Long-term management after liver transplantation: Primary care physician versus hepatologist
2009; Lippincott Williams & Wilkins; Volume: 15; Issue: 10 Linguagem: Inglês
10.1002/lt.21786
ISSN1527-6473
AutoresJ. Christie Heller, Allan V. Prochazka, Gregory T. Everson, Lisa Forman,
Tópico(s)Liver Disease Diagnosis and Treatment
ResumoLiver TransplantationVolume 15, Issue 10 p. 1330-1335 Original ArticlesFree Access Long-term management after liver transplantation: Primary care physician versus hepatologist† J. Christie Heller, J. Christie Heller Division of Gastroenterology and Hepatology, University of Colorado Health Sciences Center, Denver, COSearch for more papers by this authorAllan V. Prochazka, Allan V. Prochazka Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver, CO Division of Ambulatory Care, Denver VA Hospital, Denver, COSearch for more papers by this authorGregory T. Everson, Gregory T. Everson Division of Gastroenterology and Hepatology, University of Colorado Health Sciences Center, Denver, COSearch for more papers by this authorLisa M. Forman, Corresponding Author Lisa M. Forman [email protected] Division of Gastroenterology and Hepatology, University of Colorado Health Sciences Center, Denver, CO Telephone: 720-848-2292; FAX: 720-848-2246Division of Gastroenterology and Hepatology, University of Colorado Health Sciences Center, 1635 Aurora Court, B-154, Aurora, CO 80045Search for more papers by this author J. Christie Heller, J. Christie Heller Division of Gastroenterology and Hepatology, University of Colorado Health Sciences Center, Denver, COSearch for more papers by this authorAllan V. Prochazka, Allan V. Prochazka Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver, CO Division of Ambulatory Care, Denver VA Hospital, Denver, COSearch for more papers by this authorGregory T. Everson, Gregory T. Everson Division of Gastroenterology and Hepatology, University of Colorado Health Sciences Center, Denver, COSearch for more papers by this authorLisa M. Forman, Corresponding Author Lisa M. Forman [email protected] Division of Gastroenterology and Hepatology, University of Colorado Health Sciences Center, Denver, CO Telephone: 720-848-2292; FAX: 720-848-2246Division of Gastroenterology and Hepatology, University of Colorado Health Sciences Center, 1635 Aurora Court, B-154, Aurora, CO 80045Search for more papers by this author First published: 29 September 2009 https://doi.org/10.1002/lt.21786Citations: 25 † See Editorial on Page 1162 AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Abstract As long-term survival after liver transplantation increases, metabolic complications are becoming increasingly prevalent. Given concerns about which group of providers should be managing liver recipients and how well metabolic complications are managed, we administered a postal survey to 280 transplant hepatologists to determine attitudes, perceptions, and practice patterns in the management of metabolic complications after transplantation. The response rate was 68.2%. There was great variation in patterns of practice across the United States with respect to the number of posttransplant clinics, clinic format, and number of recipients cared for per week. Hepatologists, primary care physicians (PCPs), and surgeons were primarily responsible for the overall care of liver recipients 1 year or more after liver transplantation according to 66%, 24%, and 8% of respondents, respectively. Hepatologists felt that metabolic complications were common, but few strongly agreed that hypertension (33.3%), chronic renal insufficiency (3.8%), diabetes mellitus (8.8%), dyslipidemia (11.1%), and bone disease (12.8%) were well controlled. The majority of hepatologists indicated that ideally PCPs should be managing recipients' hypertension, diabetes mellitus, dyslipidemia, and bone disease (78.8%, 63.1%, 78.3%, and 72.5%), but they felt that in actuality, PCPs were managing these conditions less frequently (45.4%, 51.4%, 44.6%, and 38%). In conclusion, metabolic complications are perceived to be common but not well controlled post-transplant, and most hepatologists feel that PCPs should take a more active role in the management of these complications. Future studies are needed to identify barriers to care in the treatment of metabolic complications post-transplant with the goal of improving long-term morbidity and mortality. Liver Transpl 15:1330–1335, 2009. © 2009 AASLD. Approximately 6000 liver transplants are performed each year in the United States. Since the era of liver transplantation began in 1963, survival after liver transplantation has significantly improved, with overall 1- and 5-year patient survival rates of 86.9% and 73.6%, respectively.1 As long-term survival increases, cardiovascular complications are emerging as major causes of morbidity and mortality. The negative impact of cardiovascular disease on liver transplant recipients has only recently been addressed; recent data indicate that accelerated cardiovascular disease is second only to malignancy as a cause of late mortality in liver transplant patients.2 As more