Help givethem freedomfrom occasionalirregularity *ACTIVIA ® helps withoccasional irregularity *RECOMMEND©2012 The Dannon Company, Inc.ACTIVIA ® 33Get yourcouponreferralpad**TODAY!Offer availableto healthcareprofessionalsonly.**Scan this code to request yourcoupon referral pad or go towww.activia.us.com and clickon “<strong>for</strong> healthcare professionals.”*Clinical studies show that ACTIVIA, ® with Bifidus Regularis ® (Bifidobacterium animalis lactis DN-173 010), helps with slow intestinal transitwhen enjoyed 3 times per day <strong>for</strong> two weeks as part of a balanced diet and healthy lifestyle.<strong>ADVANCE</strong> <strong>for</strong> <strong>NPs</strong> & <strong>PAs</strong>
HepatologyFirstline therapy <strong>for</strong> overweight patientswith PTDM is met<strong>for</strong>min. 15 For patients ofideal weight, a sulfonylurea should be used.If oral agents do not adequately controlglucose levels, insulin may be needed. 5Tight glucose control is important inpatients with PTDM, especially those withhepatitis C. Patients with hepatitis C are atgreater risk <strong>for</strong> infection, cardiovascularcomplications, graft loss and death thanpatients without this virus. 6,16RejectionOrgan rejection occurs when the patient’simmune system attacks the transplantedorgan. Although rejection is most commonin the first 3 months after liver transplant,it can occur at any time. 1 Signs ofrejection include increased liver enzymes,fever, jaundice, fatigue and abdominalpain or distension. 1,6 An increase in liverfunction of 1.5 times normal is generallyconsidered significant. 1 Rejection is diagnosedvia liver biopsy. Rejection episodesare typically managed by a transplantcenter, and treatment usually involveshigh-dose corticosteroids. 1,6InfectionInfections are the primary cause ofmorbidity and mortality in patientsafter transplant. 17 Due to high levelsof immunosuppression, even relativelycommon infections such as pharyngitisand urinary tract infections can progressto sepsis. 17 Patients with a fever greaterthan 38.5° C should receive a completeworkup including urine, blood and sputumcultures, chest x-ray, complete bloodcount, and liver function testing. 17 Signsof sepsis include fever greater than 38.5°C, hypotension, increased heart andrespiratory rates, and altered mentalstatus. 17 The most common viral infectionsin the posttransplant patient arecytomegalovirus, Epstein-Barr virus andherpes viruses; these usually occur in thefirst 6 months after transplantation. 6Vaccinations are an important tool<strong>for</strong> preventing infection. Inactivatedvaccines are safe <strong>for</strong> patients both be<strong>for</strong>eand after transplant, but live vaccines arenot routinely given to immunosuppressedpatients due to the risk of shedding livevirus (Table 2). 1,6 Transplant patientsroutinely receive prophylaxis regimens toTable 2Common Inactivated and Live Virus VaccinesInactivated Vaccines◗ Diphtheria◗ Hepatitis A & B◗ Haemophilus influenza type b◗ Human papillomavirus◗ Influenza inactivated◗ Meningococcal◗ Pertussis◗ Pneumococcal◗ Tetanusprevent Pneumocystis carinii and variousfungal, bacterial and viral illnesses. 4Renal DysfunctionSome level of renal dysfunction is commonin liver transplant recipients, but the riskof this progressing to chronic renal failureis only about 10%. 6 Approximately 14% ofpatients have a normal glomerular filtrationrate 6 months after transplant. 6 Themost notable cause of renal insufficiency isthe CNIs. Their use can lead to reversibleacute nephropathy and irreversible chronicrenal damage. 6 When chronic renal damageis suspected, a prescriber (usuallythe patient’s hepatologist) may attemptto decrease CNI doses and add a secondagent, or he or she may completely switchfrom CNIs to sirolimus or mycophenolatemofetil. 