Long-term management of immunosuppression after pediatric liver transplantation: is minimization or withdrawal desirable or possible or both?

Sandy Feng, Sandy Feng

Abstract

Purpose of review: The aim is to review available data regarding the risks and benefits of indefinite immunosuppression against attempted immunosuppression withdrawal for children who have undergone liver transplantation.

Recent findings: Emerging data suggest that conventional immunosuppression practices may well be responsible for a substantial proportion of the long-term mortality and morbidity burden borne by pediatric liver transplant recipients. The cumulative risk of chronic kidney disease, infection, malignancy, and cardiovascular risk factors such as hypertension, diabetes, and hyperlipidemia appear to threaten the health and well being of children more than that of acute or chronic allograft rejection. In parallel, single-center experiences have suggested that gradual immunosuppression withdrawal can be done safely with higher success rates in pediatric compared with adult liver transplant recipients. The coalescence of these two data streams has engendered substantial interest in systematic exploration of the safety and efficacy of immunosuppression withdrawal in conjunction with a vigorous scientific effort to elucidate an immunologic signature predictive of successful withdrawal.

Summary: There is a concerted effort within the transplant community to identify biomarkers that can accurately predict the success of immunosuppression withdrawal after liver transplantation. Freedom from lifelong immunosuppression is likely to yield considerable benefit, particularly for children who face the longest lifetime horizons.

Figures

Figure 1. Declining death rates within one…
Figure 1. Declining death rates within one year of pediatric deceased donor liver transplantation
Data from the Scientific Registry of Transplant Recipients regarding death rates after pediatric deceased donor liver transplantation by age group for transplants performed between 1997 and 2005. [Figure 10 from Magee et al., AJT 2008; reference 3].
Figure 2. Late patient death and graft…
Figure 2. Late patient death and graft loss after pediatric liver transplantation
Kaplan-Meier patient and graft survival for recipients who were alive one year after transplantation with functioning primary allografts. [Figure 1 from Soltys et al., AJT 2007; reference 4*].
Figure 3. Probability of acute rejection after…
Figure 3. Probability of acute rejection after pediatric liver transplantation
Kaplan-Meier probability of first episode of acute rejection over time after liver transplantation. [Figure 6–Figure 4 from SPLIT Annual Report 2006; reference 21]

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