transplant recipients survive into their first and second decades post-transplant, it is likely that more will develop metabolic complications such as hypertension (HTN), chronic renal insufficiency (CRI), diabetes mellitus (DM), dyslipidemia (LIPIDS), obesity, and osteopenia/osteoporosis (OP). There are no specific guidelines for the treatment of cardiovascular complications in liver recipients, it is unknown whether or not recipients are receiving adequate management, and what group of providers can best deliver optimal care for these conditions has been debated. Although primary care physicians (PCPs) claim to be comfortable managing the care of liver recipients, transplant hepatologists usually assume these patients' overall care.3, 4 Hepatologists may not be as comfortable as internists in managing cardiovascular complications and may not do as good a job as PCPs in managing these complications. Anecdotally, liver recipients have expressed dissatisfaction with the care that they are receiving from PCPs, whom they feel are hesitant to treat them and are unfamiliar with the immunosuppressive medications and potential drug-drug interactions. Given these concerns about which group of providers should be managing liver recipients and how well metabolic complications are managed, we conducted a study to determine attitudes, perceptions, and practice patterns in the management of metabolic complications after transplantation among transplant hepatologists. Abbreviations AST, American Society of Transplantation; CRI, chronic renal insufficiency; DM, diabetes mellitus; HCV, hepatitis C virus; HTN, hypertension; GI, gastroenterology; LIPIDS, dyslipidemia; OP, osteopenia/osteoporosis; PCP, primary care physician; SD, standard deviation; UNOS, United Network for Organ Sharing. MATERIALS AND METHODS The study was approved by the Colorado Multiple Institutional Review Board. We administered a postal survey to transplant hepatologists across the United States. The survey was sent to all hepatologists in programs that, in 2004, performed more than 8 adult liver transplants. To determine which programs met the criteria and to obtain data on the actual number of annual transplants performed, data were gathered from the United Network for Organ Sharing (UNOS) Scientific Registry of Transplant Recipients. We obtained listings of transplant physicians from both the American Society of Transplantation physician registry and UNOS. After these databases were obtained, each transplant center that performed more than 8 adult liver transplants per year was contacted individually, via either phone or e-mail, to obtain the names and mailing addresses of additional hepatologists that may not have been included in the American Society of Transplantation or UNOS databases. Following Dillman methodology, we mailed an introductory letter followed a week later by a pretested survey, cover letter, $5 cash incentive, and postage-paid return envelope.5 A reminder letter followed a week later. Hepatologists who failed to return the survey after a month received another survey with a reminder letter. Nonrespondents at 2 months received a third and final copy of the survey. With each mailing, we gave hepatologists the option to indicate on a postage-paid return postcard whether they were retired or did not wish to participate in the study. In the former case, we removed them from the denominator; in the latter case, we sent no additional mailings but retained them in the sample as nonrespondents. In the event that an uncompleted survey was returned by the post office and we were unable to determine a correct address, we removed that person from the denominator. A copy of the survey (22 items) can be found in the online article. The first section contained questions about hepatologists' perceptions regarding the prevalence of metabolic conditions after liver transplantation, how well these conditions are controlled, barriers to control, and the effect that metabolic conditions have on recipients' 10-year morbidity and mortality. The second set of questions addressed which type of physician was primarily responsible for the care of transplant patients, hepatologists' own comfort level in treating metabolic conditions and the perceived comfort level of PCPs, which type of provider should ideally manage metabolic complications versus who is actually managing them, and hepatologists' satisfaction with the level of involvement of PCPs. A series of demographic questions were asked as well, including age, gender, years from fellowship, center size, center region, clinic format, and number of recipients cared for per month. As an internal control, questions were also asked regarding the prevalence, control, and management of recurrent hepatitis C post-transplant. These questions helped to validate the other responses given because we expected that very few if any transplant hepatologists would state that recurrent hepatitis C virus (HCV) was uncommon post-transplant or easy to treat. A 4-level Likert scale was used in the majority of the questions: respondents were asked