Immunosuppressants: what's new?

Advances in surgical techniques and combinations of conventional immunosuppressants have made paediatric liver transplantation the success story it is today. However, the increasing numbers of survivors reaching adulthood highlight important issues of long-term quality of life and drug induced complications. The aim of this review is to describe the trends and advances in immunosuppression for paediatric liver transplantation over the last 12 months.

As our knowledge of the immune cell populations and intracellular mechanisms involved in alloreactivity improves, induction immunosuppression has emerged as a powerful therapeutic manoeuvre to counter the initial alloimmune response. Many centres have adopted a more focused use of biological agents at induction to improve immunosuppression in the critical peritransplant period and to reduce the level of subsequent maintenance requirements. Corticosteroid avoidance and calcineurin inhibitors minimization trials have obtained encouraging results. New immunosuppressive strategies have evolved towards the goal of inducing operational tolerance, and paediatric liver transplant recipients seem to be a particularly promising target. New strategies are being developed also to improve quality of life and reduce nonadherence in adolescents and young adults who underwent liver transplantation. New drugs target B-cell and complement driven rejection and new monoclonal antibodies and small molecules are under trial to inhibit specific signals in the immune response.

We review current trends of immunosuppressive protocols in paediatric liver transplantation, focusing on induction agents, corticosteroid avoidance and calcineurin inhibitor sparing protocols, protocols for adult transition and new drugs currently under development.