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Quantification of the Immunosuppressant Tacrolimus on Dried Blood Spots Using LC-MS/MS
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Immunosuppression in patients with grade 3 acute-on-chronic liver failure at transplantation: A practice analysis

Francois Faitot1,2, Thierry Artzner3, Baptiste Michard1

  • 1Hepatobiliopancreatic Surgery and Transplantation Department, Hopital de Hautepierre, Hopitaux Universitaires de Strasbourg, Strasbourg, France.

Clinical Transplantation
|January 2, 2022
PubMed

Insights

Optimizing immunosuppression management, including stable tacrolimus levels and early mycophenolic acid use, significantly improves 1-year survival for liver transplant patients with acute-on-chronic liver failure grade 3 (ACLF3). Treating rejection is crucial for survival.

Area of Science:

  • Hepatology
  • Transplantation Immunology
  • Pharmacology

Background:

  • Liver transplantation for acute-on-chronic liver failure grade 3 (ACLF3) shows high survival rates (80-90% at 1 year).
  • ACLF3 patients experience organ failure, altering drug metabolism and increasing toxicity risks.
  • Effective immunosuppression is vital but challenging in this critically ill population.

Purpose of the Study:

  • To identify immunosuppression-related factors influencing survival in ACLF3 liver transplant recipients.
  • To evaluate the impact of immunosuppression strategies on patient outcomes.

Main Methods:

  • Retrospective monocentric study of 100 ACLF3 patients transplanted between 2007-2019.
  • Analysis of immunosuppression: type, timing, trough levels, and intra-patient variability (IPV).
  • Primary endpoint: 1-year survival; secondary endpoints: overall survival, rejection, surgical complications.

Main Results:

  • Predictors of 1-year survival included tacrolimus IPV < 40%, no early tacrolimus overdose, anti-IL2-receptor antibody use, and early mycophenolic acid introduction.
  • Treated rejection was an independent predictor of survival (HR 4.2).
  • Early everolimus introduction showed no increase in rejection or surgical complications.

Conclusions:

  • Immunosuppression management is critical for ACLF3 liver transplant recipients.
  • Stable tacrolimus levels, avoiding overdose, and early introduction of mycophenolic acid are key survival factors.
  • Early mTOR inhibitor use appears safe and effective, while managing rejection is paramount for survival.
Keywords:
basilliximabcritically ill patientseverolimusmycophenolic acidrejection

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