Since liver transplantation was approved for the treatment of end stage liver disease, calcineurin inhibitors (CNI's) have played a critical role in the preservation of allograft function. Unfortunately, these medications cause a variety of Side effects such as diabetes, hypertension and nephrotoxicity which in turn result in significant morbidity and reduced quality of life. A variety of newer immunosuppressants have been evaluated over the last decade in an attempt to either substitute for CNI's or use with reduced dose CNI's while still preserving allograft function However, current data does not recommend complete cessation of CNI's due to unacceptably high rates of allograft rejection. As these medications have their own unique adverse effects, a careful assessment on their risks and benefits is essential, particularly when additive or synergistic effects with CNI's may occur. Furthermore, the impact of these newer medications on the risk of hepatitis C recurrence and progression remains to be elucidated. Controlled trials are urgently required to assist transplant physicians with choosing the optimum immunosuppressive regimen for their patients. This review will discuss commonly used immunosuppressants prescribed in liver transplantation, emerging therapties and where appropriate, the impact of these medications on the recurrence of hepatitis C after liver transplantation.

Calcineurin inhibitors remain the mainstay of immunosuppression in liver transplantation but are associated with important side effects such as diabetes, hypertension and nephrotoxicity which can influence quality of life and survival rates. A variety of non-calcineurin inhibitors have been used in liver transplantation, either during induction immunosuppression in an attempt to delay the introduction of calcineurin inhibitors or during maintenance immunosuppression with reduced dose calcineurin inhibitors to minimize calcineurin inhibitor toxicity while preserving hepatic allograft function. With few exceptions, single agent immunosuppression with non- calcineurin inhibitors has not been universally practiced outside of clinical trials due to unacceptably high rates of hepatic allograft rejection. Although several single center studies have reported encouraging results with these new agents when used with reduced dose calcineurin inhibitors, large, randomized studies are eagerly awaited. Furthermore, as the impact of these newer agents on the recurrence of hepatitis C continues to evolve, clinicians need to be prudent with their use until data from controlled studies is available. This article will review currently used immunosuppressants in liver transplantation, novel therapies in development and the impact of these medications of the recurrence of hepatitis C after liver transplantation.

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