title: Reducing the risks of cardiovascular disease in liver allograft recipients.
abstract: Liver allograft recipients are at increased risk of death from cerebrovascular and cardiovascular disease. We propose the following strategy of risk-reduction, based on currently available literature. Lifestyle: standard advice should be given (avoidance of smoking, excess alcohol and obesity, adequate exercise, reduction of excess sodium intake). Hypertension: target blood pressure should be 140/90 mmHg or lower, but for those with diabetes or renal disease, 130/80 mmHg or lower. For patients without proteinuria, antihypertensive therapy should be initiated with a calcium channel blocker and for those with proteinuria, an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker. If monotherapy fails to achieve adequate response, calcium channel blockers and ACE-inhibitors or angiotensin II receptor blockers should be combined. If hypertension remains uncontrolled, an alpha-blocker may be added. Consideration should be given to changing immunosuppression and avoiding use of calcineurin inhibitors. Diabetes: recipients should be regularly screened for diabetes. For patients with new-onset diabetes after transplant, stepwise therapy should be guided by HbA1c concentrations, as with type II diabetes mellitus. Hyperlipidemia: annual screening of lipid profile should be undertaken, with treatment thresholds and targets based on those advocated for the high risk general population. Dietary intervention is appropriate for all patients. A statin should be considered as the first line treatment to achieve specified targets. In patients receiving a calcineurin inhibitor, Pravastatin should be commenced at a dose of 10 mg/day. In patients receiving other forms of immunosuppression, pravastatin may be commenced at a dose of 20 mg/day. Liver tests should be monitored and patients warned to report myalgia. If monotherapy is inadequate, ezetimibe or a fibrate may be added. Consideration may be given to change in immunosuppression if combination lipid-lowering therapy proves inadequate.
authors.affiliation: Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom.
authors.forename: George
authors.initials: G
authors.lastname: Mells
authors.forename: James
authors.initials: J
authors.lastname: Neuberger
mesh_terms: D002318:Cardiovascular Diseases / Q000209:etiology* / Q000517:prevention & control*; D002561:Cerebrovascular Disorders / Q000453:epidemiology / Q000209:etiology; D048909:Diabetes Complications; D003920:Diabetes Mellitus / Q000188:drug therapy / Q000209:etiology; D050171:Dyslipidemias / Q000150:complications / Q000209:etiology / Q000628:therapy; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000209:etiology / Q000628:therapy; D015994:Incidence; D016031:Liver Transplantation / Q000009:adverse effects*; D012307:Risk Factors; D014184:Transplantation, Homologous; D014652:Vascular Diseases / Q000209:etiology / Q000517:prevention & control