Liver transplantation: role of immunosuppression, renal dysfunction and cardiovascular risk factors

In the past decades, advances in immunosuppression, organ preservation, surgical techniques and better management of post-transplantation complications have led to improvement in survival of liver transplant patients. Such extended survival of liver graft recipients in their fifties and sixties has resulted in a greater prevalence of complications, in particular chronic kidney (CKD) and cardiovascular diseases (CVD). Renal failure and cardiovascular complications in the setting of liver transplantation are associated to an increase of morbidity and mortality. A 4-fold increased risk of death is reported among patients developing post-transplant CKD, and CVD is the leading cause of death with a functioning allograft, accounting for as much as 30% of post-transplant mortality. The onset is multifactorial, with pre-transplant conditions involved, including pre-transplant renal insufficiency, hepatitis C virus infection and pretransplant diabetes. Acute renal dysfunction in the setting of transplantation is also responsible of post-transplant CKD. Immunosuppressive therapy is primarily responsible for the development of CKD. Metabolic syndrome and its individual components, including diabetes mellitus, systemic hypertension, dyslipidemia, and obesity, are increasingly being identified as closely related to immunosuppressive therapy and actively contribute to cardiovascular morbidity and mortality in transplant patients. Treatment of modifiable risk factors is mandatory aiming to prevent the development and progression of serious complications. Early recognition, prevention and treatment of these conditions may further improve long-term survival after liver transplantation.