Principal Consultant & Unit Head, Liver Transplant, Fortis Hospital, Shalimar Bagh, New Delhi, India
Part 11 of 12 in Liver Transplant
Immunosuppression After Transplant: COVID-19, Cardiovascular and Renal Risk
August 11, 2024
Asked directly about the long-term adverse effects of immunosuppression, including cardiovascular disease, osteoporosis, infection and renal failure, Dr. George was candid that these risks are real, but framed them against the alternative.
Weighing risk against no transplant at all
Post-transplant medications do carry a risk of cardiac problems, hypertension, diabetes and renal dysfunction, and immunosuppression carries a higher, though still low, cancer risk compared with the general population. But this has to be weighed against outcomes without transplant: of 100 patients with advanced liver disease who are transplanted versus 100 who are not, more of the transplanted group are alive at one, three and five years. Doses are actively managed and medications switched where complications arise, to minimise this risk over time.
COVID-19 risk after transplant
A separate question asked about COVID-19 risk specifically. Dr. George noted that post-transplant patients who contract COVID-19 usually develop mild disease, since the immunosuppressed body often can't mount a severe inflammatory response to the virus. However, patients who do develop a severe spectrum of COVID-19 can have poorer survival, since immunosuppression leaves them vulnerable to secondary infections on top of the viral illness.
This article is based on a Jivo Masterclass session conducted by Dr. Ashish George, Principal Consultant & Unit Head, Liver Transplant, Fortis Hospital, Shalimar Bagh, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
Looking for a liver transplant consultation or a second opinion? Get in touch with the Jivo team
This guide is based on a live Jivo Masterclass: Dr. Ashish George taught doctors across Africa on August 11, 2024.
FROM THE LIVE Q&A
Dr. Nasoro
On immune monitoring and tolerance after liver transplant, there is evidence of adverse effects including cardiovascular disease, osteoporosis, infection and renal failure. How can these risks be minimised to improve outcomes for patients?
Dr. Ashish George
Post-transplant medications do carry a risk of cardiac problems, hypertension, diabetes and renal dysfunction, and a modestly elevated cancer risk versus the general population. But comparing 100 transplanted patients against 100 similar patients who are not transplanted, more of the transplanted group are alive at one, three and five years. Doses are actively managed and medications changed where complications arise to minimise risk over time.
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Frequently Asked Questions
What is the survival rate of liver transplantation?▼
More than 90% of patients are alive at 1 year, 80-85% at 3 years, more than 75% at 5 years, and 65-70% at 10 years. Liver transplant does not have an expiry date because the liver can regenerate.
Is liver transplantation a replacement, a like-for-like graft, or a therapeutic treatment, essentially a cure versus a therapy?▼
It is a cure in that the patient's symptoms completely resolve. However, because the patient needs lifelong immunosuppressant medication, they remain in medical follow-up indefinitely even though the disease itself is gone.
Is it advisable for patients with chronic hepatitis to undergo liver transplantation, given the risk of the new liver becoming infected too?▼
Yes. Patients who develop decompensated chronic liver failure from hepatitis B or C should undergo transplant. Hepatitis B patients are kept on lifelong antivirals post-transplant to suppress the virus; hepatitis C is now completely treatable with directly acting antivirals given before or after transplant. Chronic viral hepatitis does not pose a major barrier to offering transplant.
How do factors like donor liver quality and recipient health condition impact the success and recovery process after a liver transplant?▼
Both donor and recipient undergo extensive two-pronged evaluation: confirming the surgery poses no major risk to the donor, and confirming the liver quality is good enough to function well in the recipient. Primary non-function occurs in under 1-2% of living donor transplants; early allograft dysfunction in about 5-10%. Donors are generally 18-55, and a younger, non-fatty liver has better quality than an older or fattier one.
Who is eligible to donate a liver?▼
Legally, the donor must be a relative of the patient. Medically, the ideal donor is blood-group compatible (A or O for an A recipient, B or O for a B recipient, any group for an AB recipient, only O for an O recipient; Rh status doesn't matter), aged 18 to 55, and free of diabetes or advanced uncontrolled pulmonary disease. An incompatible donor can still be evaluated if no compatible one exists, with longer preparation, higher cost and slightly increased risk.
What are the long-term risks of post-transplant immunosuppression?▼
Cardiovascular problems, hypertension, diabetes, renal dysfunction, and a modestly elevated cancer risk versus the general population, though lower risk overall than not being transplanted at all for eligible patients.
Is COVID-19 more dangerous after a liver transplant?▼
Usually milder, since the immunosuppressed body often doesn't mount a severe response, but patients who do develop severe COVID-19 can have poorer survival due to vulnerability to secondary infections.
In This Series: Liver Transplant
- 1.Liver Transplant
- 2.Indications for Liver Transplant: Acute and Chronic Liver Disease
- 3.Liver Transplant for Liver Cancer: HCC, the UCSF Criteria and Downstaging
- 4.Contraindications and the MELD-Sodium Score for Timing Transplant
- 5.Survival Rates After Liver Transplant, and Why It's a Cure, Not Just a Therapy
- 6.Living Donor Evaluation: Compatibility, Safety and Liver Regeneration
- 7.Who Can Donate a Liver: Eligibility, Compatibility and the Ten-Year Myth
- 8.Hepatitis B and C in Liver Transplant Candidates
- 9.Re-Transplantation: When and How Often It's Possible
- 10.Nutrition Before and After Liver Transplant
- 11.Immunosuppression After Transplant: COVID-19, Cardiovascular and Renal Risk
- 12.Cold Ischemia Time and Post-Transplant Alcohol Limits