Background: Novel drugs and combinations for immunosuppression (IS) after liver transplantation is
one main reason for improved graft and patient survival seen in the last decades. The backbone of IS is still steroids
and calcineurin inhibitors, although novel drugs are being introduced, such as the mammalian target of rapamycin
inhibitors (mTOR inhibitor). The challenge today, along with increased patient survival, is the adverse
effects of long-term use of immunosuppressive drugs, mainly nephrotoxicity and other serious adverse effects.
Concepts: The ultimate outcome after liver transplantation would be achieving tolerance, a state where all IS can
be withdrawn. In the meantime, different approaches to reduce and withdraw IS have been tested out in different
clinical trials with the aim to reduce the adverse effects of steroids and calcineurin inhibitors. This has formed the
basis of today’s clinical practice. The different combinations of immunosuppressive drugs have included mTOR
inhibitor such as everolimus and different induction drugs such as anti-interleukin 2 receptor antibodies. Regarding
induction drugs, lymphocyte depleting (alemtuzumab and ATG) and non-depleting agents, such as basiliximab,
have shown advantageous effects.
Summary: Alongside steroid and calcineurin inhibitors reduction or elimination, current strategies for post-liver
transplantation immunosuppression explore combinations of novel agents. The gauge (or yardstick) here is the
fine balance between the adverse effects of IS drugs and the risk of rejection. Long-term maintenance IS regimens,
development of tolerance and antibody-mediated rejection are also discussed in this review.