An important part of the mid- and long-term management after liver transplantation is regular outpatient review and health consultation, which is quite complicated and is summarized in the following aspects: general medical checkups: routine checkups should include weight and blood pressure monitoring, routine blood tests, blood electrolyte tests, liver and kidney function tests, and blood drug concentration tests, which should be done at least once a month. In addition, health consultation should be conducted. Screening and census of malignant tumors: After liver transplantation, there is a possibility of tumor development due to the combined effect of multiple carcinogenic factors. Long-term immunosuppression may lead to skin cancer, non-Hodgkin’s lymphoma, Kaposi’s sarcoma, cervical cancer, genital tumors and anal canal cancer. Therefore, recipients should be followed up for early manifestations of these tumors, such as unexplained weight loss. For male patients older than 40 years old, transrectal ultrasound should be performed annually to rule out prostate tumors, and for patients older than 40 years old, colonoscopy and fecal occult blood test should be performed annually to rule out colorectal tumors. For some high-risk groups, such as preoperative history of tumor, family history of tumor, suffering from long-term infectious bowel disease, etc., screening should be performed in a shorter period of time. Health counseling and medication guidance for common medical problems: Common medical problems mainly refer to some chronic systemic diseases that may occur in long-term surviving liver transplant recipients, including: renal insufficiency, hypertension, hyperlipidemia, diabetes, obesity, neuropsychiatric symptoms and bone diseases. In addition to the above issues, health counseling and related physical and laboratory examinations should be performed for patients with clinical symptoms such as fever and jaundice during follow-up visits. In the follow-up visit, patients should also be given guidance on medication, including guidance on the use and adjustment of immunosuppressive drugs, guidance on the application of prophylactic antibiotics, and guidance on the interaction between different drugs. In addition, all liver transplant patients should receive vaccinations consistent with their age, but the use of active vaccines should be limited. Common complications and management in mid- and long-term management 1 Chronic graft failure: Nowadays, it is believed that chronic rejection is not only related to specific immune attack, but also more closely related to non-specific tissue damage, so it is called chronic graft failure. Some authors believe that chronic graft incompetence is a comprehensive set of graft reactions to injury, mainly manifested as bile duct disappearance syndrome, the mechanism of which has not yet been elucidated, and there is no effective drug treatment countermeasure. As a clinician, we can only focus on prevention at present. It is believed that the following factors may be related to chronic graft loss, including: frequent acute rejection, side effects of immunosuppressive drugs, marginal donor organs, ischemia-reperfusion injury, CMV infection, so we should try to prevent the occurrence of these conditions, and once they occur, they should be treated as early as possible. 2. Recurrent diseases: In liver transplant patients, part of the recipient’s liver diseases belong to metabolic disorders, which can generally be cured by liver transplantation without recurrence of old diseases. In contrast, patients with viral hepatitis, autoimmune liver disease, primary biliary cirrhosis and primary sclerosing cholangitis who undergo liver transplantation are at risk of recurrence of old diseases. Recurrence of hepatitis B and C can lead to loss of function of the transplanted liver. Severe hepatitis B infection in cirrhotic transplants is an important cause of transplant failure. 58% of HBeAg-negative/HBV DNA-negative patients have recurrence of hepatitis B after surgery, while HbeAg-positive/HBV DNA-positive patients have recurrence in almost 100% of cases after surgery. Recurrence often occurs 1 year after liver transplantation and can progress to cirrhosis or even hepatocellular carcinoma within 2-3 years. The prognosis of patients with recurrent hepatitis B after liver transplantation is not yet satisfactory. Currently, it is believed that hepatitis B virus immunoglobulin, interferon and the anti-hepatitis B virus drugs Famciclovir and Lamivudine can inhibit HBV replication, reduce its recurrence or turn HBV DNA negative. Hepatitis B virus immunoglobulin resulted in a decrease in HBV reinfection and mortality rates. The long-term combination of hepatitis B immunoglobulin and lamivudine now significantly improves graft function and long-term patient survival. Other factors that influence the outcome of hepatitis B liver transplant patients include co-infection, cross-infection, and pre-transplant HBV DNA positivity with HBeAg positivity. Early withdrawal of hormones has been reported to reduce the recurrence of hepatitis B virus. For end-stage liver disease due to hepatitis C, liver transplantation is the only effective treatment. The 5-year survival rate for hepatitis C decompensated cirrhosis is 50%, which can be increased to 70%-80% after liver transplantation. However, the postoperative relapse rate is greater than 95%, mainly due to viremia, and does not affect the 5-year survival rate after transplantation. There are no effective antiviral therapies to eliminate its recurrence, although some data suggest that interferon may be able to inhibit its activity in some patients, but the treatment outlook is not yet optimistic. Other recurrent diseases include