How is graft rejection controlled following liver transplantation?

Updated: Dec 31, 2017
  • Author: Lemi Luu, MD, RDMS, FACEP, FAAEM; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Survival of both allograft and patient is made possible through immunosuppression following transplantation. Graft rejection is controlled through an immunosuppressant regimen. Standard therapy generally involves a combination of corticosteroids, a calcineurin inhibitor (cyclosporine or tacrolimus), and an antiproliferative agent. At the time of transplant, induction is achieved with high-dose corticosteroids and antithymocyte globulin or monoclonal antibody, followed by the addition of azathioprine and cyclosporine. Newer agents sometimes used in induction include tacrolimus (which, like cyclosporine, inhibits T-cell proliferation) and mycophenolate (a less selective inhibitor similar to azathioprine). [11]

Long-term immunosuppression usually is maintained with cyclosporine, azathioprine, and prednisone. Tacrolimus appears to be superior to cyclosporine in liver transplantation and is being used in many centers. Standard regimens often change during the course of a liver transplant recipient's life.

Studies have shown that dual therapy with steroids and a calcineurin inhibitor are just as efficacious as triple therapy while decreasing serious side effects such as bone marrow suppression. In addition, steroid withdrawal has been shown to be relatively safe in liver transplant recipients, and this has been done in some centers. If steroids are successfully tapered within the first few months of the transplant, there will likely be only minimal increased episodes of acute rejection without any increase in graft loss. Consequently, patients may be weaned down to monotherapy with a calcineurin inhibitor from a previous triple-therapy regimen.

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