Primary Care of the Solid Organ Transplant Recipient

 

Am Fam Physician. 2016 Feb 1;93(3):203-210.

Author disclosure: No relevant financial affiliations.

The advancing science of transplantation has led to more transplants and longer survival. As a result, primary care physicians are more involved in the care of transplant recipients. Immunosuppressive therapy has significantly decreased rates of transplant rejection but accounts for more than 50% of transplant-related deaths, often due to infections and other risks related to long-term use. Cardiovascular disease is the leading cause of non–transplant-related mortality. Aggressive risk factor management is recommended for transplant recipients, including a blood pressure goal of less than 130/80 mm Hg and statin therapy in kidney, liver, and heart recipients. Fertility typically increases posttransplant, and female transplant recipients should avoid pregnancy for one year after surgery. The best contraceptive choice is usually an intrauterine device. Because of the increased risk of infection, patients should be tested for graft dysfunction or infection if suspicion arises. Testing should be coordinated with the transplant center. Malignancies are a common cause of death in transplant recipients, requiring careful attention to screening recommendations and informed discussions with patients. Family physicians should maintain an ongoing relationship with the transplant team to discuss medication changes and the risk of infection or graft rejection.

Since 1988, more than 600,000 solid organ transplants have been performed in the United States, and approximately 130,000 patients are currently awaiting transplants.1 Five-year survival rates after liver and kidney transplants are 64% and 70%, respectively, and heart and lung recipients have a five-year survival rate of more than 50%.1 Because of the increasing number of surviving transplant recipients, care is gradually shifting to the primary care physician's office. This article focuses on the primary care of adults who have received solid organ transplants.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A blood pressure goal of less than 130/80 mm Hg is recommended for all liver and kidney recipients.

C

4, 6

Statin therapy is recommended for all solid organ transplant recipients.

C

4, 5, 8

Pregnancy should be delayed for one year posttransplant.

C

4, 5, 7, 19, 21

Solid organ transplant recipients should be counseled about avoiding tobacco.

C

4, 7

Solid organ transplant recipients should be educated about sun avoidance and protection and evaluated by a dermatologist annually, starting within the first year posttransplant.

C

36, 37


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A blood pressure goal of less than 130/80 mm Hg is recommended for all liver and kidney recipients.

C

4, 6

Statin therapy is recommended for all solid organ transplant recipients.

C

4, 5, 8

Pregnancy should be delayed for one year posttransplant.

C

4, 5, 7, 19, 21

Solid organ transplant recipients should be counseled about avoiding tobacco.

C

4, 7

Solid organ transplant recipients should be educated about sun avoidance and protection and evaluated by a dermatologist annually, starting within the first year posttransplant.

C

36, 37


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Medications

Immunosuppressive therapy accounts for more than 50% of transplant-related deaths, often due to infections and other risks related to long-term use.2 Patients typically receive high doses of two or more medications immediately after transplantation, with subsequent tapering over the following months to years to minimize long-term adverse effects.

Medication classes that reduce the risk of graft rejection include calcineurin inhibitors, which inhibit an enzyme that stimulates T lymphocytes; mammalian target of rapamycin inhibitors, which impede cell growth and proliferation; and purine synthesis inhibitors, which include azathioprine (Imuran), methotrexate, and the commonly used subclass of mycophenolic acid derivatives, which inhibit enzymes needed for the growth of T and B lymphocytes. Corticosteroids are often also used early after transplantation, but are tapered as quickly as possible.3  Most of the preferred immunosuppressive medications are metabolized through the cytochrome P450 3A4 pathway

The Authors

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FRANCESCA M. CIMINO, MD, is an active-duty family physician in the U.S. Navy and an assistant clinical professor at the Uniformed Services University of the Health Sciences, Bethesda, Md....

KATHERINE A.M. SNYDER, MD, is an active-duty family physician in the U.S. Navy. At the time the article was written, she was chief resident at Naval Hospital Bremerton, Wash.

Address correspondence to Francesca M. Cimino, MD, 4301 Jones Bridge Rd., Bethesda, MD 20814 (e-mail: francesca.m.cimino.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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