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Immunosuppression in liver transplant.

Tommaso Di Maira1, Ester Coelho Little2, Marina Berenguer3

  • 1Liver Transplantation and Hepatology Unit, Hospital Universitari I Politècnic La Fe, Avda Fernando Abril Martorell, 106 (Torre F5), Valencia, 46026, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, 28029, Spain; ISS La Fe, Valencia, 46026, Spain.

Best Practice & Research. Clinical Gastroenterology
|November 7, 2020
PubMed
Summary

Potent immunosuppression (IS) drugs improve liver transplant (LT) outcomes but increase long-term risks. Minimizing IS is crucial to balance graft survival and reduce adverse effects like cancer and metabolic syndrome.

Keywords:
AzathioprineCalcineurin inhibitorsCyclosporineEverolimusImmunosuppressionImmunosuppression inductionImmunosuppression maintenanceImmunosuppression minimizationImmunosuppression withdrawalLiver transplantationMammalian target of rapamycin inhibitorsMonoclonal antibodiesMycophenolate mofetilSirolimusTacrolimusTolerance

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Area of Science:

  • Immunology
  • Transplantation Medicine
  • Pharmacology

Background:

  • Potent immunosuppression (IS) agents have reduced rejection and graft loss in liver transplantation (LT).
  • Prolonged survival post-LT leads to extended exposure to IS drugs, increasing adverse effects.
  • Late mortality after LT is often unrelated to graft function, highlighting IS-related morbidities.

Purpose of the Study:

  • To review the mechanisms, adverse effects, and regimens of commonly used IS drugs in LT.
  • To discuss strategies for balancing effective immunosuppression with minimizing drug toxicity.
  • To evaluate current approaches to IS minimization and withdrawal in liver transplant recipients.

Main Methods:

  • Review of the literature on IS agents, their mechanisms of action, and adverse effects.
  • Analysis of IS regimens for induction and maintenance in LT.
  • Discussion of protocols for protecting renal function and preventing de novo cancers and metabolic syndrome.
  • Evaluation of current strategies for IS minimization and withdrawal.

Main Results:

  • Increased IS potency has decreased rejection rates but contributes to non-graft-related late mortality.
  • Adverse effects of long-term IS include cancer and metabolic syndrome, alongside potential renal dysfunction.
  • Over-immunosuppression is a recognized issue in liver transplant recipients.

Conclusions:

  • Balancing IS efficacy and toxicity requires a combination of scientific knowledge and clinical experience.
  • Strategies for IS minimization and withdrawal are essential for improving long-term outcomes and quality of life after LT.
  • Further research and clinical evaluation are needed to optimize IS protocols and reduce long-term complications.