International Liver Transplantation Society Consensus Statement on Immunosuppression in Liver Transplant Recipients

Abstract

Effective immunosupression management is central to achieving optimal outcomes in liver transplant recipients. Current immunosuppression regimens and agents are highly effective in minimizing graft loss due to acute and chronic rejection but can also produce a substantial array of toxicities. The utilization of immunosuppression varies widely, contributing to the wide disparities in posttransplant outcomes reported between transplant centers. The International Liver Transplantation Society (ILTS) convened a consensus conference, comprised of a global panel of expert hepatologists, transplant surgeons, nephrologists, and pharmacologists to review the literature and experience pertaining to immunosuppression management to develop guidelines on key aspects of immunosuppression. The consensus findings and recommendations of the ILTS Consensus guidelines on immunosuppression in liver transplant recipients are presented in this article.

Management of metabolic syndrome and cardiovascular risk after liver transplantation

“…Few data exist on the management of diabetes in the post-LT setting. In the outpatient setting, the ILTS consensus statement on LT suggests that all LT recipients should undergo fasting glucose and HbA1c measurement at least 3, 6 and 12 months after LT and annually thereafter 47 . Although there is no data on the impact of glycaemic control on cardiovascular events post LT, it is reasonable to assume that a tight control will have a beneficial effect similarly to the general population.…”

“…Although there is no data on the impact of glycaemic control on cardiovascular events post LT, it is reasonable to assume that a tight control will have a beneficial effect similarly to the general population. Therefore the treatment target is an HbA1c <7.0% for most patients 47 . Annual screening for retinopathy and proteinuria in patients with diabetes is also advisable.…”

“…In addition, it can increase the circulating LDL-C levels by binding to the LDL-C receptor. MTOR inhibitors (sirolimus) are also potent hyperlipidaemic agents particularly in combination with cyclosporine 47 .…”

Immunosuppressive Drug Levels in Liver Transplant Recipients: Impact in Decision Making

“…Significant side effects include nephrotoxicity, neurotoxicity, and metabolic syndrome. 1,8 Both available CNIs (TAC and cyclosporine) require whole-blood level measurements as the majority is concentrated in erythrocytes. 9…”

“…Prevention of liver allograft rejection in the immediate and late postorthotopic liver transplant (OLT) period involves the simultaneous use of multiple different classes of immunosuppressive medications. T cell-mediated rejection, which is responsible for the vast majority of rejection episodes, 1 is the result of a multistep process initiated by antigen presenting cells leading to T cell activation, autostimulation, proliferation, and transendothelial migration leading to alloantigen tissue injury. 2 Each step on this chain of events is mediated by specific cells, receptors, and cytokines that can be purposely targeted by various classes of immunosuppressive medications.…”