whether they strongly disagreed, somewhat disagreed, somewhat agreed, or strongly agreed with a variety of different statements. Our survey instrument was pilot-tested on 4 hepatologists (local and national) and 5 internists trained in epidemiology to maximize intelligibility of the survey, minimize ambiguities, ensure a highly readable layout, allow for survey completion in approximately 15 minutes, and guarantee a meaningful variety of item responses. It was refined before final use. Statistical methods included descriptive statistics; Student t tests and χ2 tests were used for the comparison of means and proportions, respectively. Logistic regression was used to examine respondent characteristics (with age, years from fellowship, and center size treated as continuous variables) associated with attitudes (including the type of caregiver responsible for recipients' overall care, the hepatologists' comfort level, and the type of caregiver ideally managing various complications) regarding complication management. All statistical analyses were performed with STATA 7.0 software (Stata Corp., College Station, TX). RESULTS Demographic Information for Respondents and Transplant Centers Surveys were sent to 85 programs and 298 transplant physicians. After we accounted for incorrect addresses and physicians no longer in practice, the response rate to the survey was 191 of 280 (68.2%); 73 (85.9%) of the programs had at least 1 hepatologist respond. Table 1 summarizes the demographic and transplant center characteristics of the respondents. The respondents were overwhelmingly male (85.5%) with a mean age of 46 years, and they had been in practice for an average of 13 years. Approximately 60% had completed a fellowship in hepatology. The majority of respondents (45.7%) stated that they participated in the care of 21 to 50 recipients per month; only 8.6% of respondents participated in the care of >100 recipients per month. Table 1. Demographic Information (n = 191 Respondents) Age (years), mean ± SD 45.8 ± 8.7 Gender (males) 85.5% Years since GI fellowship, mean ± SD 13 ± 8 Completed formal hepatology fellowship 59.9% Recipients managed per month (respondents) 0-20 22.6% 21-50 45.7% 51-100 23.1% >100 8.6% Transplants per year, mean ± SD 78.9 ± 54.8* At your center, who is primarily responsible for the overall care of patients one year or greater after transplant Hepatologist 66% PCP 24.1% Transplant surgeon 8.4% PCP part of the transplant team (respondents) 2.1% Abbreviations: GI, gastroenterology; PCP, primary care physician; SD, standard deviation. * United Network for Organ Sharing data. The demographic information for the transplant centers was as follows. The mean number of transplants performed per year was 80, and the average number of weekly outpatient posttransplant clinics was 3. With respect to clinic format, 49.2% of respondents stated that their center provided scheduled appointments, 0.5% had open access, and 50.3% had both scheduled appointments and open access; 42.7% of respondents stated that liver recipients were assigned to a specific hepatologist at their center. Only 4 (2.1%) of 183 respondents stated that a PCP was working as a member of the group's posttransplant team. Prevalence and Control of Metabolic Complications and Effect on Morbidity and Mortality Figure 1 summarizes the estimated prevalence of metabolic complications 1 year or more post-transplant. The hepatologists expressed a wide variety of perceptions concerning the exact prevalence of metabolic complications; however, more than 70% of respondents stated that HTN, CRI, DM, LIPIDS, and OP were present in more than 25% of their patients. One hundred percent of respondents stated that recurrent HCV was present in more than 25% of their HCV-positive recipients (88% stated that it was present in more than 50%). Figure 1Open in figure viewerPowerPoint Estimated prevalence of complications 1 year or more post-transplant. Abbreviations: CRI, chronic renal insufficiency; DM, diabetes mellitus; HTN, hypertension; LIPIDS, dyslipidemia; OP, osteopenia/osteoporosis. Figure 2 depicts the perceived control of metabolic complications 1 year or more after liver transplant. Only 33.3% of hepatologists strongly agreed that HTN was well controlled. Likewise, few respondents strongly agreed that CRI (3.8%), DM (8.8%), LIPIDS (11.1%), and OP (12.8%) were well controlled. Only 6% of respondents strongly agreed that recurrent HCV was well controlled after transplant. Commonly cited barriers to control of metabolic complications after liver transplant were dietary nonadherence, adverse effects of immunosuppressive agents, and inadequate primary care. The majority of respondents felt that metabolic complications significantly contribute to 10-year morbidity and mortality post–liver transplant (Fig. 3). Figure 2Open in figure viewerPowerPoint Percentages of hepatologists who agreed or disagreed with the following statement: "The following complications are well controlled in patients 1 year or greater after liver transplant." Abbreviations: CRI, chronic renal insufficiency; DM, diabetes