Choosing an immunosuppressive regimen for liver transplantation

Immunosuppressive therapy for liver transplantation has been greatly improved with the introduction of immunosuppressive agents such as cyclosporin and tacrolimus in the 1980s and the 1990s, respectively. These agents inhibit transcription of the messenger RNA for cytokines such as interleukin-1, interleukin-2 and interferon-gamma, thus inhibiting cytokine release from activated T cells, which in turn leads to inhibition of proliferation of killer T cells after transplantation. These cytokine inhibitors are combined in multidrug therapy with corticosteroids and/or other immunosuppressive agents with different mechanisms of action to obtain maximal efficacy and minimal adverse effects. This article focuses on immunosuppressive regimens using the highly selective immunosuppressant tacrolimus for liver transplantation, based on our 6 years experience of living-related liver transplantation and on the reports of cadaveric liver transplantation from other centres. Tacrolimus, like cyclosporin, has reduced the required dosage of corticosteroids, leading in several centres to successful corticosteroid withdrawal in 6 months to 1 year after transplantation. Further modification of immunosuppressive regimens in long term patients, including withdrawal of tacrolimus, will be required.