recurrence of malignancy and recurrence of alcoholic liver disease. In the early stages of liver transplantation, there was great enthusiasm for the use of transplantation to treat malignancies of the liver, but in situ liver transplantation is currently not considered to be effective for liver tumors that cannot be surgically removed, and the overall results have been disappointing. The recurrence rate of hepatocellular carcinoma after liver transplantation has been reported to be 39%-67%, and the survival rate at 3 years after transplantation is 15%-38%. The main cause of poor survival is the recurrence of liver cancer. Most recurrences of hepatocellular carcinoma are found within 1 year-2 years after liver transplantation. The common sites of recurrence are in the liver and lung. However, recurrence after liver transplantation for small hepatocellular carcinoma is rare and survival rates are high. In Western countries, alcoholic liver disease is a common end-stage liver disease and the most prominent indication for liver transplantation, with better transplantation results compared to other non-alcoholic benign liver diseases. However, recurrence of alcoholic liver disease is also a major problem, and it is speculated that 10-15% of patients will indulge in alcoholism again. 3. Renal insufficiency: Long-term surviving liver transplant recipients often have reduced glomerular filtration capacity and mildly elevated serum creatinine levels; this decline in renal function often occurs soon after surgery, but can often be maintained for many years and rarely progresses to end-stage renal disease. The exact cause of the decrease in renal function is not known, but it is likely to be related to the use of immunosuppressive drugs. Serum creatinine levels should be reviewed monthly after liver transplantation, and most transplant centers often adjust the blood levels of immunosuppressive drugs to reduce the nephrotoxicity of immunosuppressive drugs when serum creatinine levels change. Also some drugs that may produce nephrotoxicity should be avoided as much as possible. These include aminoglycosides and non-steroidal anti-inflammatory agents that can increase the nephrotoxicity of cyclosporine A and FK506 and should be avoided. Other drugs such as vancomycin and amphotericin B should also be used with caution. 4. Hyperlipidemia and other cardiovascular diseases: Many recipients have high risk factors for cardiovascular diseases, such as men >45 years old >55 years old women, high-fat diet, smoking, obesity, hypertension and family history, etc. About 40% of recipients may develop hyperlipidemia after surgery. Regular routine lipid testing should be performed, and when elevated lipids are detected, non-pharmacological treatment, including increased physical activity, diet control, and smoking cessation, should be taken first. Pravastatin may be the best choice when the patient develops more severe hyperlipidemia, but it may cause appetite changes and changes in lifestyle habits. The first-line drug for post-transplant hypertension treatment is a calcium channel negative blocker such as idebenone or nifedipine. 5. Nutritional problems: 40-70% of liver transplant patients will be overweight or obese after 1 year postoperatively. Dietary measurements and health pattern monitoring should be performed continuously after liver transplantation, and blood levels of corticosteroids should be reduced or even withdrawn for those who are overly obese. Some other patients will develop malnutrition after transplantation, especially those on FK506, which causes loss of appetite. However, in patients with weight loss, the occurrence of malignancy should first be ruled out. 6. Depression and other psychiatric problems: There are some recipients, especially in patients with multiple postoperative complications, who may develop depression. In addition, some patients become depressed because they are too worried about recurrent postoperative liver disease (such as viral hepatitis). The development of depression often leads to alcohol and drug dependence. For patients suspected of depression, once organic lesions are excluded, relevant antidepressant treatment should be carried out, including regular follow-up, psychological guidance, psychological counseling for those with suicidal tendencies, and application of antidepressant drugs, but attention should be paid to drug interactions. 7. Other: bone reduction and its complications often occur after liver transplantation, especially in patients with alcoholic liver disease and cholestatic liver disease liver transplantation is more frequent after surgery. The best predictor of bone disease after liver transplantation is the severity of bone loss before transplantation, with a continuous decrease in total bone mass for 6 months after liver transplantation and subsequent gradual improvement. In such patients, hormone dosage should be kept as low as possible, while timely supplementation of calcium and vitamin D is essential, especially in patients with cholestasis. In addition, hormone replacement therapy is reasonable and safe for postmenopausal liver transplant patients. Starzl has predicted that transplantation surgery will monopolize the entire field of surgery in the next century. With the resolution of the organ source problem and further breakthroughs in anti-rejection therapy, it can be asserted that liver transplantation will occupy an irreplaceable and important position in the treatment of liver disease. And as our understanding of the medium and long-term management after liver transplantation continues to improve, the long-term efficacy of liver transplantation and the long-term survival of the recipient will certainly be significantly improved.