Basics and Art of Immunosuppression in Liver Transplantation

Liver transplantation is one of the most challenging area in whole of the medical field. Despite that, it has already been established as a standard treatment options, especially in decompensated cirrhosis and selected cases of hepatocellular carcinoma and acute liver failure. Complications due to graft rejection including mortality and morbidity have greatly improved over the time due to better immunosuppressive agents and management protocols. Currently immunosuppression in liver transplant patient makes use of the best possible combinations of effective agents to achieve the optimal immunosuppression for long term graft survival. Induction agents are no longer used routinely and the aim is to provide minimal immunosuppression in the maintenance phase. Currently available immunosuppressive agents are mainly classified as biological and pharmacological agents. Though, the protocols may vary among the centers and over the time, but basics of effective use usually remains similar. Most protocols use the combination of multiple agents having different mechanism of action to reduce the dose and minimize the side effects. Along with the improvement in operative and perioperative techniques, this art of immunosuppression has contributed significantly to the recent progress made in outcomes of liver transplant. In this review we will discusses the various types of immunosuppressive agents currently in use, different protocols of immunosuppression used and art of the optimal use for achieving maximum immunosuppression without increasing the toxicity. We will also discuss about the practical aspects of various immunosuppression regimens including drug monitoring and briefly discuss over the concept of immunosuppression minimization and withdrawal.