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Russo MW, Wheless W, Vrochides D. Management of long-term complications from immunosuppression. Liver Transpl 2024; 30:647-658. [PMID: 38315054 DOI: 10.1097/lvt.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
This review discusses long-term complications from immunosuppressants after liver transplantation and the management of these complications. Common complications of calcineurin inhibitors include nephrotoxicity and metabolic diseases. Nephrotoxicity can be managed by targeting a lower drug level and/or adding an immunosuppressant of a different class. Metabolic disorders can be managed by treating the underlying condition and targeting a lower drug level. Gastrointestinal adverse effects and myelosuppression are common complications of antimetabolites that are initially managed with dose reduction or discontinuation if adverse events persist. Mammalian targets of rapamycin inhibitors are associated with myelosuppression, proteinuria, impaired wound healing, and stomatitis, which may require dose reduction or discontinuation. Induction agents and agents used for steroid-refractory rejection or antibody-mediated rejection are reviewed. Other rare complications of immunosuppressants are discussed as well.
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Affiliation(s)
- Mark W Russo
- Division of Hepatology, Department of Medicine, Carolinas Medical Center Wake Forest, University School of Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - William Wheless
- Division of Hepatology, Department of Medicine, Carolinas Medical Center Wake Forest, University School of Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Transplant Surgery, Carolinas Medical Center Wake Forest, University School of Medicine, Atrium Health, Charlotte, North Carolina, USA
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2
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Gabrielli F, Golfieri L, Nascimbeni F, Andreone P, Gitto S. Metabolic Disorders in Liver Transplant Recipients: The State of the Art. J Clin Med 2024; 13:1014. [PMID: 38398327 PMCID: PMC10889804 DOI: 10.3390/jcm13041014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Liver transplantation represents a chief therapeutic approach for acute liver failure, end-stage liver disease and hepatocellular carcinoma. Despite witnessing advancements in short- and medium-term survival over recent decades, attributed to refinements in surgical techniques and immunosuppressive protocols, long-term mortality remains impervious to modification. Notably, cardiovascular disease emerges as a predominant cause of mortality among liver transplant recipients. This trend is accentuated by the increasing prominence of non-alcoholic steatohepatitis-related cirrhosis as an indication for liver transplantation. Moreover, the administration of immunosuppressive agents is intricately linked to the degradation of the metabolic profile in liver transplant recipients, thereby contributing to the initiation or exacerbation of cardiovascular risk factors, such as hypertension, diabetes, and dyslipidaemia. In addition, the post-liver transplantation period is marked by a decline in lifestyle quality and a failure to acknowledge the psychological distress experienced by patients throughout the transplant process. These factors can precipitate a deterioration in the patient's metabolic profile, exacerbated by suboptimal therapeutic compliance. This narrative review aims to comprehensively address the principal metabolic disorders intricately associated with liver transplantation.
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Affiliation(s)
- Filippo Gabrielli
- Internal and Metabolic Medicine, Department of Medical and Surgical Sciences for Children & Adults, AOU di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
- Department of Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Lucia Golfieri
- Clinical Psychology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant’Orsola, 40138 Bologna, Italy
| | - Fabio Nascimbeni
- Internal and Metabolic Medicine, Department of Medical and Surgical Sciences for Children & Adults, AOU di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Pietro Andreone
- Internal and Metabolic Medicine, Department of Medical and Surgical Sciences for Children & Adults, AOU di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
- Postgraduate School of Allergology and Clinical Immunology, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
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3
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Lehmann CJ, Dylla NP, Odenwald M, Nayak R, Khalid M, Boissiere J, Cantoral J, Adler E, Stutz MR, Dela Cruz M, Moran A, Lin H, Ramaswamy R, Sundararajan A, Sidebottom AM, Little J, Pamer EG, Aronsohn A, Fung J, Baker TB, Kacha A. Fecal metabolite profiling identifies liver transplant recipients at risk for postoperative infection. Cell Host Microbe 2024; 32:117-130.e4. [PMID: 38103544 DOI: 10.1016/j.chom.2023.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/06/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023]
Abstract
Metabolites produced by the intestinal microbiome modulate mucosal immune defenses and optimize epithelial barrier function. Intestinal dysbiosis, including loss of intestinal microbiome diversity and expansion of antibiotic-resistant pathobionts, is accompanied by changes in fecal metabolite concentrations and increased incidence of systemic infection. Laboratory tests that quantify intestinal dysbiosis, however, have yet to be incorporated into clinical practice. We quantified fecal metabolites in 107 patients undergoing liver transplantation (LT) and correlated these with fecal microbiome compositions, pathobiont expansion, and postoperative infections. Consistent with experimental studies implicating microbiome-derived metabolites with host-mediated antimicrobial defenses, reduced fecal concentrations of short- and branched-chain fatty acids, secondary bile acids, and tryptophan metabolites correlate with compositional microbiome dysbiosis in LT patients and the relative risk of postoperative infection. Our findings demonstrate that fecal metabolite profiling can identify LT patients at increased risk of postoperative infection and may provide guideposts for microbiome-targeted therapies.
