| Summary: | Ongoing improvements in survival following liver transplantation
have necessitated a re-evaluation of immunosuppression protocols.
Corticosteroids and calcineurin inhibitors (CNIs) are the most frequently
used immunosuppressive drugs for liver transplantation but
are associated with a wide range of adverse effects, such as hypertension,
hyperlipidemia and nephrotoxicity. The need for hemodialysis
after liver transplantation is associated with poor outcomes. Renal
dysfunction in this setting may be caused by pre-existing renal disease,
hepatorenal syndrome and/or post-transplant factors, including the
use of nephrotoxic drugs, most notably CNIs such as cyclosporine and
tacrolimus. The methods that address this problem include the diligent
control of metabolic factors (eg, hypertension and hyperlipidemia),
therapeutic monitoring of CNIs and withdrawal or reduction of
the dosage of CNIs, combined with the use of newer non-nephrotoxic
agents. Although there is no clear consensus about the most effective
strategy, the optimal long-term immunosuppressive regimen would
prevent rejection without causing nephrotoxicity or other significant
adverse effects. Recent evidence suggests that the liver is a tolerogenic
organ and that some patients may need little, if any, long-term
immunosuppression.
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