Published online Jan 28, 2016. doi: 10.4254/wjh.v8.i3.148
Peer-review started: July 1, 2015
First decision: August 31, 2015
Revised: December 13, 2015
Accepted: January 5, 2016
Article in press: January 7, 2016
Published online: January 28, 2016
Immunosuppression in organ transplantation was revolutionary for its time, but technological and population changes cast new light on its use. First, metabolic syndrome (MS) is increasing as a public health issue, concomitantly increasing as an issue for post-orthotopic liver transplantation patients; yet the medications regularly used for immunosuppression contribute to dysfunctional metabolism. Current mainstay immunosuppression involves the use of calcineurin inhibitors; these are potent, but nonspecifically disrupt intracellular signaling in such a way as to exacerbate the impact of MS on the liver. Second, the impacts of acute cellular rejection and malignancy are reviewed in terms of their severity and possible interactions with immunosuppressive medications. Finally, immunosuppressive agents must be considered in terms of new developments in hepatitis C virus treatment, which undercut what used to be inevitable viral recurrence. Overall, while traditional immunosuppressive agents remain the most used, the specific side-effect profiles of all immunosuppressants must be weighed in light of the individual patient.
Core tip: The use of immunosuppressive agents is reviewed in the context of the modern post-orthotopic liver transplantation population. The side effects of mainstay immunosuppressive strategies exacerbate some patient pathologies, and combinations of different immunosuppressants could be more specifically tailored to patient needs. Acute cellular rejection and malignant complications are also discussed with respect to immunosuppressive strategies. Finally, hepatitis C virus and its impact on immunosuppression is re-evaluated in light of recent developments in viral clearance.