mellitus; HTN, hypertension; LIPIDS, dyslipidemia; OP, osteopenia/osteoporosis. Figure 3Open in figure viewerPowerPoint Percentages of hepatologists who agreed or strongly agreed that complications affect 10-year morbidity and mortality. Abbreviations: CRI, chronic renal insufficiency; DM, diabetes mellitus; HTN, hypertension; LIPIDS, dyslipidemia; OP, osteopenia/osteoporosis. Type of Physician Managing Metabolic Complications and Comfort Levels Respondents felt that hepatologists (66%) were primarily responsible for the overall care of liver recipients 1 year or more after liver transplantation, with only 24% indicating PCPs and 8% indicating transplant surgeons (Table 1). The type of physician primarily responsible for the overall care of liver recipients was not associated with the center size or region of the country (P > 0.05). The majority of respondents stated that they were comfortable managing liver recipients' HTN, CRI, DM, LIPIDS, and OP (Table 2). Gender, center size, and years from fellowship were not associated with hepatologists' comfort levels in treating recipients' metabolic complications. Age was associated with comfort level in treating HTN (odds ratio, 0.94; P = 0.011). The majority of respondents felt that PCPs were comfortable managing HTN, DM, LIPIDS, and OP. There was no statistical difference in the perception of comfort level in treating metabolic complications between hepatologists and PCPs (P > 0.05). Among respondents, 71.4% felt that they were comfortable managing CRI; however, only 23.7% felt that PCPs were comfortable (P = 0.03). The majority of respondents (98%) stated that they were comfortable managing recurrent HCV and felt that PCPs were not. Table 2. Percentage of Hepatologists Who Agreed or Strongly Agreed with the Following for PCPs Statement: "I Am Comfortable Primarily Managing the Following Conditions 1 Year or Greater After Liver Transplant" Condition Hepatologist PCP Hypertension 84.8% 74.2% Chronic renal insufficiency 71.4% 23.7% Diabetes mellitus 61.9% 70.2% Dyslipidemia 76.2% 61.6% Osteopenia/osteoporosis 77.3% 61.5% Abbreviation: PCP, primary care physician. Table 3 summarizes the perceptions about who ideally was managing metabolic complications after liver transplantation versus who in actuality was managing these complications. The majority of hepatologists indicated that ideally PCPs should be managing recipients' HTN, DM, LIPIDS, and OP (78.8%, 63.1%, 78.3%, and 72.5%), but they felt that in actuality, PCPs were managing these conditions less frequently (45.4%, 51.4%, 44.6%, and 38%). Sixty-eight percent of respondents felt that ideally specialists should be managing recipients' CRI, but in actuality, specialists were managing CRI less frequently (49.5%). PCPs were not felt (ideally or in actuality) to be managing chronic CRI or recurrent HCV. Hepatologists' perception of the type of caregiver ideally managing metabolic conditions was not associated with age, years from fellowship, center size, whether or not recipients were assigned to a particular hepatologist, or the number of recipients cared for per month (P > 0.05). Table 3. Percentage of Hepatologists Who Stated "Ideally, PCPs Should Be Managing the Following Conditions 1 Year or Greater After Transplant" Versus the Percentage of Hepatologists Who Stated "PCPs Are Actually Managing the Following Conditions" Condition Ideally Managed by PCP Actually Managed by PCP Hypertension 78.8% 45.4% Diabetes 63.1% 51.4% Dyslipidemia 78.3% 44.6% Osteopenia/osteoporosis 72.5% 38% Abbreviation: PCP, primary care physician. Hepatologists were also asked about their satisfaction with PCPs' level of involvement in their patients and whether communication between the transplant center and PCP was adequate and vice versa. Only 35.8% agreed or strongly agreed that they were satisfied with the PCPs' level of involvement. Although 72.3% agreed or strongly agreed that communication from transplant center to PCP was adequate, only 43.5% felt that communication from the PCP to the transplant center was adequate. DISCUSSION This survey of transplant hepatologists in the United States was performed to obtain data regarding attitudes, perceptions, and practice patterns among hepatologists in the management of metabolic complications after liver transplantation. Traditionally, liver recipients have been considered to be at low risk for cardiovascular complications post-transplant as they have a low prevalence of cardiovascular risk factors pre-transplant. However, as patients are living longer after liver transplantation, cardiovascular complications are emerging as major causes of morbidity and mortality.6-8 Because of the magnitude of this problem, in 2001, an ad hoc group of transplant physicians met and recommended that further research is needed.2 Important questions that need to be addressed by the transplant community include the following: 1 What are the exact prevalence and impact of metabolic complications post-transplant? 2 Who should be identifying and managing these complications? 