Immunosuppression Without CIs in Liver Transplantation
What is the experience with double therapy with mycophenolate mofetil (MMF) and corticosteroids as an immunosuppressive regimen without induction therapy in liver transplantation? The patient is 47 years old, 80 days posttransplantation, with severe cholestasis and centrolobular necrosis on biopsy. We have investigated all possible causes and only after discontinuation of cyclosporine did the serum total bilirubin decrease from 30 mg/dL to 10 mg/dL.

Eduardo Anchante, MD

Double- or single-agent immunosuppressive therapy after liver transplantation is quite common, but is based on the effectiveness of calcineurin inhibitors. A regimen employing MMF and corticosteroids without calcineurin inhibitors is reminiscent of the strategies employed in the early development of liver and kidney transplantation in which azathioprine and corticosteroids were the only immunosuppressive agents available. Compared with modern results, the use of these 2 drugs provided inferior results. Furthermore, the relatively high doses of corticosteroids required to prevent or treat rejection were associated with profound side effects. Hepatotoxicity related to cyclosporine administration is usually dose-dependent, and resolves with dosage reduction. In refractory cases, it is reasonable to switch to tacrolimus therapy. Sirolimus offers an alternative to calcineurin inhibitors, and there is increasing experience with this agent as a primary immunosuppressive agent. However, long-term therapy based only on MMF and corticosteroids cannot be recommended at this time.