available infection is patients who are at LT, the of have evidence of hepatitis the first after the of in LT recipients is highly in the of the to the development of is to 10 years, 5 of The risk of is to the first of the of cirrhosis, and the risk is to to of the is the of graft loss in this and graft are in patients with a of approximately recipients have of graft loss the is from is a risk of LT recipients acute that treatment or is more the the interval from LT, in is to the of a infection and acute The of on the of is suggest that liver and have been with a risk of to is for evidence of which is by the of to or to this with more and The primary of is the of this is with or and graft The of is is this with more and The of acute graft in patients and is which is than the in or by with in the of increased liver has been This is a of and to the of and the of in the of the and is that and or the of care the for LT recipients with 1 is approved for use in are and and as The of is of of the that in LT Liver is in and and in from causes of liver has in the management of acute be with increased and be is for 3 or or a of or and are the of The and of with are to be The of is the of a and this a for be is for liver with the of the of and after transplantation. at risk for as and be in the is by liver occur in the of liver and the the of with the or of The of from to is the use of is with and be with there are to a preferred The of the of on graft and is for the first after transplantation, with end-stage than is evidence that in LT recipients at a of 10 to is with in liver there are to in or graft LT recipients be for autoimmune and bone with evidence of treatment with at 10 to be and use is with the of liver on graft has been is for with to patients with liver is for LT with long-term with a are at increased risk for cholangitis; who have a are at risk for In patients with chronic ulcerative or after LT recipients with are at risk of and and have is evidence for the approach in LT recipients CUC, in this is in to of patients at 5 years, with graft loss due to in as as of patients with The of is based on a of and in biliary or liver and the of causes as or to of the for or transplantation, a of or active after transplantation, the use of for the treatment of the and the and the of In recipients with CUC, the risk of is evidence to maintaining in patients transplantation for there are on is that patients for in the of have with after transplantation for are be for evidence of liver every liver be at 5 The for are highly the of patients with and to increased to end-stage graft and there is evidence for a in patients transplantation for AIH, is to patients on in to to maintaining bone patients for LT have a to that of recipients is increased in recipients with and is a in the of by patients after LT The best that of LT recipients or small in the first 5 in the there were of suggest that patients who to are at risk for alcoholic alcoholic and the causes of death for the patients who to of to be patients of and The of deaths and new-onset of the in patients LT for a with patients with a of be to from be to or use patients with a of who are of be to be to the risk of new-onset of the in that is the of liver to LT in the United and is that by the for and NASH, and are after to and and and for are as the of and after LT, DM, and on patients who LT on of or cirrhosis, to in 1 or with liver from causes of liver in the liver in the liver new-onset or to with in the is in the first 5 after LT. on or graft has been LT recipients with new-onset or have been in there are to in patients who transplantation for or cirrhosis, is more in transplantation for The of or NAFLD, the of and the of causes of liver liver recommendations the or treatment of or in LT recipients be than recommendations to in and and diabetes biliary and have been with to liver is a after LT. the LT recipients with be to and to This practice guideline in with the American Association for the Study of Liver Diseases Practice Guidelines which review of the The of the and
Lucey et al. (2012) studied this question.