3 Are we doing an adequate job in management? We found that most hepatologists believe that metabolic conditions, including HTN, CRI, DM, LIPIDS, and OP, are common in post–liver transplant patients. Indeed, data from previous studies have shown that the incidence of HTN post-transplant is 40% to 85%,8, 9 the incidence of LIPIDS is 20% to 66%,8-10 and the incidence of DM is 5% to 60%.8, 9, 11 Even though these disorders are very prevalent, those surveyed do not perceive that they are adequately controlled and believe that they affect 10-year morbidity and mortality rates. For example, only about one-third feel that HTN, which is a very common disorder in both the transplant population and the nontransplant population and for which a variety of different medication treatment options exist, is well controlled. We found that there is great variation in patterns of practice among transplant programs across the United States with respect to the number of weekly posttransplant clinics, clinic format, number of recipients cared for per week, and assignment to a specific hepatologist. Only 2% of respondents stated that a PCP was working as a member of the groups' posttransplant team. Transplant hepatologists usually assume overall long-term care of liver recipients. Hepatologists, PCPs, and transplant surgeons were primarily responsible for the overall care of liver recipients 1 year or more after liver transplantation according to 66%, 24.1%, and 8.4% of respondents, respectively. These results are similar to those reported in studies by McCashland3 and Shiffman and Rockey.4 We found that hepatologists both feel comfortable themselves and perceive PCPs to be comfortable (with the exception of CRI) in managing metabolic complications post-transplant. Similarly, McCashland3 showed that 73% of PCPs were in fact comfortable managing the overall healthcare of post–liver transplantation patients. Despite their own comfort level, most respondents feel that ideally PCPs, not hepatologists, should be managing recipients' HTN, DM, LIPIDS, and OP but that in actuality, PCPs are managing these conditions less frequently. Most hepatologists feel that PCPs should be taking a more active role in the care of liver recipients. In fact, one of the commonly cited barriers to control of metabolic complications post-transplant was inadequate primary care. When asked about their satisfaction with PCPs' involvement with their patients, less than 40% of hepatologists stated that they were satisfied. Furthermore, a majority of those surveyed felt that communication from the PCP to the transplant center was inadequate. Interestingly, slightly over 70% felt that the transplant center did an adequate job of communication with the PCPs. There are many possible reasons to explain the discrepancy between who ideally is taking care of liver recipients post-transplant and who actually is. Hepatologists are very involved in the care of their patients pre-transplant and in the peritransplant period, and it may be difficult to relinquish control as patients get further out from their transplant. The discovery of metabolic diseases in these patients often necessitates additional medications, and PCPs may be hesitant to add more drugs to what is often a very long medication list in these patients. Furthermore, they may be unfamiliar with drug-drug interactions, especially with immunosuppressant medications. Some drugs, including cholesterol medications, can cause elevated liver function tests, which may cause PCPs to be hesitant to use them. Finally, PCPs may perceive transplant hepatologists as being the driving force in the management of these patients and as a result may be less proactive in treating metabolic conditions. This study has some limitations. Respondents were asked about their perceptions of care of the posttransplant patient. No hard data were obtained on the actual prevalence of metabolic complications, the control of these complications, and the percentage of patients who have a PCP actively managing their conditions. Disparities were seen between respondents from the same transplant center with respect to the type of provider who is primarily responsible for the overall care of liver recipients and who is actually managing the various metabolic complications. There is no way to ascertain whether the perceptions of those surveyed actually mimic reality. In addition, PCP perceptions were not ascertained in this study. Because this study involved a survey of hepatologists, it is not surprising that a result bias toward the hepatologist exists: hepatologists were satisfied with their level of communication with the PCP but not with the level of communication between the PCP and the transplant center. Although surveys can be prone to error, we feel that the results obtained from our survey, with the excellent 68% response rate, provide an adequate representation of the beliefs and practice patterns from a wide sampling of transplant hepatologists nationwide. We acknowledge that this study is an exploratory analysis, a springboard for future discussions, and a model to derive hypotheses for future studies. Future