Precision Immunosuppression in a Carefully Selected Liver Transplant Population: Can MMF Alone "Hold the Fort "?

Data on mycophenolate mofetil (MMF) as a standalone immunosuppressant in liver transplants are scarce, with it typically being used alongside calcineurin inhibitors (CNIs) or, less frequently, mammalian target of rapamycin inhibitors.

We conducted a retrospective review of medical records with the following inclusion criteria: on CNI with or without MMF, at least 6 months from orthotopic liver transplantation, absence of rejection episodes within 12 months, stable post-transplant course, no history of previous transplantation, and no history of autoimmune diseases (primary biliary cholangitis, primary sclerosing cholangitis, or autoimmune hepatitis). Patients were weaned from CNI or mammalian target of rapamycin inhibitors progressively over 4 weeks and, if not on MMF, it was introduced progressively over 4 weeks. Liver function tests were monitored every 1 to 2 weeks for 2 to 3 months. The primary outcome of the study was the incidence of rejection after the transition to MMF monotherapy. Secondary outcomes include graft loss or patient death during follow-up.

Thirty-three patients after liver transplantation were transitioned successfully to MMF monotherapy. Of these, 27 patients (81.8%) were successfully weaned off CNIs. The average interval between transplantation and initiation of MMF monotherapy was 84 ± 76 months, with an average follow-up duration of 8 ± 4 months. The average mean reduction in creatinine levels was 0.6648 ± 0.62 mg/dL. Acute rejection was documented in 6 patients (18.2%), with only 1 patient experiencing severe rejection requiring hospitalization; the others were managed as outpatients, with some requiring CNI reintroduction.

MMF monotherapy is a viable option for select patients after liver transplantation, with a substantial success rate and potential renal benefits. However, careful monitoring is essential to identify and manage cases of acute rejection promptly.