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Immunosuppression for liver transplantation in HCV‐infected patients: Mechanism‐based principles
Author(s) -
Eghtesad Bijan,
Fung John J.,
Demetris Anthony J.,
Murase Noriko,
Ness Roberta,
Bass Debra C.,
Gray Edward A.,
Shakil Obaid,
Flynn Bridget,
Marcos Amadeo,
Starzl Thomas E.
Publication year - 2005
Publication title -
liver transplantation
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.814
H-Index - 150
eISSN - 1527-6473
pISSN - 1527-6465
DOI - 10.1002/lt.20536
Subject(s) - immunosuppression , medicine , liver transplantation , context (archaeology) , hepatitis c virus , immunology , plasmapheresis , hepatitis c , tacrolimus , prednisone , transplantation , hepacivirus , gastroenterology , virus , antibody , biology , paleontology
We retrospectively analyzed 42 hepatitis C virus (HCV)‐infected patients who underwent cadaveric liver transplantation under two strategies of immunosuppression: (1) daily tacrolimus (TAC) throughout and an initial cycle of high‐dose prednisone (PRED) with subsequent gradual steroid weaning, or (2) intraoperative antithymocyte globulin (ATG) and daily TAC that was later space weaned. After 36 ± 4 months, patient and graft survival in the first group was 18/19 (94.7%) with no examples of clinically serious HCV recurrence. In the second group, the three‐year patient survival was 12/23 (52%), and graft survival was 9/23 (39%); accelerated recurrent hepatitis was the principal cause of the poor results. The data were interpreted in the context of a recently proposed immunologic paradigm that is equally applicable to transplantation and viral immunity. In the framework of this paradigm, the disparate hepatitis outcomes reflected different equilibria reached under the two immunosuppression regimens between the relative kinetics of viral distribution (systemically and in the liver) and the slowly recovering HCV‐specific T‐cell response. As a corollary, the aims of treatment of the HCV‐infected liver recipients should be to predict, monitor, and equilibrate beneficial balances between virus distribution and the absence of an immunopathologic antiviral T‐cell response. In this view, favorable equilibria were accomplished in the nonweaned group of patients but not in the weaned group. In conclusion, since the anti‐HCV response is unleashed when immunosuppression is weaned, treatment protocols that minimize disease recurrence in HCV‐infected allograft recipients must balance the desire to reduce immunosuppression or induce allotolerance with the need to prevent antiviral immunopathology. (Liver Transpl 2005;11:1343–1352.)