research in the area of metabolic complications in post–liver transplant patients is needed. Further studies are needed to determine whether or not the liver transplant community is doing an adequate job of managing metabolic complications. In the setting of chronic medical diseases (in this case liver transplantation), Redelmeier et al.12 demonstrated that ancillary disorders are often undertreated. It is, in fact, unknown whether or not we doing an inadequate job in controlling these complications and whether or not our management differs from that of the general population. It is certainly possible that although hepatologists perceive the control to be poor, these conditions are no better controlled in the nontransplant population. The consequences of uncontrolled metabolic complications in posttransplant patients are significant. In addition to the risk of cardiovascular disease and the other complications of metabolic syndrome (the constellation of HTN, glucose intolerance, LIPIDS, and obesity),13 it has recently been shown by Hanouneh et al.9 that liver transplant recipients with recurrent hepatitis C and metabolic syndrome have accelerated fibrosis progression. This survey clearly demonstrates that hepatologists feel metabolic complications are prevalent post–liver transplant but are not well controlled. With respect to the management and control of metabolic complications post-transplant, there are many factors that cannot be changed, such as the inherent side effects of immunosuppression medications. The transplant community, therefore, needs to be aggressive in influencing factors that are modifiable such as PCP involvement. Ultimately, a novel heath delivery system for liver recipients may need to be developed. Posttransplant care is likely to involve a multidisciplinary approach, with collaboration between the transplant hepatologist, surgeon, referring gastroenterologist, and PCP. Linzer et al.4 recently explored the interface between generalists and subspecialists and proposed guidelines with evidence-based suggestions for referral and back-referral between generalists and subspecialists for diseases such as cardiovascular disease and DM. Similar guidelines may need to be adopted for the liver transplant population. Alternatively, if PCPs are reluctant to treat liver recipients and we continue to 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. Identifying barriers to care in the treatment of metabolic complications is crucial so that the transplant community can intervene with the goal of not only improving patient satisfaction and comfort level among PCPs but also improving long-term patient survival. REFERENCES 1 The 2007 Scientific Registry of Transplant Recipients Report on the State of Transplantation. Am J Transplant 2008; 8: 909– 1026. 2 Bostom AD, Brown RS, Cosio FG, Culver K, Curtis JJ, Danovitch GM, et al. Prevention of post-transplant cardiovascular disease—report and recommendations of an ad hoc group. Am J Transplant 2002; 2: 491– 500. 3 McCashland TM. Posttransplantation care: role of primary care physician versus transplant center. Liver Transpl 2001; 7: S2– S12. 4 Shiffman ML, Rockey DC. Role and support for hepatologists at liver transplant programs in the United States. Liver Transpl 2008; 14: 1092– 1099. 5 Dillman DA. Mail and Internet Surveys: The Tailored Design Method. 2nd ed. New York, NY: John Wiley & Sons; 2000. 6 Laryea M, Watt KD, Molinari M, Walsh MJ, McAlsiter VC, Marotta PJ, et al. Metabolic syndrome in liver transplant recipients: prevalence and association with major vascular events. Liver Transpl 2007; 13: 1109– 1114. 7 John PP, Thuluvath PJ. Outcome of liver transplantation in patients with diabetes mellitus: a case-control study. Hepatology 2001; 34: 889– 895. 8 Stegall MD, Everson G, Schroter G, Bilir B, Karrer F, Kam I. Metabolic complications after liver transplantation. Transplantation 1995; 60: 1057– 1060. 9 Hanouneh IA, Feldstein AE, McCulloug AJ, Miller C, Aucejo F, Yerian L, et al. The significance of metabolic syndrome in the setting of recurrent hepatitis C after liver transplantation. Liver Transpl 2008; 14: 1287– 1293. 10 Munoz SJ, Deems RO, Moritz MJ, Martin P, Jarrell BE, Maddrey WC. Hyperlipidemia and obesity after orthotopic liver transplantation. Transplant Proc 1991; 23: 1480– 1483. 11 Saab S, Shapaner A, Zhao Y, Brito I, Durzo F, Han S, et al. Prevalence and risk factors for diabetes mellitus in moderate term survivors of liver transplantation. Am J Transplant 2006; 6: 1890– 1895. 12 Reidelmeier DA, Tan SH, Booth GL. The treatment of unrelated disorders in patients with chronic medical diseases. N Engl J Med 1998; 339: 1516– 1520. 13 Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel 3). JAMA 2001; 285: 2486– 2497. 14 Linzer M, Myerburg RJ, Kutner JS, Wilcox CM, Oddone E, DeHortius RJ, et al. Exploring the generalist-subspecialist interface in internal medicine. Am J Med 2006; 119: 528– 537. Citing Literature Volume15, Issue10October 2009Pages 1330-1335 FiguresReferencesRelatedInformation
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