Role of immunosuppression in liver transplantation. Advantages and disadvantages

Cirrhosis of the liver is a major cause of death worldwide, with a recent increase in cases secondary to metabolic dysfunction-associated steatotic liver disease and alcohol use. Liver transplantation is currently the only definitive treatment but requires immunosuppression for preventing graft rejection. Calcineurin inhibitors are the cornerstone of immunosuppression in transplanted patients. However, their use conditions metabolic and renal complications, such as metabolic syndrome, post-transplant diabetes, and chronic kidney disease. Minimizing or discontinuing immunosuppression has been shown to reduce those adverse effects in selected patients, especially those with potential immunotolerance. Predictors of immunotolerance and cardiovascular complications in transplanted patients have been identified in recent studies. Thus, there is a need for developing individualized strategies for balancing metabolic risk and graft rejection prevention.