1,6 In addition to reducing or eliminatingCNIs, the management of renaldysfunction includes avoiding NSAIDs,aminoglycosides and other medicationsthat are nephrotoxic. 6Recommendations <strong>for</strong> PracticeAs liver transplantation becomes moreprevalent and successful, transplant centersare relying on primary care providersto assume more responsibilities <strong>for</strong>patients’ ongoing care. Many factors mustbe considered when treating a transplantrecipient. To reduce morbidity and mortality,primary care providers must havea working knowledge of the factors thatmake transplant recipients unique. Theymust educate themselves about immunosuppressantmedications, signs of rejectionand common complications afterliver transplantation. Transplant centersmust be notified be<strong>for</strong>e any change inLive Vaccines*◗ Live attenuated influenza◗ Measles◗ Mumps◗ Polio (oral)◗ Rotavirus◗ Rubella◗ Vaccinia◗ Varicella◗ Yellow fever*Live vaccines should not be given to a patient who has received a liver transplant.immunosuppression is attempted and ifsigns of organ rejection surface. ■References1. McGuire BM, et al. Long-term managementof the liver transplant patient: recommendations<strong>for</strong> the primary care doctor. Am J Transplant.2009;9(9):1988-2003.2. U.S. Department of Health & Human Services,Health Resources and Services Administration. OPTN/SRTR annual report. http://optn.transplant.hrsa.gov/data/annualreport.asp. Accessed Jan. 10, 2012.3. Heller JC, et al. Long-term management afterliver transplantation: primary care physician versushepatologist. Liver Transpl. 2009;15(10):1330-1335.4. Aqel BA. Should transplant hepatologistsserve as primary care physicians? Liver Transpl.2009;15(10):1162-1163.5. Hasley PB, Arnold RM. Primary care of the transplantpatient. Am J Med. 2010;123(3):205-212.6. Kallwitz ER, Cotler SJ. Care of the liver transplantpatient. Dis Mon. 2008;54(7):486-507.7. Desai S, et al. Cardiovascular risk factors followingorthoptic liver transplantation: predisposingfactors, incidence and management. Liver Int.2010;30(7):948-957.8. Sethi A, Stravitz RT. Review article: medicalmanagement of the liver transplant recipient — aprimer <strong>for</strong> non-transplant doctors. Aliment PharmacolTher. 2007;25(3):229-245.9. Gonwa TA. Hypertension and renal dysfunctionin long-term liver transplant recipients. Liver Transpl.2001;7(11 Suppl 1):S22-S26.10. Rossetto A, et al. Cardiovascular risk factors andimmunosuppressive regimen after liver transplantation.Transplant Proc. 2010;42(7):2576-2578.11. Watt KD, Charlton MR. Metabolic syndrome andliver transplantation: a review and guide to management.J Hepatol.2010;53(1):199-206.12. U.S. Department of Health & Human Services.National Heart, Lung, and Blood Institute. Third Reportof the Expert Panel on Detection, Evaluation, andTreatment of High Blood Cholesterol in Adults. (AdultTreatment Panel III). http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.Accessed Jan. 20, 2012.13. Barclay L. Overview of lifestyle interventions inthe management of hyperlipidemia in the primary caresetting. http://www.medscape.com/viewarticle/721503.Accessed Jan. 10, 2012.14. Zachoval R, et al. Short-term effects of statintherapy in patients with hyperlipoproteinemia afterliver transplantation: results of a randomized crossovertrial. J Hepatol.2001;35(1):86-91.15. Charlton M. Obesity, hyperlipidemia, and metabolicsyndrome. Liver Transpl. 2009;15(11 Suppl 2):S83-S89.16. Bloom RD, Crutchlow MF. Transplant-associatedhyperglycemia. Transplant Rev. 2008;22(1):39-51.17. McCashland TM. Posttransplantation care: roleof the primary care physician versus transplant center.Liver Transpl. 2001;7(11 Suppl 1):S2-S12.34 <strong>ADVANCE</strong> <strong>for</strong> <strong>NPs</strong> & <strong>PAs</strong>
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