Immunosuppression in Liver Transplantation

Liver transplantation remains the effective treatment for end-stage liver disease and its enduring success can be attributed to improvements in immunosuppression. Different etiologies of end-stage liver disease such as hepatitis C virus infection and other associated conditions such as human immunodeficiency virus (HIV) infection, hepatocellular carcinoma, and acute and chronic kidney disease create unique challenges in anti-rejection therapy. The optimal dosing of immunosuppression in liver transplantation remains uncertain and target levels have been derived from experience in kidney transplant recipients. The dose of calcineurin inhibitors is usually guided by the trough whole blood level, measured by radioimmunoassay. The potential for drug-drug interactions is high in liver transplant recipients due to polypharmacy. Information regarding the treatment of end-stage liver disease in HIV-positive patients is emerging. Achieving operational tolerance through careful withdrawal of immunosuppression in highly selected individuals is possible, although it should only be done in the setting of clinical research trials at this time.