Cardiovascular risk factors following orthotopic liver transplantation: predisposing factors, incidence and management

Abstract

Background: Liver transplantation is the standard of care for acute and chronic causes of end-stage liver disease. Advances in medical therapy and surgical techniques have led to improvement of patient and graft survival rates following orthotopic liver transplantation. However, the prevalence of posttransplant cardiovascular complications has been rising with increased life expectancy after liver transplantation. Aims: To determine the incidences, risk factors, and treatment for hypertension, hyperlipidaemia, diabetes, and obesity in the post-liver transplantation population. Methods: We performed a review of relevant studies available on the PubMed database that provided information on the incidence, risk factors and treatment for cardiovascular complications that develop in the post-liver transplantation population. Results: Current immunosuppressive agents have improved patient and graft survival rates. However, long-term exposure to these agents has been associated with development of systemic and metabolic complications including hypertension, hyperlipidaemia, diabetes mellitus and obesity. Cardiovascular disease remains one of the most common causes of death in liver transplant patients with functional grafts. Conclusions: Liver transplant recipients have a higher risk of cardiovascular complications compared with the nontransplant population. Post-transplant cardiac risk stratification and aggressive treatment of cardiovascular complications, including modification of risk factors and tailoring of immunosuppressive regimen, is imperative to prevent serious complications.Liver transplantation is the standard of care for acute and chronic causes of end-stage liver disease. Advances in medical therapy and surgical techniques have led to improvement of patient and graft survival rates following orthotopic liver transplantation (OLT), with 1-and 5-year patient survival rates of 84 and 67% respectively (1). However, the prevalence of medical complications such as hypertension, hyperlipidaemia, weight gain and diabetes has been rising along with increased life expectancy after liver transplantation (2). Liver transplant recipients have a higher risk of cardiovascular death and ischaemic events as compared with an age-and sex-matched population without liver transplant (3). This elevated cardiovascular event rate ranges from 9% at 5 years post-transplant (4) to 25% at 10 years post-transplant (5). Cardiovascular disease causes 21% of deaths among liver transplant patients with functioning grafts surviving more than 3 years (6) and remains a common cause of death in OLT patients (7).Post-OLT cardiovascular complications result from a combination of factors that include pre-existing disease before transplantation and chronic exposure to immunosuppressive agents following OLT (8). Current immunosuppressive regimens include a combination of a calcineurin inhibitor, such as cyclosporine or tacrolimus, along with corticosteroids, mycophenolate mofetil or sirolimus, and have been associated with both exacerbati...

Prevalence and Prediction of Coronary Artery Disease in Patients With Liver Cirrhosis

“…It is most important to predict cardiac outcomes in adult patients who are undergoing LT, because cardiovascular disease has been found to be one of the most common causes of complications, and even death, in LT patients with functional grafts, particularly in cases with preexisting cardiac histories. 13,48 Our data indicate that multivessel CAD, which is thought to be a powerful predictor of post-LT mortality, 37 may be more common in cirrhotic patients, despite the fact that the prevalence of obstructive lesions in the cirrhotic patients was equivalent to that in the noncirrhotic individuals. Furthermore, LC patients were also at higher risk of nonobstructive CAD with more unfavorable course than normal coronary arteries, especially in extensive disease, although it remains to be seen whether management of such patients might improve outcomes.…”

Cardiovascular diseases after liver transplantation—a still emerging and unsolved problem!

“…6 Several studies have determined the cumulative risk of CVD after LT. Independent predictive factors of CVD are older age at transplantation, male sex, preexisting cardiac disease, and components of the MS. [7][8][9] In addition, patients with underlying NASH cirrhosis have a significantly higher risk of CVD compared to other indications. The frequency of major intraoperative and postoperative cardiac complications was markedly increased in recipients with known heart disease compared to those without.…”

“…6 Several studies have determined the cumulative risk of CVD after LT. Independent predictive factors of CVD are older age at transplantation, male sex, preexisting cardiac disease, and components of the MS. [7][8][9] …”

Metabolic Syndrome After Liver Transplantation

“…Concerning pharmacological measures, pancreatic lipase inhibitors like tetrahydrolipstatin (orlistat), which can be used in the general population with morbid obesity, present important interactions with the immunosuppressive agents, and thus have to be limited in the transplant population (Desai et al, 2010).…”

“…The survival of transplant patients who develop diabetes is lower than that for those without diabetes. In addition, these patients can present the same microvascular complications as in the general population, including retinopathy, nephropathy and infections (Desai et al, 2010).…”