Another major stressor is medical cost. The average cost of immunosuppressive medications alone is $10,000 to $20,000 per year.3 Most of the charges are reimbursable, although this depends on the payer and time from transplantation. Medicare pays for immunosuppressive medications for only 36 months. Beyond that point, patients will require secondary insurance or other assistance. This expenditure is exacerbated by the cost of other medications, clinic visits with the transplant center, family physicians, and specialists, and time away from work.
Although patients are usually well informed of these concerns before OLT, they often do not appreciate the financial magnitude until after OLT. Encourage patients to return to work, stay active physically and mentally, and prepare for these financial considerations.
Sexual issues
Some patients have persistent sexual dysfunction that may have an organic basis (cardiovascular, renal, liver, endocrine) requiring investigation. The safety and efficacy of sildenafil (Viagra) in OLT recipients has not been investigated to date.
However, other patients regain their libido and gonadal function immediately after OLT; pregnancy may occur in this period. Advise patients to wait at least 2 years post-OLT before considering pregnancy (SOR: C). 34 Contraception, preferably barrier-type, should be used during sexual intercourse. Hormonal contraceptives are not contraindicated but should probably not be administered until the patient ’ s transplant status is stable.
If pregnancy does occur, apprise the patient of potential complications and adverse outcomes. Hypertension and preeclampsia are more common in pregnant OLT recipients; life-threatening infections and acute rejection are rare. Fortunately, most patients deliver healthy babies; miscarriages, stillbirths, and malformations are uncommon. An obstetrician specializing in high-risk pregnancy should follow all pregnant OLT recipients.
Vaccination
Vaccination after OLT is controversial. Live vaccines are generally contraindicated post-OLT and their safety in patients with stable graft function and on low levels of immunosuppression is unclear (SOR: C). Patients should receive pneumococcal vaccination, hepatitis A and B vaccination if not already immune, and yearly influenza vaccination (SOR: C). For travel outside of the US or in uncertain situations or exposures, the best reference is the Centers for Disease Control web site: www.cdc.org.
Communication with the transplant center
Direct communication with the patient ’ s transplant center is extremely important. You and the transplant center should determine the most effective way (phone, fax or e-mail) to communicate.
When should you contact the transplant center? First, obtain the center ’ s approval for any new medications that may be used long-term or have the potential for nephrotoxicity, hepatotoxicity, or immunosuppression. Second, notify the transplant center in the event of new signs or symptoms, such as fever, weight loss, abdominal pain, or jaundice. Being cautious by communicating early is often the most prudent course. Third, alert the transplant center of any hospitalizations. Transfer to the transplant center for any transplant-related problem or prolonged hospitalization usually provides the best outcome for the patient.
On the flip side, you are the primary caretaker, and the transplant center should regularly communicate with you regarding general medical concerns and any new diagnoses, interventions, or treatments. The transplant center should also regularly communicate with you regarding general medical concerns and any new diagnoses, interventions, or treatments. A strong, mutual relationship between you and the transplant center will have great impact on the recipient ’ s long-term care.
CORRESPONDENCE
Josh Levitsky, MD, Northwestern Memorial Hospital, 675 North St. Clair St, Suite 15-250, Chicago, IL 60611. E-mail: j-levitsky@northwestern.edu