A recent study by researchers from the University of Colorado looked at post-transplant care to determine whether primary care physicians (PCPs) or hepatologists are better suited to manage the overall health care of patients who received a liver transplant (LT). Researchers learned that hepatologists believe metabolic complications to be common in LT patients, but not well controlled. The hepatologists surveyed also felt that PCPs should be responsible for managing these conditions, but that this group was not taking an active role.
Full details of this study appear in the October issue of Liver Transplantation, a journal published by Wiley-Blackwell on behalf of the American Association for the Study of Liver Diseases.
In the U.S. approximately 6,000 liver transplants are performed annually. Since liver transplantation began in 1963, survival rates have increased dramatically with overall 1-year and 5-year patient survival rates at 86.9% and 73.6%, respectively. As long-term survival rates increase, metabolic complications such as cardiovascular diseases, diabetes, chronic renal insufficiency and bone disease become a concern to the welfare of LT patients.
Lisa Forman, M.D. and colleagues surveyed 280 hepatologists in programs that transplanted at least 8 adult livers during the 2004 study year. Of the 191 respondents, 86% were male with a mean age of 50 years and had been in practice for an average of 13 years. Close to half of the hepatologists who replied noted that they cared for 21-50 liver transplant patients each month, while only 2.1% stated that a PCP was a working member of the practice group's post-transplant team.
Researchers found that more than 70% of hepatologists surveyed noted hypertension, chronic renal insufficiency, diabetes, and osteoporosis were present in at least 25% of patients 1 year post-transplant. The majority of respondents felt that these metabolic complications significantly contributed to morbidity and mortality 10 years after liver transplantation. Based on survey responses, the most commonly cited barriers to control post-transplant complications were dietary non-adherence, adverse effects of immunosuppressive agents, and inadequate primary care.
Approximately 75% of respondents felt that metabolic complications should be managed by PCPs, but believe that PCPs are adequately managing these health issues in only 38%-51% of LT recipients. "While there are many factors which influence the management of metabolic health concerns, the transplant community needs to be aggressive in influencing aspects that are modifiable such as PCP involvement," stated Dr. Forman. "If PCPs are reluctant to treat LT patients, and hepatologists assume their overall care, perhaps transplant hepatology fellowships should include rotations in cardiology, endocrinology, rheumatology and nephrology to give fellows more exposure to the management of metabolic complications," she suggested.
"Despite the fact that this study was based on perception rather than hard data, it does serve as a basis for future studies," stated Bashar Aqel, M.D.., from the Mayo Clinic in his editorial also published in the October issue of Liver Transplantation. The authors acknowledged this study was based on the perception of hepatologists without hard data collected on the prevalence of metabolic complications and noted that PCPs were not surveyed likely leading to a bias toward the hepatologist. "More research is needed to address the real prevalence of metabolic complications, adequacy of treatment and to identify the barriers to care in the treatment of metabolic complications after liver transplantation," added Dr. Aqel.
- J. Christie Heller, Allan V. Prochazka, and Lisa M. Forman. Long-term management after liver transplantation: Primary care physician versus hepatologist. Liver Transplantation, 2009; DOI: 10.1002/lt.21786
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