Immunosuppression for liver transplantation in HCV-infected patients: mechanism-based principles.
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.
Eghtesad
Bijan
B
Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Fung
John J
JJ
Demetris
Anthony J
AJ
Murase
Noriko
N
Ness
Roberta
R
Bass
Debra C
DC
Gray
Edward A
EA
Shakil
Obaid
O
Flynn
Bridget
B
Marcos
Amadeo
A
Starzl
Thomas E
TE
D000704:Analysis of Variance; D000961:Antilymphocyte Serum / Q000627:therapeutic use; D002102:Cadaver; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005260:Female; D006084:Graft Rejection; D006085:Graft Survival; D019698:Hepatitis C, Chronic / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D008111:Liver Function Tests; D016031:Liver Transplantation / Q000276:immunology* / Q000379:methods; D008297:Male; D008875:Middle Aged; D011241:Prednisone / Q000627:therapeutic use; D011336:Probability; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate; D016559:Tacrolimus / Q000627:therapeutic use; D014181:Transplantation Immunology / Q000502:physiology*
D000961:Antilymphocyte Serum; D007166:Immunosuppressive Agents; D011241:Prednisone; D016559:Tacrolimus