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Affiliation(s)
- Christopher J Lehmann
- Department of Medicine, Section of Infectious Disease and Global Health, University of Chicago Medicine, 5841 S. Maryland Ave., Chicago, IL 60637, USA; Department of Pediatrics, Section of Pediatric Infectious Diseases, University of Chicago Medicine, 5841 S. Maryland Ave., Chicago, IL 60637, USA.
| | - Nicholas P Dylla
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA
| | - Matthew Odenwald
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA; Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637, USA
| | - Ravi Nayak
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA
| | - Maryam Khalid
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA
| | - Jaye Boissiere
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA
| | - Jackelyn Cantoral
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA
| | - Emerald Adler
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA
| | - Matthew R Stutz
- Department of Pulmonary and Critical Care Medicine, Cook County Health, 1950 W. Polk St, Chicago, IL 60612, USA
| | - Mark Dela Cruz
- Department of Cardiology, Advocate Health Care Systems, 4400 W. 95(th) St, Oak Lawn, IL 60453, USA
| | - Angelica Moran
- Department of Pathology, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637, USA
| | - Huaiying Lin
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA
| | - Ramanujam Ramaswamy
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA
| | - Anitha Sundararajan
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA
| | - Ashley M Sidebottom
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA
| | - Jessica Little
- Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA
| | - Eric G Pamer
- Department of Medicine, Section of Infectious Disease and Global Health, University of Chicago Medicine, 5841 S. Maryland Ave., Chicago, IL 60637, USA; Duchossois Family Institute, Biological Sciences Division, University of Chicago, 900 E. 57th St, Chicago, IL 60637, USA.
| | - Andrew Aronsohn
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637, USA
| | - John Fung
- Department of Surgery, Section of Transplant Surgery, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637, USA
| | - Talia B Baker
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah Health, 30 N. 1900 East, Salt Lake City, UT 84132, USA
| | - Aalok Kacha
- Department of Anesthesia and Critical Care, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637, USA.
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Agostini C, Buccianti S, Risaliti M, Fortuna L, Tirloni L, Tucci R, Bartolini I, Grazi GL. Complications in Post-Liver Transplant Patients. J Clin Med 2023; 12:6173. [PMID: 37834818 PMCID: PMC10573382 DOI: 10.3390/jcm12196173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/16/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Liver transplantation (LT) is the treatment of choice for liver failure and selected cases of malignancies. Transplantation activity has increased over the years, and indications for LT have been widened, leading to organ shortage. To face this condition, a high selection of recipients with prioritizing systems and an enlargement of the donor pool were necessary. Several authors published their case series reporting the results obtained with the use of marginal donors, which seem to have progressively improved over the years. The introduction of in situ and ex situ machine perfusion, although still strongly debated, and better knowledge and treatment of the complications may have a role in achieving better results. With longer survival rates, a significant number of patients will suffer from long-term complications. An extensive review of the literature concerning short- and long-term outcomes is reported trying to highlight the most recent findings. The heterogeneity of the behaviors within the different centers is evident, leading to a difficult comparison of the results and making explicit the need to obtain more consent from experts.
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Affiliation(s)
| | | | | | | | | | | | - Ilenia Bartolini
- Department of Experimental and Clinical Medicine, AOU Careggi, 50134 Florence, Italy; (C.A.); (S.B.); (M.R.); (L.F.); (L.T.); (R.T.); (G.L.G.)
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