Early Corticosteroid Protocols in Liver Transplantation: A Survey of Canadian and American Centers

Corticosteroids remain a major component of immunosuppression following liver transplantation but their optimal use is not well defined. Practice variation persists across centers.

We conducted a cross-sectional survey of North American liver transplant centers to characterize corticosteroid use within overall immunosuppressive strategies. Data collected included corticosteroid dosing and duration, antibody induction and tacrolimus and mycophenolate use at standardized timepoints within the first six months post-transplant. Dosing ranges were standardized using midpoint estimates. Immunosuppressive intensity was summarized descriptively and visualized using a heatmap.

Thirty-four centers (7 Canadian, 27 US) participated. Corticosteroid regimens ranged from steroid-free protocols (3/34) to use beyond six months with a median duration of 55 days (IQR 21-91). Median cumulative methylprednisolone exposure was 1573 mg (IQR 1060-1900). Most centers (28/34) reported individualized corticosteroid strategies and 59% maintained low-dose corticosteroids indefinitely in selected patients. Antibody induction was used by 71% of centers, predominantly basiliximab. Tacrolimus was used universally with median trough targets decreasing from 9.0 ng/mL in month 1 to 7.0 ng/mL by months 2-6. Mycophenolate was used in 97% of centers with variation in dose reduction and discontinuation. Across centers, immunosuppressive intensity varied with lower corticosteroid exposure often accompanied by higher intensity in other components.

Immunosuppressive strategies following liver transplantation vary substantially across centers particularly corticosteroid use. Regimens appear to be adjusted across components rather than applied uniformly. Further work is needed to relate immunosuppressive intensity to clinical outcomes.