Rethinking chronic kidney disease risk after liver transplantation

Table 4 Practical algorithm for maintenance immunosuppression after liver transplantation

Step	Patient factors/clinical scenario	Preferred regimen	Alternative regimen/key considerations
1	Standard risk (normal renal function, no specific comorbidities)	TAC + MMF ± steroids	CsA + MMF ± steroids: Monitor closely for CNI toxicity and NODAT
2	Renal dysfunction (eGFR < 60 mL/minute) or CNI toxicity	EVR + low-dose TAC	Everolimus + MMF (CNI-free): Reserved for patients with severe CNI intolerance due to higher rejection risk; monitor for proteinuria and wound healing
3	History of malignancy (e.g., HCC history, skin cancer)	Everolimus-based regimen	Sirolimus-based regimen: Leverage the antineoplastic effects of mTOR inhibitors to reduce recurrence risk
4	High immunological risk (e.g., autoimmune etiology, young age)	Induction with thymoglobulin followed by TAC + MMF	Standard triple therapy: Consider delayed CNI introduction to protect renal function during the perioperative phase
5	SLKT recipients (Simultaneous liver-kidney transplant)	Standard CNI-based regimen	Individualized approach: Therapy must be tailored to protect the kidney graft while preventing liver rejection

Recommendations adapted from Nedredal et al[20] and Pollok et al[21]. TAC: Tacrolimus; MMF: Mycophenolate mofetil; CsA: Cyclosporine A; CNI: Calcineurin inhibitor; NODAT: New-onset diabetes after transplantation; EVR: Everolimus; HCC: Hepatocellular carcinoma; SLKT: Simultaneous liver-kidney transplantation.