Future directions in immunosuppression

As liver transplantation is now being performed with an excellent 5-year survival rate of approximately 70% at selected centers, attention has been shifted to reduce long-term complications of calcineurin inhibitors including diabetes, hypertension, and hyperlipidemia, which have a major effect on morbidity and mortality within the transplant setting. Cyclosporine (CsA) monitoring has been performed traditionally by measurement of predose "trough" blood concentrations (C0). Recent development of 2 hour postdose CsA (C2) monitoring strategy has emerged as a much more sensitive approach for assessing the pharmacokinetics and providing greater precision in the optimization of Neoral dosing than C0 measurements. Furthermore, a reduction of risk factors for atherosclerotic vascular disease and in the incidence and severity of acute cellular rejection have been associated with the adoption of C2 monitoring. However, further data from multicenter trials are required to evaluate the long-term benefits of this new therapeutic monitoring strategy.