Liver transplantation for pregnancy-related liver diseases, pregnancy and sexual function after liver transplantation: What do we know?☆
Article Outline
Abbreviations: OLT, orthotopic liver transplantation, AFLP, acute fatty liver of pregnancy, HELLP, haemolysis, elevated liver enzymes, low platelet count, MELD, model for end-stage liver disease
Orthotopic liver transplantation (OLT) has now reached the stage of an accepted procedure with 1-year survival exceeding 85% and excellent long-term quality of life [1]. Young recipients are expecting to lead a full and normal life including the possibility of becoming pregnant and having a normal sexual life. Not much has been written on this topic, probably because, until not too long ago, OLT was followed by a number of negative events, which rendered such quality of life issues of minor importance. Additionally, sexual problems in either women and men following OLT may have been seen as a taboo by many.
In this Eleventh forum, or the second with the new format of a single article combining the opinion of different experts [2], [3], Michael Heneghan, in collaboration with a number of experts, broadly covers issues related to pregnancy and sexual function in OLT patients. Dr. Markus Selzner from the University of Toronto, Canada, describes various liver conditions which may affect pregnancy including acute fatty liver of pregnancy (AFLP) and the haemolysis, elevated liver enzymes, low platelet count syndrome (HELLP). Some excellent insights into the pathogenesis of those conditions are provided, and the rare indications for OLT are well described. An important distinction, relevant for therapy, is made between liver disease specific to pregnancy and those coincident with pregnancy (see Table 1 inside this Forum ). Dr. Eric Yoshida from Vancouver General Hospital, Vancouver, Canada, discusses the difficult topic of sexual function after OLT. First, he describes that in the pre-transplant population, sexual dysfunction is common, highlighting a clear correlation between the model for end-stage liver disease (MELD) score and sexual activity [4]. After OLT, most young women do recover regular menstrual bleeding within one year post-surgery. Sexual health, on the other hand, is much more complex as many factors are involved such as age, medications, psychological and social issues, employment status prior to transplantation, etc. At least a third of the men seem to present distressing erectile problems following OLT. There is an obvious need for education and counselling for both the health care givers and patients in this area. Dr. Beat Mullhaupt form the Swiss HPB Center, Zurich, Switzerland, provides key information about contraception after OLT. It is obvious, that female patients need an effective, safe and reversible contraceptive method to avoid unwanted pregnancy after liver transplantation. However, the data to base such recommendations are unfortunately very limited. In 2008, IUDs appear to be the method of choice. However, with increasing knowledge and experience regarding drug interactions, it is likely that new recommendations may appear soon.
Finally, Michael Heneghan, from King’s College Hospital, London, UK, addresses the issue of pregnancy after OLT underlying the safety of the commonly used immunosuppressants during pregnancy. Each agent is discussed regarding potential risks for the mother and the foetus. Finally, outcome of pregnancy and maternal risks are also reviewed in a well balanced manner suggesting moderately increased risk such as hypertension for the mother and low birth weight for the newborn. Monitoring by an interdisciplinary team including liver transplant specialists, neonatologists and obstetricians is key to prevent the development of rejection of the graft or major diseases in the mother and preterm foetal loss.
I would like to thank Michael Heneghan for his excellent and critical coverage of a topic of which there is a paucity of data in the literature, and which is hardly ever discussed among physicians, patients and their families. I hope this second forum with the new format will provide new insight into a topic, which should no longer be neglected, and that it may help to establish counselling guidelines for all sexually active OLT recipients.
References
- . Productivity and social rehabilitation of the transplant recipient. In: Killenberg PG, Clavien PA editor. Medical care of the liver transplant patient. 3rd ed.. Oxford: Blackwell Publishing Ltd.; 2006;p. 489–502
- . Are HIV-infected patients candidates for liver transplantation?. J Hepatol. 2008;48:697–707
- . Are HIV-infected patients candidates for liver transplantation? Editorial. Tenth forum on liver transplantation. J Hepatol. 2008;48:695–696
- . Sexual functioning in patients with end-stage liver disease before and after transplantation. Liver Transpl. 2006;12:1473–1477
☆ The author declares that he does not have anything to disclose regarding funding from industries or conflict of interest with respect to this manuscript.
PII: S0168-8278(08)00482-0
doi:10.1016/j.jhep.2008.07.010
© 2008 Published by Elsevier Inc.
