Subject(s)
Biliary Tract Diseases/etiology , Death , Graft Survival , Liver Transplantation/adverse effects , Tissue Donors , Biliary Tract Diseases/mortality , Humans , Incidence , Liver Transplantation/mortality , Practice Guidelines as Topic , Reoperation , Risk Assessment , Risk Factors , Severity of Illness Index , Time Factors , Treatment OutcomeABSTRACT
Although calcineurin inhibitors (CNIs) remain the mainstay of immunosuppression in liver transplantation (LTX), their long-term toxicity significantly contributes to morbidity and mortality. The elucidation of mechanisms of alloimmunity and leukocyte migration have provided novel targets for immunosuppression development. The toxicities of these agents differ from that of the CNI and act additively or synergistically. CNI avoidance protocols in LTX have not been achieved routinely; however, pilot trials have begun to delineate the limitations and promises of such approaches. CNI-sparing protocols appear to be much more promising in balancing the early need for minimizing rejection while tapering doses and minimizing long-term toxicity.
Subject(s)
Calcineurin Inhibitors , Immunosuppression Therapy/trends , Immunosuppressive Agents/therapeutic use , Liver Transplantation/immunology , Adrenal Cortex Hormones/therapeutic use , Alemtuzumab , Antibodies, Monoclonal/therapeutic use , Antibodies, Monoclonal, Humanized , Antibodies, Neoplasm/therapeutic use , Antibody Formation , Antilymphocyte Serum/therapeutic use , Humans , Mycophenolic Acid/therapeutic use , Sirolimus/therapeutic use , T-Lymphocytes/immunologyABSTRACT
1. Liver transplantation for human immunodeficiency virus (HIV)-positive patients with end-stage liver disease in the era of highly active retroviral therapy has proven to be an effective treatment. The concerns of HIV progression have not been borne out by the growing worldwide experience. 2. CD4 counts are stable and HIV viral load is controllable with medication following liver transplantation. 3. Hepatitis C virus (HCV) coinfection in HIV-positive recipients is universal, but the severity of recurrence does not appear to be different from that in HIV-negative patients with HCV liver disease. 4. Complex pharmacokinetic interactions between the calcineurin inhibitors used for immunosuppression along with protease inhibitors are present, but management directed at recognizing the need for monitoring levels does not appear to increase the risk of toxicity. 5. The degree of immunosuppression from iatrogenic drug therapy and HIV does not lead to increased risk of infectious complications.
